Hello and welcome to this Skin Deep podcast, where we'll be looking at skin-related issues and treatments in, what I hope is, an interesting and informative way. I'm Dr Roger Henderson and I'm a GP with a long-standing interest in this area of health. And I'm Dr George Moncrieff. I was also a GP, though I retired from my practice a few years ago. I'm also the past Chair of the Dermatology Council for England.
Today, Roger and I will be talking about some skin basics, including why dry skin problems are increasing so rapidly, in both children and adults. This hostile world that we live in. You know, if we were to go back 2000 years, it would be interesting just to see, you know, the incidence of skin disease now compared to then.
And from my point of view, in my experience over the last 30, 40 years, there are probably three or four things that spring to mind as to really what have given our skin a hard time. The most obvious one, perhaps, is the modern, dry world we live in. We have central heating, we wash to within an inch of our life. Dirt is the enemy and I think we both agree that, you know, a dirty child is a healthy child, a lot of the time.
Antibiotics, we mentioned the microbiome before and antibiotics, you know, interfere with that. And obviously, unfortunately, you know, as we live longer and get older, our skin thins and we make less, less grease or sweat. So, that's my take on that. Would you concur with those, if you like, the 'big four' that perhaps have changed compared to 2000 years ago? Absolutely. I suppose also, infections were often lethal...
Yes. ...2000 years ago and things like scarlet fever were catastrophic until modern days, um, when the bacteria became less virulent and we had treatments for it. But no, absolutely, our ancestors lived in humid worlds. This world we live in now with carpets, dry walls, modern building standards, air conditioning, as you mentioned, and central heating; it means that we have this very dry environment for our skin. It didn't use to have to cope with that dry environment.
I think people underestimate just how damaging washing is. If you just look at the prevalence of atopic eczema in children after the Second World War, i.e. in living memory, about 1 child in 40 had eczema. It was that sort of number. It's now 1 child in 4 has atopic eczema. I can think of no other inflammatory condition affecting the body, um, that has increased in that way. And it's just increased absolutely continuously.
It's plateauing now at this epidemic level and so what has changed in these 70 years? I think, as you say, I think it probably is our washing. Our ancestors, up until about the end of the Second World War, washed maybe once a week. Certainly if you go back a few centuries, people very rarely washed or not at all. Yeah. And washing does a lot of harm. Not only does it wash off the body's natural microbiome, which is important, but it also raises the pH, rendering the skin alkaline.
And that is very damaging to the top layer of the skin, to the barrier of the skin. The barrier becomes weaker. But it also degreases the skin. Detergents are designed to degrease and the grease is a top layer on top of all that skin that prevents water evaporating. So detergents are very damaging to the skin. As you mentioned, antibiotics. They will wipe out that microbiome, which is healthy and it keeps things at bay.
Older people don't make much grease and they certainly sweat a lot less and sweat is acidic. So their skin is particularly vulnerable. So I totally agree with you. Yeah, all those. When I talk to patients about antibiotics, some of them now uh, they have made a link between taking oral antibiotics and their gut flora, their gut microbia. But they really don't twig that it can impact on their skin, uh, as well.
You sometimes just have to talk about that with them when you're prescribing antibiotics. But the rise and rise of dry skin because of all the reasons that we've mentioned, these obviously can then be exacerbated by the common mistakes that people with dry skin then make. Which in all fairness, they think they are doing the right thing but actually their skin is really protesting at what they're doing. I mean, I've got a little handful of tips that I always give to my patients.
What are your messages from the wayside pulpit when you're talking to someone with dry skin about what to do and what not to do? I can't tell you how often I've seen somebody with essentially a dry skin condition, eczema, psoriasis, maybe even rosacea and when you talk to them, you discover that they're still washing with detergents. They're using a shower gel. They're washing their hair and they're vigorously rubbing that down onto their itchy, dry scalp.
And they're allowing that shampoo to rinse off over their skin. Down past their dry, cracked legs and onto their dry, cracked heels, which they're standing on in this broth of detergent. [They] may be using a foam in a bath. Having a bubble bath occasionally and they're using soap on their skin and vigorously adding it to the skin. All these detergents, these harsh detergents are powerful alkalis and they all degrease the skin.
And I say to them, look, your skin will never get better until you stop [using] those detergents. Instead, you can wash with an emollient as a soap substitute. Emollients are balanced to preserve the acid mantle. They have a slight acidic buffer in them, so maintain that acid, um, buffer. They also will regrease the skin when you're washing, rather than degreasing it. So, washing with an emollient can dramatically change things. Really, really important.
That's probably the most common mistake; that people are continuing to wash. I haven't used shower gel. I haven't used shampoo, perhaps for other reasons. But, I haven't used bubble bath or any soap on my skin, apart from my hands, for over 20 years now. I wash with an emollient. I wash every day, but I wash with an emollient. I think the next problem people have is that they, sometimes after washing, they apply an emollient.
Which is the right thing to do, when the skin is still nice and moist and a little bit warm, from the, hopefully not too hot, bath or shower. If it's too hot, you'll melt off natural oils and make it more itchy. But then they rub their emollient in, or their creams in, far too vigorously. They need to be stroked onto the skin and in the same direction as the hairs. So you just stroke the emollient on all over the skin. In eczema, the whole skin is abnormal.
Not just the areas where you've got visible eczema. The whole skin has a raised pH. The whole skin has an abnormal microbiome. So the whole skin needs to be treated. Same with psoriasis. And that is actually a point that is often forgotten. Not only by patients, but also by, I think, some healthcare professionals who concentrate on the inflamed part of what you can see and ignore the other, sort of, nine-tenths of the iceberg under the water that you can't. Yeah, absolutely.
It's such an important point. It really is. So you need to cover the whole skin and I say you need to put enough on. Actually, I say to little children, "can you draw a little face when you've applied it or write your name?" It's that sort of quantity you should put on and within a couple of minutes it soaks in. So, just stroke it on, the whole skin, in the same direction as the hairs. Just doing it gently. Another problem I see is all ointments come in tubs and some creams come in tubs.
It's unforgivable to put a cream in a tub because you could have a pump. But if you extract the cream or the ointment from that tub with your fingers, we now know that within a week the cream will become contaminated. Then the next time you put that on to your broken skin barrier, you're putting back bad bacteria onto your skin. It can cause an eczema flare or an infection. So you should extract it with a spatula or a spoon.
There's one product now, AproDerm® Ointment, comes with little green spatulae in the lid. Which I think is a really good message for our patients to extract it with that spatula, you can then clean the spatula, let it dry, and it won't carry infection into it. And if you're using the spoon, when I've seen this in some patients, don't use the spoon and then just leave the spoon on top of the tub quietly gathering bacteria. Use a fresh spoon every time.
Clean it and dry it that's, all it needs to be done. Yes, exactly. And occasionally put it in the dishwasher, I guess. And I think, the other thing is, people use too little. Emollients are not expensive and, if you're going to use enough, you need a few kilograms per month. Um, NICE, the National Institute of Clinical Health Excellence, advise that a child with eczema should expect to get through half a big pump dispenser. 250 grams per week. So they need a kilogram of emollient per month.
That will raise a lot of people's eyebrows. Absolutely right. Absolutely correct. But, when people are used to getting 30 grams prescribed or 60 grams, they're homeopathic levels of emollients. If we're going to, I suppose, have one take-home message amongst all the many, in this particular podcast, it would be always get enough emollient. You almost can't have too much. If you are having to, sort of, go back repeatedly to get small tubes of ointments or creams, it's being done all wrong.
The only advantage of the small tubes is perhaps to have one in your handbag or one in your car, so that, uh, when you're out and about you can use some. But absolutely, couldn't agree with you more. So we'll talk in the next podcast about emollients in a little bit more detail. But from the point of view of this one, you can really, I think, already just see how crucial our skin is, not only to our general health and wellbeing, but also to our survival.
Also, it's important to keep it so well moisturised. And for those of you listening, I hope you found this interesting. Huge thanks to AproDerm® for all their help in putting these Skin Deep podcasts together. We couldn't have done it without them. Absolutely. So until the next time, it's goodbye from George. Goodbye. And it's goodbye from me. Goodbye.