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

Welcome to the Huberman Lab Podcast where we discuss science and science-based tools for everyday life. I'm Andrew Huberman and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. My guest today is Dr. Teo Soleymani. Dr. Teo Soleymani is a double-board certified dermatologist and dermatologic surgeon.

He did his training at Stanford University and he was a clinical professor of dermatology and dermatologic surgery at UCLA, that is the University of California Los Angeles. Today we discuss all things related to skin appearance, skin health and skin longevity. For instance, we discuss sun exposure and the impact it can have on both the appearance and health of one skin.

In reference to that, we discuss sunscreens, which ones are safe, which ones perhaps elicit a bit more concern or perhaps should be avoided, and we discuss the surprising relationship between sun exposure and skin cancer. We discuss laser treatments for the skin, both for the appearance of skin in order to make it appear more youthful, as well as to prevent certain forms of skin cancer.

We discuss retinoids, we discuss supplements and nutrition, all in reference again to skin health and appearance. Thanks to Dr. Soleymani's incredible depth of expertise, as well as clarity of communication about the dos and do-nots that relate to skincare and appearance and to avoiding and treating skin cancers. By the end of today's episode, you will be armed with an immense amount of knowledge that is the very latest in our understanding of how to improve and protect your skin.

Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science-related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is Roca. Roca makes eyeglasses and sunglasses that are the absolute highest quality.

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Today's episode is also brought to us by Juve. Juve makes medical grade red light therapy devices. Now, if there's one thing I've consistently emphasized on this podcast, it's the incredible impact that light can have on our biology.

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I also have a Juve whole body panel, and I use that about three or four times per week. If you'd like to try Juve, you can go to Juve, spell j-o-o-v-v dot com slash Huberman. Juve is offering an exclusive discount to all Huberman lab listeners, with up to $400 off select Juve products. Again, that's Juve, j-o-o-v-v dot com slash Huberman, to get $400 off select Juve products. Today's episode is also brought to us by Helix Sleep.

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Right now, Helix is giving up to 25% off mattresses and two free pillows. Again, that's helixleap.com slash Huberman to get 25% off and two free pillows. And now, for my discussion with Dr. Theo Solomani. Dr. Theo Solomani. Welcome. Thanks for having me. It's awesome to be here. I'm very, very privileged to be here. Thank you. Well, it's an honor to have you. Let's talk about this amazing organ we call skin. So, skin, of course, covers our other organs. It's its own living biological entity.

And just for sake of educational purposes and to frame the rest of what we're going to talk about. How much turnover is there in our skin? Meaning the skin that I'm wearing right now is that going to be 100%, 50% of the skin that I'm going to be wearing a year from now? I'm 49 years old. Well, you look great for 49. So whatever you're doing, keep it up. So, the skin's an amazing organ. Just like you said, it's the largest organ, largest dynamic organ we have in our body.

You have new skin, brand new skin, every 28 days. So, the surface of your skin turns over about every month. Now, the stem cells, which are in the lowest portion of our epidermis, remain and they generate the skin cells. But you have brand new skin the same way you have new gut lining every 28 days. It's amazing for many reasons because the skin is one of the few organs that can regenerate because of this. So, you can grow new skin, you can test things on skin.

If your skin gets injured, it will regenerate and heal itself. Whereas many other organs cannot do that. And because of this, it also allows us to use it as a model platform for studying diseases of all kinds. So, skin's an amazing organ. I mean, I guess I'm biased, but... Well, I find a 28-day turnover just to be incredible. The skin, as I understand it, is innervated. That is, it receives connections from the nervous system.

So, I think for many people, their interest in skin is skin appearance, although we will also talk about skin health. But in terms of skin appearance, how much does stress, short-term and longer-term stress impact the appearance of our skin? And how does that work? I could imagine that the neurons release certain things into the skin. Does stress make our skin age faster? Does that mean it turns over more quickly or turns over more slowly?

Maybe you could link these two aspects of our biology for us. Yeah, that's a great question. So, in order to understand that, we have to just look at the structure of the skin. So, the skin generally is three layers, the epidermis, the dermis, and the subcutaneous fat. And the dermis is where most of the biologic activity resides. That's where our blood vessels are, that's where the nerves, the innervates sensation, and movement reside.

That's where our hair follicles, oil glands, and sweat glands reside. So, stress has two components. There's what we call acute stress, meaning stress that happens within a short period of time. And then there's long-term stress or chronic stress. And both have different processes in the skin. And you see the results of stress both immediately in the skin with release of certain chemical messengers in an autocrine, paracran, and holocron fashion.

And then you see the long-term deuterious effects of stress in a different mechanism in which there's actually breakdown of the skin. The easiest way to see this is when people are stressed and they lose their hair. And the hair obviously is an extension of our skin. It's a biosensor of our well-being. And we see this all the time, you know, I see students during finals time where they're really stressed out and they're coming with their hair falling out.

Or after a large medical illness or a pregnancy, patients will come in and say their hair's falling out. So, that acute stress is seen right away and that's due to several different reasons and release of messengers and hormones and chemical mediators that do this. Long-term stress is usually mitigated or caused by cortisol.

And everybody knows cortisol. It's the, you know, fundamental stress hormone of our body. It falls in the same family as drugs that we give like prednisone falls in the same family of cholesterol, testosterone, estrogen. But cortisol does something very different. It breaks things down to allow our body to utilize it in times of stress.

Unfortunately, our body doesn't understand the difference between 21st century stress and old stress. So, us being chased by a lion to our, to our bodies messaging system is the same as meeting chronic deadlines at work. And what happens is cortisol is responsible for the breakdown of things like collagen and alastin, thinning of vessel walls, which allow our skin to look supple and healthy.

So, as we have a lot of stress and a lot of cortisol release, we see aging. And there's accelerated aging studies that look at patients and people who are under high periods of stress, a great example of studies we look at presidents in which they appear to have aged much more rapidly than matched controls in a four year period of time. So, stress plays a really important role. You see it both immediately and long term.

I guess people rarely are sympathetic to presidents for aging quickly because I guess if there were a president who did not age quickly, we would worry they did not work hard enough or something of that sort. But the relationship between stress and skin fascinates me because not just of the direct relationship, like when we see people in their stress, like it seems like the power of their skin changes.

The kind of level of gleam in their eyes change. And the eyes are a direct piece of the nervous system really there's close to the brain as one can get you outside the skull. But it also suggests because of the dynamic turnover of skin every 28 days, that if people were to become less stressed that their skin health and appearance might improve, is that also the case?

For sure, it's why you see people have a glow after vacation, but you can't quantify that in a test tube or a lab. So in the immediate phase, there's a big shift in blood flow to the skin. And when you're feeling very stressed out immediately, there's a fight or flight response that constricts the blood vessels in our skin to shuffle them to muscles and places where we need to our body things we need to utilize them more.

That's why when people are really stressed out, they may look pale or gaunt. And that's the we see that right away. And then as that builds up over time, the health, the actual quality of our dermis and fat deteriorate from chronic stress changes mainly due to cortisol and it's sibling hormones and messaging systems in our skin.

So for sure, I mean, stress is like something that is impossible to quantify in a lab measure, but very easily seen on exam, just looking at your skin, I can tell you've had either a rough day, if you didn't sleep well, you can see it in your skin, your eyes. So absolutely, I mean, that's why everybody likes to live a stress free life.

And we see changes and improvement in skin health when people move away from that stress or whether it's a physical stressor, emotional stressor, psychosocial stressor, there's actual quantifiable improvements in skin health. And that's pretty fascinating. It is fascinating. It also speaks to the value of having some immediate and long-term stress reduction techniques just as a sort of first principle of taking care of one skin.

There are some other things that cause vasoconstriction, basically the tightening of the vessels and capillaries to the skin as I understand. Maybe we could just take through a few of these and get your sense. I consume caffeine every morning, usually year-bomantate, some coffee a little bit later. Those will increase vasoconstriction to some extent, although chronic caffeine intake may cause vasodilation.

So I'd like to know the relationship between caffeine and blood flow to the skin and skin health and appearance. That's the first question. And then dovetailed with that question is nicotine, which is also thought to be a vasoconstrictor. It raises blood pressure because it's a vasoconstrictor. What are the effects of caffeine, both acutely and chronically, and nicotine? Let's assume that nicotine is consumed either by smoking or oral ingestion on skin appearance and health.

That's a good question. So caffeine is a known vasoconstrictor, fortunately, when it's consumed in quantities that we have in coffee, tea, and equivalent beverages. The amount that affects the tiny capillaries and arterials in our skin is minute and transient. So you may get a transient vasoconstriction with high caffeine intake, but usually there's a compensatory vasodilation as a result. So the effects on skin are not as dramatic as people may make it seem.

Now, one thing that we do see, and it's a little unclear as to why, is that people who have chronic high caffeine intake tend to produce more sebum in their skin. And it may be a result of vasoconstriction, maybe a result of something that we don't understand that's compensatory as a result of those changes. So a lot of people who consume coffee may experience a little bit oilier skin.

That being said, the data is equivocal as to whether or not caffeine is a deleterious, beneficial, or net neutral effect on the skin. I drink a lot of coffee. I haven't found that the vasoconstriction is something that's noticeable, but there are people who have different skin types, patients who have rosacea, for example, who are much more sensitive to those changes. And they may notice that change in the color and the vasoconstriction more with caffeine consumption.

What used to be thought was that caffeine itself was a problem for flushing and redness. And now we've realized it's actually not so much the caffeine because the concentration that reaches the skin is so minuscule, it's actually the temperature of the beverages we drink. Hot beverages can affect the color of your skin, can make your flush more, make the redness more pronounced. Cold beverages tend not to have that effect.

So it used to be an old adage in people who had rosacea, for example, we'd say don't drink coffee, don't drink tea. It's actually the temperature of the beverage, not so much the caffeine content. Interesting. And what about nicotine? So nicotine, great question. It is a known vasoconstrictor. Now the concentration of nicotine when smoked is higher in the skin because of inhalational effect and the local effect of nicotine on our skin.

So you do see a measurable vasoconstriction in the skin that becomes a problem, which is why patients who smoke age faster, patients who had surgery, who smoke have a higher risk for poor wound outcomes, for poor healing because of that vasoconstriction. Usually people who use or consume nicotine aren't doing it once a week. Most people are using it daily or multiple times a day.

So that chronic vasoconstriction adds up and has a net negative effect on the skin. So if you want to keep your skin healthy, if you want to look younger, I would refrain from nicotine use. What about vaping nicotine or oral use of nicotine? So nicotine gum, mint, pouches. And let's touch on vaping first because that's becoming more common.

So with vaping, we see the same problems in the skin. We don't know if it's an inhalational issue or if it's actually the same concentration of nicotine that's reaching local skin causing the effect. But we see the same vasoconstriction when you match cigarette smoke with vaping if you have the same nicotine content. Now for patches and gum, it's less of a problem.

And why that is is the concentration of nicotine that reaches the skin is much lower. Usually when you chew it, it has to go through your digestive tract, then enter your bloodstream, then reach the surface of the skin when you have a transdermal patch. It still goes through the bloodstream, then ends up in the skin. So because of how much it has to be processed, the concentration that reaches the skin is much lower.

When we operate, when we do surgery, whether many surgery of any kind, we try to transition people who smoke or vape to at least gums or patches to mitigate their withdrawal effect. But, you know, so they don't have the feelings, but, you know, it doesn't have the same constrictive effects on their skin.

What about alcohol? You know, I did an episode of this podcast on alcohol, which somewhat to my surprise, you know, was very widely shared only to my surprise because I've never been a big consumer of alcohol. But apparently, many out there are. And the data came back, at least to my understanding, that zero alcohol is healthier than any. And that up to two drinks per week is probably okay as long as you're an adult of drinking age and not an alcoholic.

You don't have issues with alcohol use disorder as it's now called probably okay. But beyond that, you start running into some health issues that can be offset by better behaviors of other types. But what about the direct effects of alcohol on skin in the short term? Does it increase blood flow and therefore improve skin? Are there long term indirect effects? I could imagine that alcohol disrupts the gut microbiome, which then disrupt skin, et cetera.

So maybe we could break this down into direct acute effects, meaning immediate effects that are really direct from consuming alcohol that day, that week, let's say, versus chronic effects through other systems like disruption of sleep. And microbiome. Yeah. Great question. Alcohols, alcohol and skin connections, complicated, convoluted, but generally thought to be a negative, both short term and long term.

So first alcohol tends to be a mild diuretic. So it makes our body dispose of water a little bit more frequently. What happens short term is that one, you get an almost a mild diuretic effect from alcohol consumption, which is why you tend to be thirsty in the middle of the night and wake up in the morning tend to be parched.

As a result, you see that diuretic effect on our skin. You see a little bit of hollowing in areas that you'd have normal volume and suppleness, which is why there, you know, people tend to see bags under their eyes, or they look like they had a hangovers from that mild diuretic effect.

Also, as a compensatory mechanism, the skin produces a bit more sebum to compensate for that drying out effect. So in the acute phase, your skin dries out, you look, look a little bit worse because of that diuretic effect. In patients who cannot or people who cannot tolerate alcohol and their genetics and Asian populations and Southeast Asians that have a difficulty in breaking down acetaldehyde, that isn't a toxin that shows up in the skin and makes the skin vasodilate as a result.

That common college term that we used to hear, you know, the flush or the glow or, you know, incorrectly called the Asian glow is as a result of the inability to break down alcohol. And that usually you see immediately people get a very bright red flush in their skin because of the acetaldehyde build up in the skin.

And long term won the diuretic effect becomes a problem. So over time, your skin is producing constantly more sebum to keep the skin supple, your skin is drying out. And as a result, you run into things like breakouts and, you know, congested skin, you know, blackheads, whiteheads, things like that.

Long term alcohol uses also associated with lifestyle choices that may make your skin health worse. Generally speaking, when people are out binge drinking, they tend not to come home and do things that will maintain their skin. Now that's not a fixed rule.

But most of the time when you're out, you know, having a few beers or cocktails at the bar, you tend to come home and not do your diligent skincare routine or you may not be up, you know, with your hydration status or your dietary habits. So that's something we can't quantify easily, but contribute significantly to faster aging poor skin health.

Then the gut microbiome question, this a great question because the data is widely variable for alcohol consumption and the effects or changes permanent or transient in the gut microbiome. There are some alcohol products like kombucha that has a higher alcohol concentration that's healthy for your gut. Then there's hard alcohols with a higher concentration that act as anesthetics and act as gut paralytics.

So one of the things we see in people who consume a lot of high percentage alcohols is actually gut immobility and gut paralysis, partly because of the anesthetic effect, partly because of the analgesic effect of alcohol and also because it affects gut motility as a toxin.

So generally speaking, gut, the gut health, depending on your consumption, patterns, use and concentration can be very diluterious. Some people are very sensitive and they have changes that reflect in the skin as a result of drinking a lot. And then there are some people who tolerate it more or maybe consuming things that are healthier for the gut microbiome like things like fermented alcohols like kombucha and things like that.

So generally speaking, the higher the concentration, the greater the problems, the higher the percentage of alcohol, the greater the problems. That includes the diuretic effect that includes effects on the gut microbiome, that includes lifestyle habits.

So drinking a lot of higher percentage alcohols, you tend to feel the effects, not just in the skin cognitively behavior wise that can affect you. Whereas sometimes lower concentration alcohols, depending on the setting and lifestyle, maybe neutral, maybe positive unclear on that part. But I'm not hearing any positive effects of alcohol on skin health. Generally not. The same is what we've seen with other organ systems, the brain, the liver, the skin reflects the same thing.

If anything, it may be a net neutral. Most of the time, it's a net negative. And what I'm pulling from all of the discussion we've had up until now is that improved blood flow and strong hydration status are both important. Do you recommend patients drink a certain amount of fluid each day or maintain adequate hydration as a means to build or maintain skin health and appearance?

Great question. So that's another common misconception that I see in that thinking drinking a lot of water will or drinking a lot of fluids will directly affect the hydration status of their skin. And while there's a certain degree of truth to that, if you're dehydrated and that you need replenishment of fluid, you know, systemically, the every study that's looked at trans epidermal water loss has not shown a great connection with regular fluid intake and water intake and skin hydration status.

And that tends to be genetically defined and genetically encoded. Some people have drier skin. They need more methods to moisturize their skin. Some people have oily or skin and their sebum provides that moisturization. Now, if you're doing things, if you're active, if you're an athlete, if you're doing things in which you are dehydrated, then totally different story.

But if you're living a more or less balanced life or a sedentary life and you're doing all the regular things, drinking a lot of water or fluids has not been shown to improve skin health. So that's why generally speaking, most dermatologists will recommend some sort of moisturizer to replenish that. But you got to know your skin. For example, my skin, I tend to be oilier.

I don't usually need a moisturizer as much. Whereas somebody who is drier will need some sort of barrier protection to allow to minimize that trans epidermal water loss. What are some of the parameters for selecting a moisturizer? Yeah. People are immediately going to say, well, what constitutes a good moisturizer? What should it have in it? What are some things to avoid?

Yeah. It's a crazy market. There's a lot of things out there. I mean, you can Google skin snail moisturizer and you'll find people putting snail mucin on their skin. As a moisturizer telling me before this recording started, there are people who and forgive me for those that cringe when I say this that put placental extract human placenta as a means of rejuvenating their skin health.

I don't advocate it or don't say anything against it. But I probably wouldn't recommend that there's better, safer, more cost effective ways of doing this. Simple things you want to look for. One, is it non-comino genic? That's a word you want to look for for any moisturizer that's been tested not to clog your pores. That's a basic thing to look for where you won't cause another problem in trying to fix one problem.

Number two, how oily or dry are you? Generally speaking, there are three flavors of moisturizers. There's ointments. There's creams and there's lotions. Ointments are greasy. They're like petrolotum, gel layer, vasalane based. Those are the best for moisturizing your skin, but they're greasy. Then there's creams which are water emulsions with oil suspended in it. And then there's lotions which are generally powders that are resuspended with water.

We as dermatologists tend to like the grease here the better. It provides the best barrier protection, but you have to know your skin. If you're somebody that is eczema prone, you will need something that is an ointment that does better to protect the skin from drying out. If you're somebody that is acne prone, you won't tolerate greasy things. You'll break out more. So you want to look for a lighter moisturizer that's non-comino genic.

In a long story short, it's very, you know, person to person specific. You got to know your skin, but the fundamental things you want to look for is has this been tested to not clogged pores. And is it in a pump bottle or is it in a jar? Jar is tend to be more occlusive. They tend to provide more moisturization, but they can lead to problems like macning breakouts, whereas things in a pump bottle because they're suspender powders and suspension.

And they have to put alcohol in the product to allow it to come out of pump mechanism. They tend to be lighter and not provide as much moisturization. So when I think about something in a jar, you have something like aquafore or something, which is pretty thick, thick stuff. So that would be fine for someone with eczema not okay for somebody with acne.

Exactly, exactly the grease here, the more occlusion it provides, but in doing so, it clogs everything. If you're one that has some sort of skin issue in which you need that, it's the best thing. If you're one that is breaking out all the time, you want something lighter. I'd like to take a quick break and acknowledge our sponsor, AG one by now. Many of you have heard me say that if I could take just one supplement, that supplement would be AG one.

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Why do people wake up with bags under their eyes if they just slept for six or eight hours? Maybe you need a little more sleep or maybe you had a wild night, you can't tell, but generally the bags are caused by two things. One fluid retention, so there's some lymphatic change that occurs under the eyes that's most noticeable because the skin under our eyes and on the surface of our eyelids is the thinnest.

So fluid changes are seen the quickest there. And as we're in a supine or prone position, fluid moves from our extremities back to our central nervous system. And it's easier to collect in the face. So we see it around the face. The other thing that we do notice with bags is just age-related fat herniation that shows up more as we wake up because of positional changes.

So if you've had heavy meal the night before something that has high salt content, you're going to retain a little bit more water because of that salt shift, you may notice your eyes are puffed here in the morning. If you have allergies, seasonal allergies, asthma, eczema, they run in a family, that tends to make your skin retain a little bit more water as a result of that allergy response.

So people will notice springtime or falltime, their eyes are swollen or their eyes are puffy especially when their allergies are flaring. It's a product of water retention from all the histamine release and changes that occur in the skin. Skin cleansing is a topic that gets a lot of coverage and I sometimes get chuckles or even attacks for saying I've always just used unscented dovesop, the bar, not the liquid soap or like a set of fill soap.

And this is because when I was younger, like much younger, I had very sensitive skin. When I was a kid, 7, 8, 9 years old, I think I just started using unscented dovesop at some point and things like it gentle, you know, soaps without fragrance is what are your thoughts on those and I ask not for my own purposes, I'm going to stick with it because it works for me unless you tell me I shouldn't.

But I see this enormous market for skin cleansers that includes a range of costs from relatively low to near astronomical. And if you tell me that this unscented dovesop or set of fill soap is the way to go and by the way, I'm not sponsored by either of those, I don't even know who they're manufactured by. So there's no commercial angle here, but I'll be relieved because they tend to fall on the lower end of the cost bracket relative to some of these astronomically priced cleansers.

Skin care is an incredible multi billion dollar market. That being said, there is not a shred of evidence that anything more expensive works better than anything cost effective. So that's first and foremost.

And then, two, dove white bar soap is amazing. It's what we recommend for newborns and kids with sensitive skin. Generally when we say sensitive skin, especially in kids, toddlers and adolescents, there's a component of some sort of exema or atopic dermatitis that is not bad enough to have a diagnosis, but enough to say, you know, I had sensitive skin.

So, dove white bar soap is what I use for my kids and I'm not sponsored by anybody either, but I think it's an amazing product because it's safe. It's effective. It has the least amount of ingredients, no fragrances. These are all things that can irritate or cause an allergic response to a skin that is sensitive meaning your skin mounts an immune response to some sort of environmental allergen or trigger.

That's what we generally mean when we talk about sensitive skin. I personally use Cedar fill. That's my face wash. I have oily skin. I use the one that takes off more of the oil. So what you're looking for is defined by what bothers you or what your skin predicament is.

What I do see is a problem. Nowadays is particularly in the United States, where a hyper hygienic society. So what people tend to do is over cleanse. And they over cleanse for several reasons. One, because they are told that cleansing will fix their skin issue or number two, they're told that some sort of organism is on their skin or some sort of bacteria that needs to be cleansed off to keep their skin healthy neither are true.

The first thing you want in terms of cleanser is something that's mild fragrance free and has been tested to be high-biologetic or nonchabita. That's first Cedar fill, dove, survey great, great stuff. No association with any of them.

The unscented non fragrance diversion of them exactly. That's first fragrances tend to be a problem for sensitive skin patients who have atopic dermatitis or eczema. They tend to trigger allergic responses or exacerbations of their eczema flare. So we try to avoid fragrances by all means.

And then things that are gels or liquids tend to have preservatives in them to increase shelf stability, whereas bars tend not to. So if you are going to pick something that is a gel, a liquid, look for one that's been tested by a dermatology group or verified by the American Academy of Dermatology is one that is not allergenic or has multiple preservatives because that's another well known.

But unidentified source of problems well known to the dermatology world, not known to the late, you know, the average person that the preservatives in our cleansers are a problem. Over cleansing becomes really problematic in eradicating the skin microbiome. So what we see a lot of times are cleansers that are either. But they are bacteria, acytel, bacteria, statics, things like benzoyl peroxide, things like salicylic acid, things like certain astringent toners that are alcohol based.

And what they do is not only do they strip the normal oils from our skin that keep our skin supple and healthy, but they eradicate the normal host skin microbiome. Those are all the microorganisms that live on our skin and we have trillions of them actively surveying our skin, living in normal symbiotic homeostasis, meaning there are friends, they're living there for a reason they don't cause any problems.

But when you cleanse them off, you open up an area for pathogens to take effect. And that's when we see a lot of problems more so in industrialized countries. The United States is a notorious place for washing especially after COVID wash, wash, wash, wash more use a toner, wash some more. And that becomes really problematic because it sets up for organisms to take seed one they shouldn't be there.

So overall cleansing is great and the amount that you need to cleanse is based on how oily or sebaceous your skin is. And when you're older you get you may not need to cleanse as much. They're older patients don't need to cleanse their skin at all every day because they don't produce as much sebum or oil as younger patients. But everything should be defined by your skin's characteristics. So if you are one in which you notice by the end of the day I'm oily. I'm breaking out.

Cleansing may be something that's beneficial for you to take off that excess sebum. If you're one that has dry skin, if you're one that had sensitive skin as a child, then over cleansing is going to be a problem you're going to want to minimize that and keep that moisturization or that barrier protection going.

So does that mean that people should bathe probably once or twice a day but the people that are bathing three times a day it's probably excessive. I mean are we saying that you can't get into water. I mean when you say cleansing or talk about face cleansing, I realize this is going to be highly individual but you know some people are just out of habit.

You know shower and use cleanser twice a day or once a day. I think for me it's in the morning or in the evening sometimes both if I do a workout I try and shower as close as possible after the workout as soon as possible after the workout rather because otherwise I will break out.

It sounds like one has to kind of learn what their cadence is and that's going to vary by age. There's a lot of factors to this. I think Ashton could could your and melecunus famously said they shower I think once a week or something like that and it stirred up a lot of conversation when that came out.

If you're being told you don't have to cleanse every day if your skin is otherwise fine and healthy and you're not bothered by anything. You live a lifestyle in which you're not sweating excessively or producing a lot of sebum. I myself same thing I work out so I shower after working out and I usually shower before I get into bed because after a long day of work I tend to have you know things on my skin that shouldn't be there.

For me because if I don't I tend to have problems I tend to break out I tend to have things that you know shouldn't happen because of my hygiene habits. That said there is no indication or no medical necessity to have to cleanse your skin even once a day. Sometimes older patients cleanse or shower once a week and they're totally fine but it'll have to be defined by your skin and what problems or ailments are specific to you.

Generally if you work out if you let sweat dry on your skin it causes several problems. Number one is irritation itself from the salts that crystallize from the sweat drying off. Number two the sweat itself is a source of food for certain yeast that are normal symbiotic yeast that live on our skin. So it contributes to things like dandruff what we call tinny aversa color which is a type of yeast that grows on our skin.

So generally if you work out try to wash those you know things off also if you are one of you know acne prone skin if you're an adolescent if you're a teenager for an adult dealing with acne. The sebum that your body is producing is food for the bacteria that cause this. So you tend to want to clean some of that excess sebum off those are simple indications to cleanse both your face and your body.

But if you're not having any problems you actually don't need to do any of that in Europe they shower and cleanse at a fraction of the frequency that we do in the United States and when you look at incidences of the most common skin conditions there's the same. Including things like acne, psoriasis. Most people think about shampooing for sake of hair but there's the scalp component.

And since you're an expert in skin we should probably spend a bit of time on this. For people that tend to have a dry or flaky scalp what should they do about that my understanding is that some of the more typical commercial anti dandruff shampoos can contain things that might cause issues for hair itself. So they might help with the flaking and drying of the scalp but damage other aspects of you know either appearance or health of hair.

What are some really good options for people that have dry scalp what are some great options for people that have oily scalp. And let's leave aside the frequency of use and just perhaps just put it on the shelf as as much as you need it but not more so that could be once a week it could be daily could be twice a day if in extreme cases it sounds like.

So when we think about the scalp when we think about dry or flaky scalp we think about two main conditions either seborrheic dermatitis which is medical grade dandruff or or the medical name for dandruff or psoriasis. There are two different entities but they generally contribute to the same problem which is redness flaking and dryness of the scalp. Now it's important to note that the hair on your head is dead it's not alive the only area that's alive is two and a half millimeters in the skin.

So the hair that we see on our scalp is not a living entity so there's a common misconception that you can affect the health or quality of your hair by putting things on the hair and I'll go into that in just a minute.

But the hair itself that you see is not living the only area that's living are the stem cells in the papilla of the hair and in the bulge region of the hair which reside in the skin so nothing that you put on your scalp will make you lose your hair will make you grow new hair for the most part. Why that's important when we treat dry or flaky scalp we treat it with several things the most common cause is an overgrowth of yeast.

From the sweat and oil that is produced from our scalp and that's sebaric dermatitis that's the medical name for dandruff and so we treat it by one lowering the amount of that yeast that's living and that's usually with the shampoos that are prescription or over the counter you know things like zinc or ketoconazole shampoos are very common things.

And then the other thing that we do is to dampen the immune response to this overgrowth of yeast so the reason our skin flakes and gets red and proliferates is our immune systems responding to something it's either responding to the yeast or it's responding to itself which is what psoriasis is it's an immune mediated over proliferation of skin cells because the immune system is overactive in the skin.

And the way we treat that is just topicals or certain medications that suppress the skin's immune system or immune activity. None of that affect the actual hair itself what does happen is shampoos tend to have things that strip oils as a mechanism of cleaning.

So when you take a cross section of the hair there's seven layers and the the layer that provides that color sheen and structures called the cuticle as we age we lose the cuticle and that's that's a common problem what we see in male and female pattern hair loss or androgenetic alopecia is we lose that cuticle which makes us lose the shine and the structure and the strength of our hair.

Our body tries to replenish that with the oils so when people wash their hair sometimes they feel like the hair becomes more limp or dull or lifeless it's because we've taken that artificial oil coating that replace the cuticle and and washed it off so good news is you're not going to do any harm putting any of the topicals on your scalp bad news is you probably won't bring a lot of it back to life either but when we treat flakiness you know redness.

Things like that we're treating to entities usually with topicals and because we're either trying to treat over proliferation of something or trying to calm down the skin's immune system. Got it so it sounds like the best options for cleansing skin for shampooing really stem from knowing whether or not your skin tends to air oily or dry.

Figuring out how often to cleanse and then as you pointed out before even though there's an enormous range of cost for these things none of the solutions that you're describing sound like they fall on the high end of cost or even in the middle end of cost which is a bit surprising to me this might be one of the few areas where you know like if I had a magic wand I would make for all you know organic.

Non processed and minimally processed foods to be very inexpensive but it turns out those things tend to be more expensive you can go to farmers markets and cut back on the cost etc but there seems to be. An unfortunate trade off between availability and cost and benefit at least risk but it doesn't sound like that's the case with skincare or scalp care that one can exercise really excellent skin and scalp care without having to go into a range of spending and outrageous amount of money.

No I think one you're absolutely right there is the more expensive does not mean better if in fact they sometimes become more problematic because there's more ingredients in the more expensive products including elegant fragrances and stuff like that which can be problematic that's number one.

The second thing to know is that generally speaking there is some connection between skin health skin care and this realm of beauty which people overlap a lot in and there when we trend into this realm of beauty glamour etc price and objectivity are taken out and that's why you see a lot of skincare products that are so expensive because they draw toward another.

Level of desire that's not just medical it's aesthetic and that's where you'll find creams that are two three hundred dollars for a little amount of cream that does the same thing that your jar of petrolotum or vasoline or aquifort does.

That part is really hard to mitigate but in general almost everything that we as dermatologists and skin cancer surgeons and experts in the field recommend are really cheap cost effective and they have the least amount of ingredients in them and that's what I would recommend that's what I recommend from my family and from my patients you don't have to spend a lot to have excellent skin care and you don't need to have it be a multi step routine oftentimes people over do it.

The more steps there are there's more chances that something your skin will respond to negatively the more chances you are to have about outcome to an ingredient of a product you're putting on your skin so keep it simple keep it cheap and you'll do great.

It's going to be very reassuring to many people it's also going to be somewhat destabilizing to people who are really attached to the idea that the more expensive products are really doing something that much more beneficial for them not much at all not not anything in another important thing to consider when looking at skin care skin health and then trending into that area of aesthetics and beauty is that most. Active ingredients.

If they're really active tend to be controlled by the FDA so most things that are sold over the counter have active that are not at a concentration high enough to be considered therapeutic because that's when you get into the definition of a drug so looking at things like. Anti-dandruff shampoos you anti aging creams you know.

Acne medications they work a little bit if they work perfectly then most medical dermatologist would be out of a lot of patients and we see a lot of skin disease that still continues because the active ingredients aren't at a concentration high enough to provide therapeutic benefit. So save your money if you really need something to change some part of your skin see a good dermatologist see an expert and see what they can come up with.

So this seems like an appropriate time to ask about sun exposure and then we'll also talk about sunscreen sun blocks skin cancer. But what is the relationship between sun exposure and skin health specifically meaning how much sun exposure is healthy for our skin.

I'm a big believer in getting sun exposure to the eyes early in the day linking as needed to protect the eyes of course but in order to set one circadian rhythm for elevated daytime mood focus and alertness and improve nighttime sleep there's just so much data to support setting one circadian rhythm properly for sake of health.

And there's so much data to support the fact that sunlight viewing in particular is the best way to do that and sunlight viewing in the early part of the day in particular is the best way to do that but beyond that how much sun exposure to the skin is good for us is it zero is it five minutes does it depend.

Great like great controversial question and depends on which school of thought or camp you belong in as a skin cancer surgeon and somebody who's developed a reputation for seeing some of the worst most complicated life threatening skin cancers in in Los Angeles obviously I see some of the consequences of long term sun exposure and chronic photo aging.

That being said I absolutely think that getting sun is healthy for us now why the studies that talk about vitamin D and we'll touch on vitamin D as its own entity and then overall health as another entity but most of the studies that look at vitamin D synthesis from you the exposure on the skin suggests that you only need about 15 minutes and that you don't need a broad surface area of exposure you can get enough vitamin D formation with just about 15 to 20 minutes of sun on your forearms.

So there's a whole school of thought by a lot of experts who think there's no amount of UV exposure that's healthy for the skin and I tend to be on the other camp for several reasons one there's a component of that feeling of a skin cancer that feels goodness if that's a word from being in the sun that affects overall skin and physical biology when you're out in a sunny day you tend to be less stressed you tend to be a little happier now it's a generalization but most of the time

you get outdoors you get outside and it's a nice sunny day you feel better and although you can't quantify that feeling better there are some parameters that can be measured decreases in color to solve response improvements in skin appearance and texture. The other important thing about being out in the sun is finding out your own tolerance right so I have a little bit more all of skin I can tolerate the sun a little bit longer than somebody who is fairer and lighter eyes.

In my opinion I don't think in most of the evidence there isn't a finite amount of time because that time is dictated by your skin's ability to tolerate the UV but I absolutely do not think that sun avoidance is a healthy thing and this is coming from somebody who operates on head and neck skin cancers literally every day I think there is a component of sun exposure that's not just for vitamin D synthesis but something that improves your overall wellness that is.

I'm not a visible and maybe not laboratory measurable but you definitely are healthier when you're feeling better and you're happier I lived on the east coast in places that had lower days of sun and I had seasonal effective disorder bothered me my mood was lower I felt not as healthy you know I'd come home my family would say hey you look sick and it just I wasn't sick I hadn't had any sun now is lighter than I was and my family interpretive that as.

Not being healthy you know my wife on the other hand didn't she didn't mind the grain is so there's a timeline for biologic processes like vitamin D formation that's helpful people can argue that you can get it through supplementation and food and that that's correct but there is a component of sun exposure that makes you feel better overall and provide some sort of wellness that you may not be able to quantify but you see an appearance and in discussion and longevity.

So absolutely I think you should be out in the sun I don't think you should burn and I don't think you should be out long enough where your skin starts to turn red that's the first sign that you're reaching kind of critical mass in terms of UV exposure but I absolutely think the sun is a good thing for us.

So even midday sun you know maybe if there's some cloud cover or we have some sunscreen on or a physical barrier like sun and long excuse me like hat and long sleeves then getting some sun exposure in your mind is good for our overall well being mood etc yeah I think you know I mean midday sun has a higher UV index so you're more likely to burn and have a problem with prolonged exposure but yeah absolutely I think.

You know there's been numerous studies that have looked at people who go out for a walk in you know busy urban cities and work environments if they go out for a walk in the sun they feel better their stress responses are lower their questionnaires and responding to life stressors and day to day stressors are decreased there's a lot of studies that look at being outside as a measure of well being mental health well being is improved with outdoor sun exposure so there's a lot of that now.

Can I quantify it in the skin hard to say one thing we do know is that obviously too much sun exposure like anything too much of a good thing can be a bad thing but I really do think that being out in the sun for the amount that your skin can tolerate is a good thing.

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What about sunscreens and sun blocks and I think we should distinguish between those two labels. You know, in the old days as I understand sunscreen was the word used to describe stuff that you put on your skin that absorbs UV and then sun block is the stuff that you put on your skin to reflect UV. Typically nowadays people say sunscreen more than they say sun block or they use them interchangeably without any knowledge of the underlying mechanism.

So first of all, let's clarify sunscreen versus sun block. Yeah. So a lot of the nomenclature data understanding chemicals, things that were considered okay to be used came from an original FDA 1999 manuscript. And that data hadn't changed for almost 20 something years and more recently in 2021 the FDA released a proposed final order for the term sunscreens as a whole now.

When we talk about sunscreens, sunscreens are considered an over the counter non prescription drug so they're regulated tightly by the FDA. They're in the same category as any over the counter drug. So before this decision ruling, there was a lot of nomenclature wording confusion sun block seemed better than sunscreen, suntan, suntan oil.

All of that's been changed recently or has been proposed to get rid of to unify the field and make it very clear what the goal is so no longer do we use the term sun block, although in the past.

And that had been used for things like zinc or zinc and titanium based creams like the old 1980s or 1990s white life guard knows as if you remember that used to be thought as sun block, whereas less less protective chemicals were used as sunscreen now that's changing and the FDA 2021 proposed order says we need to unify everything and call it a sunscreen.

Sunscreens being regulated drugs take a lot of scrutiny for many reasons they take scrutiny from the FDA in terms of proving efficacy and safety they take a lot of scrutiny in society for being dangerous or not dangerous effective or not effective causing downstream effects or not causing downstream effects.

So that's been a big point of contention in terms of the population, the American academies stance dermatologist stance and then the skin cancer patients beliefs, the beauty experts beliefs and average persons opinions. Sunscreens generally fall into creams, lotions, topical products that protect the skin against sunburn.

And that's used to be able to suggest that they reduce the risk of skin cancer, prevent premature aging, but that can be a little convoluted and the FDA is rewording that and to not being able to say that anymore in their proposed order.

But sunscreen's intention is to protect the skin against excess UV exposure and they come in two flavors, they come in mineral based sunscreens which tend to be in the category of zinc and titanium minerals and they tend to be chemical sunscreens which are a bunch of different chemicals.

Mineral based sunscreens are sometimes called inorganic, inorganic or physical sunscreens, whereas the chemicals are considered organic or chemical sunscreens, totally right is the mechanism for these to the same because I was under the impression that the mineral based inorganic sunscreens reflected back UV rays, whereas the chemical based sunscreens absorbed UV rays. But there's a bit of an online debate about this, claiming that they all absorb UV rays.

So historically it had been thought that mineral or physical sunscreens, zinc and titanium sunscreens, worked by basically acting as a metal reflecting shield. For the most part that thinking is not incorrect, there's there was a new study that showed that they work by actually absorbing them, but not having any sort of chemical change.

So the way chemical organic sunscreens work is they absorb the ultraviolet radiation, they undergo a chemical reaction to reduce its energy and dissipate that energy as heat. So chemical sunscreens work by actually absorbing it and undergoing a change, whereas mineral or physical sunscreens don't do that. I still think of them simply as minerals basically shield the skin, like armor, whereas chemicals act as a sink and undergo a change to reduce that energy.

So that's kind of the simplistic way that sunscreen topical sunscreens work. So what is your recommendation about protecting oneself from the sun? And maybe for the moment let's just set aside sunscreens and acknowledge that a physical barrier like hat long sleeves, long pants, provides a pretty good barrier to the sun. Correct? Yeah. In fact, physical barriers like shade, clothing, hats have been shown to be more effective than topical sunscreens for several reasons.

But there are many ways to protect your skin and you have to ask why you're protecting your skin. So is it because you're worried about premature aging, photo damage and things like of that nature, or you worried about your risk for skin cancer. Do you have a sun sensitive skin condition like lupus or PMLE that is sensitive to UV exposure. So the first question is, why are you worried or why are you taking protection and then you customize your approach to that.

Now sunscreen topical sunscreens are not the only form by and large there. There are many other forms, both physical blockers and certain things in the supplement world that can protect your skin. For example, I myself take a product called sun powder that provides an internal sun shield allows me to be in the sun longer without the need to reapply or if I can't reapply.

But you know, by and large, the best way to protect your skin is some sort of shield, whether it's clothing, hat, or some sort of cream that you put on. For patients who are worried or for people who are worried about premature aging, they don't have a strong family history of skin cancer. They've never had one before themselves. Then the approach to that is a little bit different than people who are worried about skin cancer development, strong family history of skin cancer.

They're worried about, you know, losing a part of their ear or part of their nose to skin cancer development. And that's very different from medical conditions that are very sun sensitive. By and large, the patients who have medical conditions that are sun sensitive, the large one being lupus, for example, need the most sun protection because they are so inherently sensitive to UV exposure.

Something that's very interesting, we know without a doubt that every common skin cancer, there's many, many skin cancer types, but the three most common are, you know, basal, cell carcinoma, squamous cell carcinoma and melanoma. Those are the three most common ones we see. They have all been shown to have UV mutation signatures when we sequence the tumors.

However, in every single clinical trial and every single randomized trial that looked at topical sunscreens as a means of reducing risk, there has not been a single study that showed any sort of risk reduction in the development of the most common skin cancer, which is basal cell carcinoma, one in four Americans will develop this. Also, there hasn't been a single study to date that showed that diligent sunscreen use topical sunscreens will reduce disease specific death or dying from skin cancer.

So if you think every skin cancer is sun driven, there are UV mutation profiles in these tumors, then by using sunscreen should reduce that right. It's not that clear, we don't understand fully the drivers of this. So why I bring this up and why we talk about sunscreens and barriers to blockade first sunscreens, topical sunscreens are not the only form, you know, in fact, clothing and shields, you know, shade and hat or in my opinion better and a lot of studies suggest that they're better.

There are oral supplements that can also protect your skin from burning and reduce your skin cancer risk. And number three, not everything is sun driven. We do know that diligent sunscreen use decreases the incidence or the amount of melanoma formation and squamous self formation, but we still don't know whether that reduction has changed the number of patients dying from that.

We also know that it has no bearing in the development of the most common skin cancer, which is basal cell. So we go back to the drawing board and scratch our heads saying, hey, what is the trigger, you know, the genetics loads the gun, for example, and maybe even pulls the hammer, but what in the environment is the trigger? Is it strictly UV? Is it some other culprit? So sunscreens are really hotly debated topics so many things to talk about in terms of sunscreen.

So if I understand correctly, you're saying that the use of sunscreen can protect against premature aging. Let's say sunblock, because I think we're going to arrive at mineral based sunscreens, probably even the better option, but we can make sure that we double click on that, so to speak.

But that sun exposure itself, perhaps, is not linked to the most deadly of skin cancers. That tells me two things. It doesn't tell me that I can just spend as much time as I want in the sun, but it does tell me that I should probably look into the things that cause the most deadly skin cancers.

Yeah, okay. But I'm also hearing that regular application of sunblock and or physical barrier will protect my skin against some forms of premature aging caused by sun exposure, but will not necessarily protect me against the most common forms of skin cancer.

That is peculiar in the sense that or even baffling to the non-dermatologist me, because we already know that sun exposure causes UV mutations, mutations in the DNA of cells is one of the core components of cancers. So how do we square all of this? Great question. And the more we dive into this and the more experts we look at and the more data we collect, the more we're scratching our head as to we don't know and why this occurs now.

I'm not saying don't use sunscreen. Let's just let that be known. I think sunscreens are excellent forms to protect against premature photo aging and signs of sun damage. I think sunscreens help reduce the incidence of common garden variety skin cancers, but they are not the only form of protection and they seem to not be as important or have as much effect in reducing the incidence of our most common skin cancer, which is basal cell carcinoma.

And moreover, I would say and the data unfortunately shows that the majority of skin cancers that we see that end up hurting people or killing patients don't arise in chronic, sun exposed areas to begin with.

I have a 27 year old patient right now dying of a metastatic melanoma that arose and completely sun protected skin. I have a 56 year old mechanic right now who's dying of a squamous cell carcinoma that arose from the back of his ear and most experts who have this type of type of experience dealing with these patients have the same observation. What's pulling the trigger for the most part you replace a big role.

The mechanism in which cancer forms if we believe this the basic high school biology is hyperplasia, metastasia, dysplasia, carcinoma. And the trajectory of changes that are occurring as a result of cumulative mutations in the skin, if we believe that trajectory, then every skin cancer should see that change and we just don't see that also we know that skin cancers that arise in sun damage skin behave differently than the ones that are very lethal.

So why I bring this up I think sunscreen is very helpful, but we have this unfortunate trend in medicine, particularly in dermatology to guilt people into thinking that they cause this to themselves and I don't think that's right nor okay and I don't like that because they make it seem that oh the sun you got in 1987 that one sunburn and Hawaii did it to you and that's absolutely not the case.

There are many things that play fundamentally your genetics and immune system that play a huge role in skin cancer development that sunscreen cannot address and will not address now the. The wild card is okay what are my genetics and that's the part we don't know which is why dermatologist say okay let's at least control the thing that we can which is UV exposure but.

I bring this up because you know don't feel bad about getting some sun and don't feel guilt into something that if if something bad occurs it's not your fault it's some of it is out of your control and that that's really important because I see a lot of very bad skin cancers in my practice and I hate this feeling of patients feeling like they did it to themselves.

I think most people would prefer not to have the premature aging caused by sun exposure so what should those people do yeah I've taken on a practice of putting a mineral based in organic sunscreen on my face my arms if they're going to be exposed back in my neck tops of my ears if I'm going to be out in midday or late day sun that feels intense.

And I'll do that every single time I go out on over cast days not so much for viewing morning sunlight I don't do that in fact when the sun is low in the sky I don't tend to wear sunblock that's me that's been my choice it there were a few years there where I didn't put on sunscreen or if I did it was like on a camping trip or skiing or something where the sun felt very intense and in that case I would just reach for whatever sunscreen or sunblock was available because I was.

And I was aware that some of the ingredients and certain chemical based on screens may be problematic so I think I fall into the typical category of a lot of people but of course there's the category of people that are like nope sunscreen sunblock is terrible all the time or they're just too lazy or uninterested in applying it but then there's this whole category of people that are putting it on every single time they go outside in hopes that that's going to keep their skin much appearing much younger.

And just generally are kind of afraid of the sun a lot of good points so there's that famous New England Journal of Medicine picture of the truck driver that got chronic sun exposure on the left side of his face and you see all this wrinkling and modeling of the skin on the left side and nothing on the right side so by.

So by absolute measure sun protection or UV protection will reduce premature aging interestingly that guy did not develop anything in that area so again it goes back to well what's going to so the question is what's pulling the trigger is it truly UV or something else we're missing if you tell me that he got skin cancer on the opposite side i'm really going to gas.

But I don't know if he's had any on the opposite side but in that photo it's purely premature aging so things that you want to do obviously don't let your skin turn red take some sort of some form of barrier protection whether it's a sunscreen supplement like polypodium something that protects your skin from the inside out and skin changes are cumulative so what we can tolerate in our teens and 20s is very different than what we can tolerate in our 40s 50s and 60s because we're going to have a lot of skin care and it's going to be a lot of good things.

So we're going to have a lot of good things in the past 50s and 60s because there's a cumulative mutation profile burden that we see. Interestingly there was an eyelid study that was published recently that looked at eyelid skin that was removed during your cosmetic surgery upper eyelid lifts that was otherwise discarded and when they ran genetic sequencing on normal eyelid skin they saw the same mutations that they would see in matched skin cancers.

So we know UV triggers these mutations and we know UV degrades collagen and Alastin it thins blood vessel walls as a mechanism of of its effects on the dermis.

The data is equivocal as to how those mutations trigger skin cancer formation but in terms of premature aging absolutely so you want to take some form of protection now what type of protection you take depends on your genetics how much you can tolerate and what your family lineage looks like some people have the genetics of early aging it's part of their skin biology and you can't change that but you can mitigate that risk with more strict UV avoidance.

Some people you know they look young longer you know some family lineages just have great genetics in their skin they can tolerate a little bit more sun in terms of physical sunscreens versus chemical sunscreens that's a hotly debated topic in my personal practice and for my family I tend to only recommend minerals zinc or zinc and titanium sunscreens for several reasons. In the original set of sunscreens that were approved by the FDA that came out in 1999 there wasn't enough data to look at.

Biologic effects efficacy internal organ involvement etc fast forward 20 years and we've gathered a lot more information about these chemical organic compounds.

There is an amazing 2020 study that looked at absorption of chemical sunscreens when they're applied onto the skin they looked at absorption with single application and they looked at absorption over four days of application now in the study they applied a little bit more than real world experience wood but even with single application they saw blood plasma absorption of these chemicals that were. 100 to 500 times greater than the upper threshold defined by the FDA.

Now the question exists okay what does that mean is this healthy is this not healthy is it neither that's still up for debate but in looking at the more recent literature and looking at the chemical structure of these compounds a lot of these are phenolic compounds meaning they they have one or two usually two benzene rings attached together and they they look very similar to one another.

There's been a lot of basic science animal study and retrospective human studies in the last two or three years that suggest that some of these chemical compounds particularly oxybenzone particularly octocrylene particularly octane oxenate that can have endocrine disruption or affect the nervous system because they mimic a lot of biologic phenolic compounds and a lot of biologic hormones.

If you actually look at the structure of oxybenzone it looks very similar to the structure of bisphenol A which has been now banned in a lot of the lining of plastic bottles why because the same concept now the data is not 100% one way or another but there's enough

small during evidence that makes me think we should reinvestigate this and in fact the FDA's proposed final order in 2021 changed these chemicals from grace generally recognize the safe and effective to not grace because of these concerns there's data that suggests that the chemicals are found in breast milk, amniotic fluid blood plasma urine.

There's a lot of things that we don't know and I always say this in science we take two steps forward and then maybe one step diagonally or sideways because we ran into unexpected things.

I tend to recommend mineral sunscreens because they don't have any of that data they haven't for the last 30 40 years are considered safe and in fact for young kids particularly those six months and under the American Academy of Dermatology and the American Academy of Pediatrics generally recommends avoiding chemical sunscreens.

Why children skin particularly infants and toddlers behaves more like mucus membranes than adult skin their barrier is not as tightly woven so they absorb these things at a much higher concentration. So if you are to apply something on kids especially young kids six months or under we recommend minerals to begin with.

So I say if you have a pool of compounds that has maybe even smoldering evidence on the basic science level that something's off versus a group of compounds that have really no data which one would you pick and they do the same thing I naturally gravitate towards that.

So the takeaway for me is physical barrier no issues mineral based sunscreen safest so that zinc oxide titanium dioxide and that's mineral not like powder not mineral powder but mineral topicals because mineral powders are a whole other issue will talk about that. Okay and then chemical based sunscreens probably best avoided and then you mentioned polypodium so this is a pill it's a supplement basically that one can take I only call it a supplement because it's not a prescription drug correct.

Yeah that protects your skin from UV damage from the inside. Yeah so exactly right mineral based creams and lotions I tend to prefer and recommend in my practice and most people will if you're worried about any risk any consequence chemicals I tend to personally avoid now this may not be in line with all my dermatology colleagues but I tend to avoid them and I do not recommend them for kids.

In terms of things that you can do in addition to provide sun protection polypodium is a fern from the Amazon rainforest that was discovered when they studied an indigenous population that would eat this fern before they would go on their fishing expeditions on the Amazon and they began for three days they eat this fern and come back not burned.

So a lot of studies were done on this fern in the last five 10 years that showed it increases your skin's minimal erythema dose the amount of redness your skin gets from UV exposure that's our general barometer for effectiveness without any topicals it's taken or ingested orally I personally use a form called sun powder that also has nicotinamide in it when you can talk about nicotinamide later but if in and of itself it works great in conjunction with topicals.

You get the best of both worlds you get internal shielding and external shielding now it is a supplement so it's not a controlled drug the way the FDA regulates sunscreen so it isn't really a sunscreen but it's a way to prevent sun burns increase the amount of time you can be outside and increase the efficacy of your topicals so if you're somebody who is very fair skin who burns all the time or if you're somebody who has like what we call sun hives or people who are looking for sun hives.

Or or people it prickly sun rash PMLE this is an added thing that you can use that will boost your sun protective factors it's awesome and if you're somebody who's active like you're in the water or you're you know exercising you're playing a sport you can't reapply I love polypodium for that added benefit.

What are the dosages of polypodium that are useful and are there any side effects yeah great question so there's been a wide variety of doses investigated anywhere from 50 hundred to 4480 generally some of the 1500 sorry 50 milligrams 100 milligrams 240 480.

Somewhere in the between 50 and 480 milligrams is what's commonly used the most common side effect can be a little upset stomach if you can't tolerate the plant for daily it's taken you can either take it daily as a method of preventing premature photo aging and pigmentary change or you can take it as an as needed an hour before you get sun to shield you from the sun.

The other thing that it helps prevent that some sunscreens cannot particularly the chemical sunscreens cannot is the effects of visible light so there are certain skin conditions the most common is melasma which a lot of women have you know it's I think the bane of their existence used to be called the mask of pregnancy.

And melasma is something that is very sensitive to both UV and visible light chemical sunscreens don't do a good job blocking visible light polypodium has been shown to help block the effects of visible light as well which makes melasma worse it's this discoloration that we see mostly in women usually after pregnancy or women who are on birth control it is really challenging to treat.

The sun protection is the first line like diligent sun protection but we found that supplementing with polypodium enhances this and makes patients treatments more effective interesting and you mentioned sun powder as a potential that's a brand name.

Yes, sun powder is a brand it's a product that I help formulate with one of my colleagues over at Harvard who's a laser and aesthetic dermatologist Harvard trained and this is something that we came up with when I was up at Stanford and it's a it's a supplement dedicated to skin health and it does two things I take it daily myself as a single scoop.

It helps reduce your skin cancer risk your non melanoma skin cancer risk by up to 30% and the data was published in the New England Journal of Medicine in a phase three randomized trial for one of the ingredients the other ingredient obviously is Nick that is polypodium and I take that one to prevent you know sun related changes but also help reduce my risk of burning often when I personally find the need for sunscreen is when I can apply

water I'm swimming you know my my son he's seven he races on a swim team I cannot get this kid to reapply sunscreen so this is a supplement that I give him and we took us several years of formulation and testing including MED testing which is minimal erythema dose testing to come up with. It's easy over the counter and it's one of many supplements that contain polypodium I just like it because it's a single scoop and I mix it into my morning drink and I'm done terrific.

I think we both agree that the mineral based sunscreens are going to be the best option of the ones out there if one is at all concerned about some of these chemical components and chemical sunscreens. Yeah absolutely yeah so within that category are there particular things to look for I'm not necessarily trying to aim for particular brands here but given that I have no relationship to any skin care products.

I would just like to know which one to look for or will any zinc oxide and or titanium dioxide containing sunscreen provided there no chemical components in there. Besides the inactive ingredients of course will any suffice because in that case people can just shop for cost or availability.

Yeah so I tend to take a pragmatic approach in this my my recommendation is a brand that you will use because if I recommend a brand you don't like it doesn't feel good or smell good you're never going to use it and it's a waste of your money in time.

So number one any brand that is mineral based is fine you what you're looking for is broad spectrum coverage which almost all mineral based sunscreens provide broad spectrum meaning UVA and UVB and we know these two UV forms do different things in the skin.

We know that UVB is more implicated in redness and some early skin cancer changes we know UVA is linked to premature photo aging and certain melanomas so you want something that provides broad spectrum coverage you're looking for a number the SPF we talk about you're looking for a number above 30 why why 30 because every study.

That looked at defining the SPF required you to put a certain amount on the skin general it's an entire shot glass worth of the product on sun exposed skin most of the time in real world. Practice people don't put on that much they put on maybe half that so what you're really getting when you buy something that's SPF 15 is like an SPF of eight.

So if you're looking for something that provides protection SPF 30 or greater is higher higher the zinc concentration the better it protects against UV invisible light the chalkier it may go on so that's kind of where you find that balance that's actually where the chemical sunscreens came about is the cosmasutical industry finding things that felt nicer on the skin so that people could put makeup on without that grainy chalkiness but in doing so we ran into some issues.

What are some if any of the concerns that some of the components in chemical based sunscreens can cross the blood brain barrier. It's not unjustified to think that they are organic phenolic compounds they are hydro phobic they're a lipophilic meaning they can cross memberings very easily which is why they run into this endocrine disruption and some nervous. System dysregulation.

Whether that's been validated to be problematic in humans has yet to be seen but at least in vitro studies in certain animal models we see this so when you apply a certain concentration and with that 2020 study that showed that we're seeing it in the blood at levels that are 200 to 500 times the upper limit of normal as defined by sunscreen criteria.

Now we have to scratch our head where is this circulating where is this going are we collecting it in our adipose tissue if we're collecting it there we may be collecting it up here we may be collecting it in the nerves so it's a really fascinating world to see where we're going with these and in fact the 16 most common chemicals that in 99 were everywhere from you know spray sunscreens and bottles and things like that are now being defied as hmm question mark maybe not safe by the FDA.

The very company that regulates it. Another call for the mineral based on screens just as a you know why why take the risk or even you know shade hat clothing you know if you're really worried about putting something on an absorption you get excellent protection by actual barriers.

This seems like a good time to shift a little bit of our attention to nutrition and the gut microbiome now this isn't infinitely large topic you know we could spend several episodes discussing this but if you were to provide us some of the and like major takeaways as it relates to nutrition and skin health nutrition and skin appearance got and skin health and appearance what would those be so.

So there is an incredible connection between the gut microbiome and skin health and the skin microbiome of which we're only now just understanding the gravity the extent in the connection. We know from many studies many elegant studies a lot of studies done out of my colleagues labs up at Stanford that modulating the gut microbiome affects inflammatory conditions of the skin meaning if you control the dis regulation of the gut microbiome if you have an anti inflammatory dietary habit.

So the actual skin disease decreases in intensity and severity psoriasis eczema acne and this is not just. Subjectively it's measurable and quantifiable and reproducible so the connection is fascinating now how we modulate it that's the unknown.

So in many different studies that some patients got microbiomes are wildly fluctuated to what they do from their environment in terms of dietary habits antibiotics things like that some people's got microbiomes or rock solid nothing changes them and deciphering whose will benefit from what is the hardest part.

In terms of nutrition overall obviously everybody's told you this since you know the dawn of modern medicine is a well balanced diet is good for everything unfortunately the 21st century there are a lot of diets there are a lot of fad diets there are a lot of restrictive diets.

And that's where we see nutrition play an important role in both appearance and actual skin disease health and there's so many different avenues to discuss this things like dietary habits and changes for acne things like dietary habits and changes for anti aging things like dietary habits for rash disorders like psoriasis and eczema it's so much to explore.

So my understanding and we'll get into this more as it relates to acne is that patterns of eating either content food volume that is caloric load etc that increase insulin and things like mTOR are sort of pro acne they're going to aggravate or increase acne. Whereas the things that tend to lower circulating blood glucose insulin and reduce inflammation tend to be kind of anti acne or sort of pull in the other direction towards reducing acne load.

But if we were to just step back and say okay the typical person who wants to have the healthiest best appearing skin who's not dealing with any specific issue because we will get into those specific issues.

Can we say they should eat you know a vegan diet of vegetarian diet is okay to be an omnivore some people are on the extreme of this you know kind of carnivore type diet some of those people actually report you know elimination of certain skin conditions I don't know I've never tried one of those extreme diets but you hear this but I think I can hear a lot of things.

So it seems to me that the relationship between keeping the got microbiome healthy and ingesting sufficient amounts of fiber is pretty clear the relationship between keeping the got microbiome healthy and overall that is systemic inflammation low is pretty clear and that eating foods that are mostly unprocessed or minimally processed keeps inflammation on the lower side as opposed to eating more processed foods.

But you know assuming you would you agree or disagree with that feel free to disagree. Yeah so assuming that that's all true is there any evidence that the ingestion of specific foods can make skin healthier like you'll see this stuff like oh you know if you have two cups of blueberries a day your skin is going to be healthier or is all of that indirect by virtue of specific micronutrients that are in those foods.

So there's a lot of layers to unravel on this so if you're going to pick one simple diet for optimal skin health it's a high protein anti inflammatory diet so high protein animal source proteins fruits and vegetables based on your ability to tolerate the fibers and the fruits and vegetables.

Things that are inflammatory inflammatory for two reasons one the glucose insulin pathway but number two the bacteria in our gut process and release by products of metabolism of certain things and those by products basically their digestive products can be very prone inflammatory so often you hear these anecdotal stories of I eliminated tomatoes and my psoriasis got better that person may have had an inability to tolerate tomato.

Because of their gut microbiomes ability to digest the like a peanut or whatever it is. We do know for certain that anti inflammatory diets do improve skin health that are measurable and seen in clinic so absolutely high protein you know a complete protein when I say complete protein tends to be animal based products eggs meat chicken fish less so plant proteins just because of bioavailability and complete.

I mean acid profiles you want to high protein and time inflammatory diet that's number one in terms of what you can introduce to your skin to improve one or two parameters I don't think that's real why bring this up. We see a lot of talk and you've had a lot of people discuss collagen for example and this is an incredibly popular product in the skin world because it's claim to fame is it does everything keeps you looking young keep your skin healthy et cetera et cetera.

We know collagen is essential to our skin health literally it's what our dermis is made up that give us our suppleness or youth no wrinkles you know things like that. Collagen is made of three amino acids glycine proline and usually hydroxy proline hydroxyl lysine okay those three amino acids are non essential amino acids meaning your body has the ability to synthesize these from sugars and fats that it eats so collagen supplementation is not an essential protein unlike.

Animal proteins which provide all 20 amino acids including the essential ones your body cannot synthesize now you may ask okay well I see all these studies that suggest collagen supplementation improves skin health skin appearance there's several reasons for that I don't think it doesn't I think there is some benefit.

The question is what are the confounding variables to this where the people in the studies on restrictive diets because they were thinking about beauty and aesthetic where they restricting patterns of food dietary food things like that in which they weren't getting a sufficient amount of protein source to begin with so when they supplemented we saw improvements in their skin.

And a lot of these studies are patient recall or patient question your studies in which there's inherent subjectivity and confounding variables in this when people take an intervention that says hey you may look better or this may approve the appearance of your skin not only do you have a placebo effect and saying yeah I do look better you may also do other things during your day change your behaviors and lifestyle to fit the goal that you subconsciously want so that's one.

Number two there is a component in for example collagen supplementation that is forgotten about quite a bit and that's the increase in blood osmolality and I learned this in the fitness world I was really big into fitness and college and it was my escape you know from life stress and.

We found that people who supplemented with any powdered protein source does matter collagen album and way and more so with people who supplement with creatine that there is an increase in blood osmolality so the solute concentration increase in the blood which draws water in that's predominantly how things like creating make you look bigger and I know we're going to a little bit on the tangent but.

One of the reasons the way collagen works is your blood osmolality increases you draw a little bit more water into the vessels which plumps up the appearance of the skin so there is a hydration component from the water draw and this is measurable you can draw patients blood after consuming collagen protein way protein and see this spike in plasma protein so there's that component as well which is not truly a benefit but it's.

And aesthetic benefit why that tends to be a problem is sometimes people supplement with collagen and I end up actually having high blood pressure and they're otherwise healthy and this was something that we saw in the fitness world a lot is that young college athletes high school athletes that would come in they would otherwise be completely healthy and would be running high blood pressures if you took away their protein and.

Creatine supplementation their blood pressure is dropped and it's really fascinating stuff and you know I used to work out at UCLA with one of the professors of Fyseye who is a really big dude we worked out together we did all these studies and looked at you know you know young otherwise healthy people so that's one component.

The other question is do any of these food changes actually quantifiably increase skin collagen density skin elast and density there's no evidence that taking these things will traffic or meaning we'll go to where you want them to it's kind of silly to think if I drink this it's going to go into my stomach go into my intestine be absorbed and then note to go exactly.

To my cheek usually doesn't occur that way and when we've looked at histologic comparison studies the data is equivocal some studies have shown a slightly increase in collagen density and you wonder are those patients one that are unrestricted diets to begin with and then there's some studies that have shown there's really no density change in collagen and last and so the supplements really don't actually make a physical difference now the other question is is that study too short of term how long do you stay on these and you know how long you stay on these.

Data is wild and there's a lot to understand but we do know high protein complete proteins and time flammatory diets absolutely critical for skin health. I guess the most direct question is do you yourself consume collagen proteins in a supplement form or making a point to eat things like bone broth which contain high percentages of collagen.

Great question I do supplement only in sun powder which is my daily supplement it contains bioactive collagen peptides aside from that I think natural sources are better so you know my wife cooks a lot at home bone broth beef bone broth chicken bone broth a lot of animal meats my diet tends to be more in the

school you'd call it key to atkins or keto diet where I eat a lot of proteins and mostly fruits and vegetables I'm not very restrictive but I know that's what's made the biggest difference I know that if I go on a sugar binge in a few days I'm breaking out it's like clockwork for me some people are not sensitive my body is and that's that's where the personalized medicine comes in.

Is there a role for omega three fatty acids like fish oils and things of that sort for skin health specifically yes and no. Yes there is some evidence that omega three supplementation and tends to be better in fish form than you know non fish formats but omega three's tend to be anti-inflammatory so there's an improvement in skin health because of that.

One thing we do see is they thin the blood so people tend to bruise a little bit more so actually in my practice I have people stop omega three's before any sort of surgery because they believe more. What about some treatments that are known to be beneficial for the appearance and health of skin that people are not as aware of yeah right because I think people who are concerned with their skin health and appearance you know they think about sunscreen yeah we've learned a lot about that from you.

But what are some things that really work to improve skin health and appearance that perhaps require a visit to the dermatologist but that you don't hear enough about yeah so.

Two big categories so we know the skin turns over right it turns over every 28 days so in theory if you keep turning the skin over you can get rid of those mutations that occur in the skin that's stacking up and hope to bring out more vital youthful skin that's not just appearing vital but actually biologically healthier and there's two categories of things you can do.

The first is the family of retinoids amazing medications amazing drugs been around for 50 years they come in oral form and topical form and these increase the time or they shorten the time they increase the skin turn over from 28 days to somewhere between seven to nine days.

And in doing so they've been shown to decrease skin cancer and pre cancer formation they've been actually shown to grow new collagen they've been shown to increase elastin and appearance and this has been histologically verified in study after study meaning we take a biopsy of the skin have them start a prescription retinoid re biopsy the skin and stain if for collagen or elastin and you see a market improvement it's every dermatologist well known.

The tool and for some reason it's still not well known in the population it's original indication was for acne and still is first line for acne because what it does is it dries out the oil glands but in doing so it also helps repair skin so I recommend every single person to be on a prescription strength retinoid which is different than over the counter retinal and there's a lot of confusion and I think the confusion is intentional in the cosmaceutical world.

As to why this is but everybody should be on a prescription strength retinoid usually topicals is all you need most common or things like treto no end adapt lean or tizerate and there's oral forms the most common is acutane or isotretinoin and to a lesser known

drug called acutretin or seriotane and I usually reserve that for my high sun damage skin cancer patients it really makes a difference but I'm going to touch back about retinal versus retinoids so many many years when we studied retinoids the way retinoids work is there actually and they activate transcription factors their nuclear messaging hormones so these compounds bind retinoic acid receptors and then we're going to do that.

In the last few days we know that we can't really get back to the acid receptors and they activate the transcription of certain genes. One of the genes we know that it can affect is the sonic hedgeog pathway in some of the embryologic genes. Why that's important is when we first studied retinoids and oral or cream version we notice that these can affect the development of a fetus and they can be passed through breast milk and through

sperm or semen. So because of this issue, the FDA regulated it very tightly and it's pretty regulated worldwide because the effects are devastating, you know, missing arms, missing legs type of birth defects. Because the medication was so effective and we saw an improvement in both quality and appearance of skin, the Cosmaceutical Beauty World said, oh, okay, this is awesome. We need to figure out a way to get this on the shelf, but not be a prescription. Out came retinols with an OL, which is

the inactive version of retinoic acid, which is retinoids. And what has to happen is retinol needs to be converted in a two-step process to become active retinoic acid. Otherwise, it's a completely inactive pro drug, which is sold over the counter at concentrations that are not biologically active. That's how Cosmaceutical companies can get away with prescribing this for people of childbearing age. In my opinion, if you want a retinoid, get a prescription for it. The over-the-counter

stuff is not very effective if at all. The shelf stability, many studies has shown that almost all retinoids over the counter retinols over the counter are basically unstableized by one year. So you don't even know what you're paying for. The prescription is easy to get. You can see pretty much any dermatologist, and it's the only version that's truly effective. So everybody should be on it. Protects your skin, keeps you looking young, reduces skin cancer risk, grows

new collagen. Literally, the only consequence is that when you first start your skin may be a little bit red or pealy, as this can acclimate, or turns over, other than that. Nothing. Why do you think given the immense interest in skin appearance and health that we don't hear more about this? Because that's a great question. So we hear so much about retinol. Every magazine you open that has anything you'll see, like intensive night cream, intensive eye serum,

regenerist eye repair, and all of them have retinol. None of them have retinoid or retinol, for many reasons, originally was made for acne. And the patients that came in to get them for acne were not necessarily in the same line of thought of premature aging and longevity. So they were retinol. Yeah, retinol exactly, or acutane, or different. These are the brand names for these products. So there was a disconnect between the people seeking the anti-aging

effects and the people getting it as a prescription. That's one. And number two, as soon as Cosmaceutical companies figured out a way to market over the counter inactive versions, that went haywire. So you can Google retinol and there's a million things. When you Google tretno, and you only hear about acne. So there's a little bit of a disconnect, much like all in medicine, between what docs know and think the population knows and what the population actually

knows. But that's the one thing I think we've been doing a great job on, you know, in modern day social media is advocating for these for these medicines. Now, that's one realm of things that you can do to absolutely improve the quality of your skin, long term health, appearance, actually revitalize the skin. Then there's a whole set of procedures that you can, that can be done that have been shown to improve not only the appearance, but actual biologic health.

So that's where we fall into the laser world. And somebody who's, you know, been in photo biology, albeit a slightly different realm, you know, the effects of light and the incredible changes that it can have in biology. Most of what we understand for lasers and medicine came out of dermatology studies. You know, a lot of the understanding of laser biology came out of the Wellman Institute over at Harvard, where many of my colleagues are.

And we now know that certain laser devices, certain resurfacing devices, not only improve the appearance of your skin, clinically they reduce your risk of skin cancer by 20% maybe greater. And even more amazingly is when you do microarray gene studies, they actually activate the genes of more youthful healthy skin cells that were quite ascent as we age. So there's genetic verification, clinical verification, and aesthetic verification. These things are awesome. Now, laser is a big umbrella term.

Some of the devices we use are not lasers. They're actually light broadband light or intense pulse light. Some of them are laser, some of them are ablative, some of them are non ablative. And we get into the nuances of these things. But there are a few lasers that have been shown to make these dramatic differences. So if you're interested, I mean, see a, see an expert. So this would be go to your dermatologist, ask for some, is it laser

resurfacing? Yeah. Yeah. So laser resurfacing tends to be and what's really popular is two forms of laser resurfacing. There's what we call non ablative, meaning it doesn't burn or vaporize the top layer of skin. And then there's a blade of resurfacing, which vaporizes the top layer of skin. Obviously, ablative ones are much more aggressive, much more effective, a lot more downtime and a lot of risk here, because you're

literally peeling the face off or any part of the body. And it regrows without any scarring. That's also then another beauty of the skin is you can literally peel it off entirely and have it regrow as if nothing ever happened. So people have this done once a year or so. Yeah. For, for, not for ablative resurfacing, it's like once every five years or so on, it's, it's pretty dramatic. And how long is the downtime? For ablative resurfacing two weeks, usually two weeks are pretty raw and

sore. It's fallen out of favor in most big cities because of the downtime and inherent risks, but it's still used in the right patient. Non ablative resurfacing, meaning it doesn't vaporize the top layer, but drills holes into the dermis and targets certain parts of the epidermis without causing burn injury. That's become much more popular because the downtime is markedly less. People can go back to work and enjoy their activities while having pretty much the same benefits albeit a little bit

less than ablative lasers. These we generally recommend annually or biannually depending on what you're trying to target. A large Harvard study just came out that showed that non ablative fractionated laser resurfacing, particularly with a device called Prakzel actually cuts your skin cancer risk by 20% because it eliminates those mutations and gets rid of those cells that had been collecting this stuff. It's amazing.

How is this different than exfoliating skin? Like if one word to just try and scrape away some of the dead skin through some, you know, semi vigorous buffing of the skin with a like a sponge, I've never done I've never done either of these procedures. I think as I have my skincare routine is very basic. It's the unscented dovesop. The shower once or twice a day and your skin looks great to keep doing what you're doing. I feel pretty good. I mean, I think, you know, sleep seems to play a

significant role for me. I do get probably a bit more sun exposure than most people. I'm conscious of checking for skin cancers and we'll talk about that because those do run in my family. But and I try to eat right and exercise right, having consumed much alcohol in my lifetime. Look, your skin will tell you if something's wrong. So that's the first line. Now, you talk about, you know, dermabrasion or micro dermabrasion,

the good old st. Ives apricot scrub that every dermatologist, you know, frowns upon, but ironically, I use myself after I have you work out of the beach and I'm all greasy. But don't, you know, don't get mad at me for using that stuff. The depth is key. So when we do micro dermabrasion or some sort of dermabrasion, the only thing we're really scraping off is really the stratum corneum, which is the highest layer of skin cells that don't even have a nucleus. They're dead skin cells. That's all

you're scraping off. Whereas lasers target through the epidermis and into the dermis and you control for that depth. And what you control for it is the amount of heat energy delivered to that depth to target a certain thing. So in theory, what you describe in terms of dermabrasion is the same premise the old school ablative lasers do. They just fry everything off and you grow new skin and in frying everything off, it fries off sun damage wrinkles, pre cancers and

skin cancers. But in doing that, you're a bloody mess for a few weeks. Not popular for many reasons, but very effective. We did a ton of this at Stanford and we did a ton of the other one at Stanford. In my practice, I do a lot of laser work as well. The non-ablative stuff picks and chooses that was the beauty of identity learning about laser and photo biology is how we target a certain structure

and avoid damaging all the other ones. That's the theory of selective photo thermalizes that came out of Rox Anderson's lab at Harvard. That was the game changer. We can now pick any appendage in the skin and find a way to target it and leave the rest undisturbed. So if you have broken blood vessels, you decide to use BPC157 and it worked great and the blood vessels started to grow and you're like, I don't like the look of them. There is a laser that targets solely

blood vessels. Is that the IPL laser? IPL is okay. IPL stands for intense pulse light. It's somewhat effective, but not very effective. The gold standard is what we call pulse dilaser or the V-beam laser. That is a not 595 nanometer laser that targets oxyhemoglobin. I've had that actually because I had an angioma. Yeah. That at three times and the third time they hit this thing, it went away, but not without a very significant bruise lasting almost a month.

Like, you know, I mean, it was pretty dramatic. Right. But it did eliminate the vessel that was right. Any means necessary, right? It's just near the skin. So as long as we're on the topic of photo biomodulation, what about red light near infrared light? Is there any evidence that it can benefit skin health and appearance? Nowadays you can find masks that will emit red light. Some people will purchase red lights. They stand in front of I think they're very effective. I think they work great.

The question is to what extent is that improvement objective and measurable and what extent is subjective? That being said, there's a lot of evidence that shows that red light therapy improves vascular flow in the skin. We use it for things like hair restoration, post procedure recovery, improvement in skin health after UV damage. We actually found a recent study that looked at red light therapy and irradiating mice.

And if you pre-treat the mice with red light therapy before they get UV exposure compared to controls, the pre-treated group had much less of the changes with UV exposure. So very fascinating stuff. How it works, uncertain. We think a lot of it has to do with increased vascular flow, which is why a lot of times we recommend it for post procedure. We recommend it for hair regrowth. There's some evidence that if you increase blood flow to the dermal papilla, the hair, it grows new hair.

That's how an oxidol or Rogain works. But I like it. I think it's a great product, a great, great group of products or devices. As a standalone uncertain as to how effective they are. And one of the reasons of the heterogeneity and the data are like so much difference is there's no regulation in terms of the energy, the density of light, the type of light, the duration of treatment. So some devices have high wattage, high energy output, high density of lights.

They may be more effective than its equivalent counterpart. And until that gets defined more uniform in accessibility, I don't know which device to recommend. Obviously have preferences one way or another. But there's so much on the market that's marketed as red light that is not effective. And some stuff that's really good. So probably looking for something that's at least endorsed by dermatologists. Yeah, absolutely. And I should say here I have no angle into this.

I want these masks that emit red light or I don't have any business relationship to them. So that's not why I bring it up. I was just very curious. I see them in my Instagram feed probably by virtue of doing public facing health and science information and my interest in light. Yeah. What about, oh, yes, excuse me. I'm going to say the panels tend to be much higher in energy, much more effective. And most of the studies have looked at the big wall panels.

The battery powered face masks just aren't powered enough to have much improvement. We do see some improvement when red and blue is used together, mostly for acne prone skin because blue light alone has some anti-microbial properties. So when used in conjunction, you can get some improvement in actual skin illnesses. But the masks alone with just red light, most of them are not powered enough. They don't have enough energy. But there are some that are good. The wall panels tend to be better.

Thank you for that. And full disclosure, I was accurate in saying that I don't have any relationship to any red light mask companies or products. But this podcast is sponsored by Jufe, which makes medical grade panels for red light and near and for red light. And I do own one of those and I use, I have a small portable one I use and then I have a panel I stand in front of. So that includes my face. And then I'll turn around and do a whole body. Yeah. And panels are good. Juve is a good company.

It's been around for a while. And most of the experts in laser and photobiology agree the panels are their way to go if you want red light. It's interesting when people see and hear about red light and near and for red light therapies. I think a lot of people think, oh, this is kind of like next-age biohacking. But there was a Nobel Prize given for photobio modulation for the treatment of lupus in the early 1900s.

So this is a longstanding thing, the use of light, of particular wavelengths or combinations of wavelengths of which red light and light are. Of course, in order to target different layers within the skin to get some desired effect. Yeah. Yeah. Light has been around for a long time. I have a phototherapy unit in my practice in which we use narrow band ultraviolet B light to treat conditions like psoriasis to treat conditions like Vidaligo.

There's a very strong immunomodulatory effect of light on the skin. It actually suppresses overactive immune activity. It can help increase vascularity in the skin and can improve blood flow. So depending on the wavelength you pick and where it overlays on the absorption curves makes a big difference. It's interesting that we talk about light and as a skin cancer surgeon, this has always been interesting to me in that we use UV light to treat certain conditions.

And we assume UV light is purely pathogenic. And I don't think that's the case. And why I bring this up is one of the most common things we use like light therapy for is patients with Vidaligo, which is this autoimmune condition in which your immune system attacks the cells that produce our skin color. And the standard treatment is certain creams that suppress the immune system in the skin phototherapy, eczema laser, which is a UV laser.

And then now the new world of immunotherapies by pill form the Jack inhibitors have made a huge difference. But if we thought, and I go back on this tangent because the more we think about it, the less we know. If we think UV is truly deleterious, then patients with Vidaligo should have an higher incidence of skin cancer. And in fact, the opposite is true. They have a lower incidence of skin cancer, even when you match them for amount of UV exposure over time.

So it goes to tell us that there's so much about light and skin. We don't understand so much about sun and UV and skin. We don't understand an incredible component about our skin's immune system that we're only now figuring out that play an important role. Patients who have transplants, for example, transplant patients in the early 90s, the number one cause of death for transplant patients that was not related to their transplant was metastatic skin cancer.

And this was in patients who were strictly sun protected. So we talk about biology, photo biology, LED, UV and skin health. And there's so much we don't know is we gather more data and look at populations and cohorts. So I know why I brought that up as a tangent. Well, I think it's a very relevant tangent because the relationship between immune system function and skin is very clear.

And these conditions that you're referring to, Vitiligo, Acne, psoriasis, eczema, et cetera, have interesting relationships to the immune system. So that's actually a perfect segue for what I'd like to talk about next. So let's start with psoriasis. Yeah. That is the story with psoriasis. What is it? What can make it worse? What can make it better?

Psoriasis is like the quintessential skin condition I have it myself, my elbows and knees. And for about 100 years, it was thought to be a problem, a rash that is caused by too much skin turnover or excess skin proliferation. And for 100 years, we treated it the same way. We gave medicines that basically took the skin off, what we call caratolytics. We found that that wasn't very effective and some people can be hospitalized and it can be life threatening if psoriasis involves the entire body.

It usually looks like red patches or plaques with kind of a silvery scale on the surface and starts usually elbows and knees or the scalp, but can involve pretty much the entirety of the body. And what we found in the last 30 years with a lot of elegant studies and a lot of very, very nice basic science research is that it's actually due to overactivity of our skin's immune system.

So there's overactivity of certain interleukins, which are these messengers that our immune cells produce that makes the skin turn over faster than it should. And this epiphany was remarkable because we found that instead of targeting the skin, we can target the immune system and we can eradicate or treat psoriasis entirely. And in the 90s and early 2000s, that targeting was very crude. It was a very umbrella approach. We suppressed the entire immune system and ran into the consequences of that.

So medications that we gave for that increased risk for infections and skin cancers, etc. Now we have amazing drugs that target one or two molecules, messenger molecules of our immune system and clear up people psoriasis. I mean, we have drugs now you take three times a year and you could have head to toe psoriasis and be completely clear. It tends to run in families. There is a very strong hereditary or genetic component to it and it tends to be associated with arthritis, psoriatric arthritis.

So psoriasis is like the quintessential skin condition that people see dermatologists and even rheumatologists for. So these drugs that target these specific interleukins seem like the most direct way to treat psoriasis. Some people for whatever reason have an aversion to prescription drugs. Not necessarily one of those people, but I like everybody else would like to know what we can do to reduce symptoms of things like psoriasis without having to, quote, unquote, take anything.

Yeah, I should probably backtrack. So psoriasis obviously comes in severity. There's mild disease, which majority of people have. There's moderate and severe. And generally speaking, the most common things that we treat mild psoriasis with is creams and lotions, moisturizers, sometimes low potency topical steroids or high potency topical steroids and then things like

psoratolytics like psalicylic acid that take that excess scale off. We also know that there because it's an immune inflammatory condition that diet plays a big role in improving mild or moderate cases. And we also know that weight loss plays a very big role in improving the appearance of psoriasis.

So as we lose weight, as there's improvement in insulin resistance and as we transition diets and lifestyles from inflammatory to anti inflammatory psoriasis tends to clear without any intervention needed without any medical intervention needed. If there's still continued, you know, rashes and skin activity, then you look at topicals like, you know, cortisones, emolients like aquifform vasoline, you know, things with some sort of acid or retinoid to get rid of that excess scale.

That's the fundamental cornerstone of treating psoriasis. And then when it gets bad, we talk about additional pharmacologic interventions. Also interestingly, one of the earliest conditions in which phototherapy was used is psoriasis. We know that when we shine UV light on the skin, that it suppresses the skin's immune system and clear psoriasis. And that's an excellent way to treat it without pharmacologic intervention without any creams, pills, injections or otherwise medication.

It used to be used in the Dead Sea. People would go lather in the mud in the Dead Sea and sit out in the sun. And that was the first crude way to use phototherapy to treat psoriasis. That was my question since the sun emits UV. Why not just get some additional sunlight exposure for psoriasis. So you can. That most dermatologist wouldn't recommend it. I think it's actually not a bad thing. My psoriasis clears in the summertime and flares in the winter time.

The problem with pure sunlight is that it's a mix of rays, right? There's x-rays gamma rays, which generally don't penetrate the atmosphere. There's UVC, UVB, UVA, visible light, infrared light. That heterogeneous light some have no improvement in psoriasis and some have great improvement. So we were able to figure out which wavelengths make a big difference.

And it's around the 311, 312 nanometer range. But sunlight does clear people's psoriasis up. That's why we see in northern latitudes where there's less sun intensity. The incidence of psoriasis is markedly higher than equatorial latitudes. And patients will say their psoriasis gets better when they're on a beach vacation. And when they go back home, their psoriasis flares. There's also some component with vitamin D as well. But I think that's just secondary to the lack of UV exposure.

What about Vidaligo? This is something I did not cover in the solo episode about skin health. But I got a lot of questions about Vidaligo, of course, being this. Typically patchy, non-pigmented regions of skin that you said is at least some cases are related to the immune system. These people get skin cancers less often. Is that right?

Yeah. So Vidaligo is autoimmune, meaning your immune system is attacking itself, deep, pigmentary skin disorder, meaning it's a condition in which your immune system attacks and kills the melanocytes, which are the cells that produce our skin's color.

We've found that it's an autoimmune condition from many basic science and elegant studies. It's also very closely associated with other autoimmune conditions. So patients tend to also have a topic dermatitis, autoimmune thyroid disease, autoimmune anemia. There's some sort of immune dysgrasia that involves Vidaligo patients. And what happens is the immune system at first paralyzes these cells with immune activity attacking them. And over time, these cells no longer survive and die off.

Cornerstone and treatment has always been, some way to suppress the skin's immune response. When most of the time Vidaligo tends to be focal, single areas, or segmental, unfortunately, in certain cases, it can be whole body or completely deep, deep, digmenting, very uncommon, but we see this.

We treat it by doing things that will help quiet the immune response in the skin. So topical creams, topical steroids, et cetera, topical calcine urin inhibitors, which are non-steroidal anti-inflammatory medications.

We also use certain wavelengths of UV light to treat this, eczema laser at 308 nanometers, UVB, UVA. And then the renaissance of Vidaligo has happened in the last three or four years with the identification of Jack inhibitors, which are these drugs that block the Janus kinase pathway.

And we found that the Jacks that pathway plays a really important role in autoimmune mediation of melanocyte death. So new creams and actually oral medications have come out for patients who have very refractory Vidaligo. The immune component is very fascinating because understanding immune biology and the immune systems effects on skin health comes from studying these patients.

When patients have Vidaligo, they lose all of their color. So you would assume that they're much more susceptible to sunburns, which they are. But when you look at incidence of skin cancers, they have a significantly lower incidence of skin cancer. And this is because of the immune phenomenon in immune surveillance of cancer.

And that occurs throughout the body, but the skin is a model platform for this. What happens is your immune system surveys for mutant changes that occur, whether it's UV related, et cetera, infection toxin, whatever. And patients who have Vidaligo have overactivity of these immune cells and over surveillance. So they are able to clear a lot of these precancerous changes before they form into something.

So that played a big role in not only understanding how to treat Vidaligo, but some of our new medicines, actually the medicines that won the Nobel Prize in 2018 for treating melanoma came from understanding immune activity and cancer pathogenesis. It's fascinating. Again, speaking to the fact that skin is far more than just this protective outer, outer sheath, it's a reflection of so much that's going on internally. And we know that intuitively. Also by observing others.

I think this is one of several ways that parents can communicate well with their children or their children with their parents rather in terms of how they're feeling prior to language. They'll look at their skin, their stool. Yeah. Obviously fussiness and mood and those things too. But we seem to have developed an intuitive understanding that a shift in the kind of like tone of the skin or some other features of the skin signal to us wellness or lack of wellness.

The skin is a biosensor. The entire skin hair nails is a biosensor. So you can utilize the skin as the first barometer of illness. I mean, from acute illness to chronic illness acutely, you can see changes in just like looking pal, you know, with paler looking ghastly things like that, but chronic illness as well.

You know, when you used to go to the pediatrician and they would do this to look into your eyes, what they were looking for was the color of the congenitiva. If it was white or pale, they knew you had iron deficiency. You know, when kids get hand foot mouth syndrome and they have a high fever, they lose their fingernails.

When college students are stressed out, they lose their hair. The body's amazing ability to tell you its under stress is shown in the skin hair and nails, what it does is says, why am I wasting energy producing something that is not necessary because I'm fighting something else. Let's just shed this. And you can tell right away. I mean, we used to in clinic when I'd see, you know, medical students or college students come in. I knew as finals week, they've come with clumps of hair.

And as soon as finals week passed, usually took a few months, their hair grew back. It's awesome. The skin is a really cool biosensory and you can tell a lot. It is so cool. What about acne? Yeah. And acne seems very common, you know, as we progress through puberty, there seems to be more acne. Sometimes it's transient. Sometimes it's not. What are some things that people can do to prevent or reduce acne? Another quintessential derm problem that is affects so many people.

And acne tends to be a condition that is bimodal, meaning we tend to see it in adolescence. We tend to see it in 25 to 35 year olds. And for the unfortunate group of people that bridge that gap, we see it anywhere from 12 to 35. And acne is a condition that's usually seen by pimples, you know, what we call blackheads or whiteheads, zits or boils. And it's thought to be caused by three important things.

It's an overproduction of sebum, which is the oily stuff that comes out of your skin. And that's dictated by your hormones. Your hormones will increase the output of sebum. It usually occurs in puberty, but can also occur if you're taking medications like prednisone, cortisol, testosterone, anything that is a hormone driver. So sebum is the first cause.

Sebum is the food for the bacteria that cause acne. So as there's more food, the bacteria proliferate. And in proliferation, it recruits an immune response. And then the system says, hey, there's a little bit too much of these organisms. Let's go and take care of them. That's where you get that red zit. So in treating acne, you got to treat all three components to get really effectively clear skin.

Somehow reduce the sebum, get rid of the bacteria and calm the immune system down. That's done with creams, oral medications, and you have a combination of both. Sometimes certain lasers can help eradicate the oil glands that feed the bacteria. But acne's a fascinating condition. Almost everybody will have it at some point in their life. Is it true that eating a diet that is of slight access in calories?

Is it will tend to push the insulin glucose regulation system more into the positive, as opposed to, let's just say, higher levels of insulin in a circulating blood glucose than one would observe at say maintenance calories or sub-maintains calories that, you know, overeating a little bit could cause acne. And that any foods that promote increases in glucose and insulin, so sugary foods, high glycemic foods, these sorts of things. Can that actually increase acne fried foods?

So it's not the caloric, caloric deficit or the caloric surplus. It's the glycemic index or the amount of insulin response. So that high glycemic index foods will make acne worse. And almost every study that we've looked at in sugary processed foods will flare your acne. There's some component of that inflammatory response that not only drives the production and bacteria growth, but actually worsens the skin's immune response.

The skin's immune response is a little feisty when you're eating pro-inflammatory things. The other thing that I do hear a lot about is dairy. And there's this misconception that dairy causes acne. What we really see when we looked at a really cool study that was done at a Penn State is that it's not so much whole fat dairy products, but skim and nonfat dairy products that can make your acne flare.

And the reason for that is usually in the United States, there's a molifier that's put in nonfat or skim products to give the same mouth feel as full fat so people feel like they're getting the same without the calories. And that has a glycemic response. So it's usually sugary foods, nonfat skim dairy products that will make your acne flare.

What about rosacea? I hear so much about this and I'm going to assume that we can mark off at least one thing as clear, which is that alcohol can exacerbate rosacea. Maybe directly, but certainly indirectly by impeding some aspects of the microbiome, disrupting sleep, rosacea gets worse. But what are things that people can do, do's and don'ts that is for rosacea, if it's mild rosacea, like excessively ready cheeks or superficial riding capillaries that seem to bother a lot of people.

I know that bothers a lot of people because they asked about this quite a lot in the questions when I solicited for questions. So rosacea, commonly known as adult acne, tends to come in four flavors. The first form is the redness form, what we call erythematotelangic tatec form, or the redness broken blood vessels, redness of the cheeks and flushing.

That's by and for the most common form. There's also the papula postular form, which is the pimple form, which is what we think about an adult acne. There's also the fymidous form, which is the enlargement of the nose that kind of looks like toad skin. We used to think it was a sign of alcoholism or sailors or construction workers that would have these enlarged nose.

We thought it was a product of their environment that's actually a form of rosacea. And then there's ocular rosacea, which affects the eyes. By and far, the two most common that we see people in practice for is the redness form, redness and flushing, or the pimple form. You're absolutely right in that alcohol can contribute to it and we're seeing it for two reasons. One, alcohol itself is a vasodilator and acetaldehyde is a much more potent vasodilator.

So when you drink, you flush also chronic impairment of the microbiome and lifestyle changes that make you drink more probably will exacerbate your rosacea. But things that trigger the redness include UV light because of vasodilation, spicy foods, hot beverages, emotions, life stressors, all the things that make you flush.

What triggers the breakouts is a little bit different. And why that's important is how we treat them. So what triggers breakouts is thought to be both organisms that live on our skin, including bacteria and certain mites, but also immune dysregulation in our skin. That we don't really understand or just now elucidating how the immune system in the skin becomes dysfunctional to show those breakouts.

In terms of treating redness, we have some creams that are okay at temporarily blanching those vessels out, but they're not great in their temporary. We don't have great treatments for them, but we have great lasers for redness. So when patients come to see me for redness or any dermatologist for redness, generally there's a discussion about laser destruction of those blood vessels.

When we talk about breakouts or pimple form of rosacea, we have excellent medications in terms of both creams and oral medications that suppress both the bacterial and microth, as well as the immune response in the skin. So you kind of have to take a look at what form you have and what will be the best treatment. Eczema. Umbrella term for what we generally consider as atopic dermatitis or what used to be colloquially determined as sensitive skin and childhood.

And that's a very prominent skin condition, also dictated by the immune system, but in two forms. Eczema tends to be caused by three major prongs. The first prong is a genetic barrier defect in the skin. So patients with eczema tend to have a microscopic weave of their skin that's not as tight as somebody without eczema, and that's usually defined by a gene called filagrin.

That's the first reason to develop eczema. The second reason is an environmental allergen or trigger that's able to get through these weaves easier because of this genetic change. The third thing is an aberrant immune response to these triggers. So patients with eczema tend to have an immune system that responds a little bit more vigorously or overactively to the same environmental trigger, probably because there's more trigger getting in through the barrier defect than somebody who doesn't.

So the cornerstone in treating eczema is treating these three things. Why dermatologists make a big stink about moisturize moisturize moisturize for eczema is to seal that barrier with a moisturizer because we're basically putting the mortar back in between the bricks, which are the skin cells, to seal the skin off to not allow the environmental allergen to get in.

That's the second is to avoid environmental triggers. So fragrances, preservatives, seasonal allergies, pollen, things that trigger that immune response we try to mitigate. Now, obviously trying to control environmental pollens is hard, but using things like we talked about earlier, you know, fragrance, free cleansers, fragrance, free detergents, fragrance, free skin care products, non-preservative based skin care products.

We'll mitigate the environmental triggers. And then the third thing is just calming the immune system down. And that can be done in a variety of ways. Most commonly, it's topical medications like topical steroids that dampen the immune system in the skin.

And when eczema is really, really bad, there are biologic medications that control certain interleukins. And they've made an incredible advancement in eczema control. People we can control patients for life with some of these injectable medicines.

A couple of things that you taught me that I just want to pass along in short form and please correct me if I have this wrong. One, if you can avoid popping pimples, definitely avoid it because it can cause damage, recruitment of these matrix metallic proteases, which essentially digest some of the deeper layers of the skin, leave scars.

Yeah, totally. So it's, I mean, it's very gratifying and you want to do it. There's like some subconscious desire to like pop a pimple. I haven't myself anytime I see a pimple. I'm like, man, I got to want to get at this. I think to eradicate the infection type of thing. You know, even if it's not an infection, I think possibly like a like a evolutionary reason. Yeah, very, very possible.

The reason we don't want to do that. And the reason why we always say don't pick at your skin is when there's an immune response in the skin, the immune systems trying to fix something and fight something and in doing so, it recruits different enzymes. The most common enzyme is what you exactly describe matrix metallic proteases, which are these enzymes that eat apart collagen and last in to allow it to remodel.

When you cause physical trauma in the skin, you recruit a much larger immune response than what was warranted for that insult. So these MMPs, these matrix metallic proteases enter at a much higher amount and they eat away the collagen and last in that's what leaves an acne score.

People are going to pop their pimples whether we want to or not. So if you're going to do it, I don't recommend it. But if you're going to do it, generally what we recommend is if there is no tip, don't even think about it. If there is a small white tip and not much pain or interation, you can use a warm compress to see if you can soften that and see if it'll expel itself pushing.

We don't recommend stretching can sometimes unroof a pimple tends to cause less trauma, but again, if you listen to one thing, don't do it. And if they pop on their own, can't believe we're having this conversation, but that's a skin health and appearance episode. After all, if they pop on their own, then cleaning it with a gentle cleanser is probably the best way to go.

Yeah, no topical antibiotics. Is that right? Don't use any hydram peroxide. It's a common misconception thinking it fights things. Proxide doesn't let wounds heal. It just kills anything living. So no peroxide and no topical antibiotics that are over the counter. Most of these don't have any antibiotic properties anyway, because most organisms are resistant to them because of the widespread availability and use.

And two, they cause a lot of allergic contact dermatitis and rashes and people who are susceptible to them. So we just say if it pops on its own, leave it alone. They want to put a little ointment on there if you have a sore, but otherwise ignore it. And what about the use of corticosterone cream? Like if somebody has a red bump and they're headed to an event or something and they want to, you know,

eliminate some of the redness and bump. So a common thing we see a lot of people for it's like a day before their wedding or a day before a big social event they have a zone for it and they say, you know, what can you do for me? I need this gone. So exactly like we talked about topical corticosteroids and to a greater extent injectable intralesional corticosteroids suppress the immune response temporarily.

So you can use them cautiously if you have an event within the next day or two long term use it causes multiple problems it causes thinning of the skin and can increase the risk of the acne scar forming and you can have rebound acne from topical steroids used all over the face.

Oftentimes we see a lot of people who are in the public eye asking for steroid injections of their acne. I, as a surgeon, usually see a lot of the consequences of that. So I tend not to utilize steroid injections for acne. The reason for that is if you place just a little too much and we're talking less than 0.1 milliliter difference, you can have a permanent atrophic divot in the skin that is only fixed by surgery.

So I see a lot of young patients that come in who have an acne spot injected here and now that divot is left and that's permanent. If it's going to be done, it should be done by a dermatologist who knows what they're doing low concentrations usually bottom half of the face can be effective in getting rid of a really bad pimple that needs to be gone immediately. You just got to know the risks. Assuming sterile technique and other safety measures in place are tattoos inherently bad for skin.

No, I don't think so. I think tattoos are an awesome form of art and I think it used to be linked to you know stereotypes that are no longer true. I think the challenge with tattoos is two things, making sure that what is being placed underneath the skin is not an allergen.

We see this mostly with the reds that use cinamates. They produce a lot of granulomatic reactions or foreign body reactions. One, making sure obviously they're using clean safe equipment that's sterile. You know, you don't want the bloodborne pathogens. The real challenge is surveying for growths in patients who have a lot of tattoos. It's hard to see small skin cancers form or changes in moles because usually the tattoos are of dark color.

So the surveillance part becomes a little bit more challenging. So if you have a lot of tattoos, just make sure you're a dermatologist and somebody who feels comfortable and confident in screening. And that, no, they've been around for hundreds and hundreds of years and I think they're fine if done correctly. That's a good segue into surveying for skin cancers. Earlier you talked about some of the more common forms of skin cancer, squalmousel carcinoma, basal cell carcinoma.

But then there's the one, no one truly wants, which is melanoma. So I was taught to keep an eye on my moles. If they change, change in border, change in size, etc. To notify a dermatologist, I get my moles checked about, I don't know, I just had it done less than a year ago. But what about getting all skin checked? I mean, what do you, this is your area of expertise. So, so if you had a magic wand to help prevent skin cancers, what would you, what would you have people do?

That's a great, great question. So obviously there are many forms of skin cancer, but the three most common like we talked about basal cell carcinoma, squalmousel carcinoma and melanoma. There are other types like merkle cell and etc., but they're far less common. Now, historically melanoma has been our number one killer for skin cancer. Until about a few years ago, around 2018, when the Nobel Prize was won for the new drugs that treated melanoma.

This year, we expect three times as many deaths in the United States from squalmousel carcinoma, then we do melanoma, but nobody talks about that. We lose a patient every about 62 minutes to melanoma, but one every 37 minutes to squalmousel carcinoma. First and foremost, the thing that you want to look for in terms of skin cancer risk and predisposition is look at family history. Your family history and your genetics plays the largest role in predisposition for skin cancer development.

If you can gather a family history, you can understand your risk in developing it and it can help dictate your screening. Now, if you can't get a family history, you don't know your family history, not a problem. Generally, we recommend an annual skin exam by a good reputable board certified dermatologist. And that includes every square inch of your skin, including your hair between your toes in the general area.

We can develop a skin cancer anywhere. Bob Marley died of a melanoma on his toenail that was thought to be a soccer injury. Jimmy Buffett died of a Merkel cell carcinoma, one of these rare types that occur in sun exposed areas. Anybody can get them. Obviously, there's predispositions in higher risk populations, but it's such an easy, non invasive exam to do that everybody should get one at least once a year.

The other reason why I bring this up is skin cancers can develop in sun protected areas, one of the areas that I see a rapid increase in skin cancer development is in genital areas and in the mouth due to HPV. And we see this a lot and younger and younger patients, probably in the last month, I've operated on six or seven young patients under the age of 40 with squamous cell carcinomas caused by HPV in the genital region.

This is obviously not sun driven. It's not something you can put sunscreen or take a, you know, product to protect you from, but it's something that's easily monitored or surveyed. So I would say at the very minimum, get a family history or personal history, get an annual surveillance exam. If you have a lot of moles, I used to direct the pigment and lesions and melanoma clinic.

This is something that was really hard for a lot of dermatologists and patients to follow when they hit when they're covered with moles, see which one is changing. There are tools that can be utilized, including whole body photography, mole mapping and some new AI based software that basically track the moles and look for changes as you feed the software more and more pictures from the patients.

It's fascinating. A lot of the stuff is developing from our, well, I should say my alma mater, but up at Stanford is these AI based software apps that allow us to survey some of the most challenging patients. So if you have a lot of moles, your screening may be more than once a year. If you have a lot of moles, you inherently have a slightly increased risk for melanoma.

Now, we always use these terms interchangeably melanoma, skin cancer, basal, squamous, etc. Importantly to know for every one melanoma, there's 10 non melanoma skin cancers that's namely basal, saline, squamous, saline. About 5 million Americans will be diagnosed with one of the non melanomas this year alone. 5 million. It's a big number. That's about one in four Americans at some point in their lifetime will develop a skin cancer.

Encroaching one in three Americans by the end of their, by the end of 2030. So it's a lot majority of these are not life threatening, but they're functionally and cosmetically disfiguring. They arise on sun exposed areas, so surveillance is really important for the HPV that eventually becomes squamous cell carcinoma is the HPV vaccine effective even at older ages.

Yeah, great question. So the we are seeing HPV become a real problem in many cancers in the body, not just the original cervical cancer, which was the number one killer and young women for cancer until the vaccine came out. But we're seeing it now as the number one cause of throat cancer and young adults and sexually active adults significantly increased risk of squamous cell carcinomas in sun protected areas, immunosuppressed patients.

The vaccine, the Gardasil vaccine, which treats or builds immunity to HPV covers the strains that cause cancer 16 18 31 33 and so on. I recommend anybody who is either sexually active or anybody who in population literally anyone should get vaccinated the new guidelines have extended the age up until I think late 40s for both men and women.

It used to be only for young young women because the cervical cancer risk, but now we found that so many things are implicated with HPV that the on label use is up to the late 40s. So if if you have any concern, I highly recommend getting the vaccine. We call planters warts, which are these words that borrow a kind of route into the bottom of the foot, they're very painful that actually can be caused by HPV. It's a form of HPV. And it's not sexually transmitted. It's locker room transmitted.

So HPV comes in about 200 strains or like 190 strains. Strings one, two, and four, for example, cause warts on the hands and feet, what you see like gym goers and kids, you know, they get warts HPV 6 and 11, for example, cause genital warts HPV strains 16 18 31 and 33 cause cancer.

The question is when you get something, does it come with its its brothers or its siblings, and that's the question we don't know. The vaccine was made to treat high risk strains, but because of cross antigenicity, we see that patient to get vaccinated. Their warts go away. And we saw this in the hospital and transplant patients who were covered with warts because of their immunosuppressed effect.

When we would vaccinate them, their warts would get better. So warts on their fingers, warts on their planters, warts on their feet. Yeah, transplant patients and anybody who is immunosuppressed, they have a tough time fighting plant or warts, you know, finger warts, any sort of viral based condition because their immune system is suppressed from medications or otherwise.

So they usually have a tough time fighting these things, they have a higher incidence of a lot of things, but the vaccine was cool, eradicating it. Now I'm not saying go get a vaccine, because you have a plan to our worth. That's silly and overkill. Usually warts we treat with, you know, freezing in office procedures, easy things, but planters warts can be burnt out. Yeah, we burn them are freeze them are scraped them use a little medication, but the vaccine does improve some of the burden of disease.

Even though it doesn't target that strain. Do you think soon we will be in the landscape of vaccines for all forms of skin cancer. I think we're on the forefront and the term vaccine is a really big umbrella term loaded term. Yeah, I know it's going to garner a lot of questions. I think yes, absolutely. There was a new study that showed that

an mRNA vaccine and that is already pretty controversial was shown to improve melanoma survival after surgery and chemotherapy. So what the goal of all these things is to prime your immune system and have the immune system know what to target. It's to teach the immune system, hey, this is bad. Next time you see this go attack it. It's like showing a blood how to stake and then going on the hunt. The blood how now knows what to send for and what is normal and what isn't.

So the vaccines have a lot of controversial things. I think for medicine and cancer biology, it's going to be revolutionary. We see it for brain tumors, we see it for glioblastoma, incredible changes with dendritic cell vaccines. We see it from melanoma now. And in the future, maybe use for all skin cancers with an asterisk, depending on how much we can activate the immune system to target it.

Fascinating and a good place for us to probably pause until the next time we have you back to talk about where that technology evolves because today you've taught us so much about skin. What it is, you know, it's anatomy, it's physiology, what it reflects in terms of our internal workings, health or in some cases challenges with health.

I talked about various conditions such as psoriasis, acne, eczema, dandruff, as it's sometimes called. And what we can do, you know, the role of nutrition, avoiding certain things like excess alcohol, nicotine, etc. But also some of the newer and more exciting treatments that exist for all these conditions, some merely cosmetic and uncomfortable, some truly life threatening and dangerous like melanoma.

For all those reasons, and also for taking time out of your very busy clinical schedule to come talk to us, I really appreciate it. And I want to voice my appreciation for myself and for those listening and viewing. I have many, many questions, so we will refer them to your social media accounts and links to your clinic and so forth so that they can have those questions addressed and who knows maybe get the chance to work with you.

In the meantime, I just want to say thank you for this public education gift that you've given us. I'm thinking about skin very differently now. And I plan to do and not do certain things in light of today's conversation. No pun intended. Thank you for the opportunity. Incredibly grateful to be here. I think I think teaching is really important having evidence based discussions is really important.

Challenging dogma is also important done in the right way in the evidence based way. I love what I do. I love everything about the skin. I love, you know, seeing patients and also, you know, challenging, you know, the status quo on certain things. So thank you for the opportunity. It's been a lot of fun. There's a lot to talk about in skin. We probably talk for a decade if you let me, but I appreciate it. Thank you.

Well, we will certainly bring you back to further discussion. Meanwhile, thank you ever so much for your soul money. Thank you. Thank you for joining me for today's discussion about how to improve and protect your skin with Dr. Teo, Soleimani. To learn more about his work and find links to his clinic, please see the show note captions.

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