#56 Mirror, Mirror - The Science Behind Skin & Cosmetics

Dr. Julia Carroll, Ontario Regional Director of the Canadian Dermatology Association


March 13, 2019

Step 1, wash face. Step 2, tone. Step 3, apply serum. Step 4, hydrate. Sound familiar? Most of us have a facial routine that looks something like this. While the amount of steps may differ, most would agree that they follow a variation of the above regime. Today's episode questions where this and other daily hygiene/cleanliness routines come from, and explores the unique intersection at which dermatology lies - between medicine, and beauty. We talked to two dermatologists, medical professionals that specialize in the domain of skin, hair and nails for this purpose. Dr. Sandy Skotnicki, Founder of the Bay Dermatology Centre and Assistant Professor in the Department of Medicine, University of Toronto, told us about her new book Beyond Soap, exploring our culture's hygiene practices, and enlightening us on the sinister side of soap. Dr. Julia Carroll, Ontario Regional Director of the Canadian Dermatology Association, discussed the complex interplay between dermatological conditions and cosmetics, and how these things are hard to untangle. To wrap up, we asked the question we know you are perhaps most interested in: what are the most essential products for healthy and well-balanced skin? Tune in to find out! Until next time, keep it hygienic - not clean!

Written by: Alexandra Mogadam

Dr. Sandy Skotnicki's Website
Beyond Soap by Dr. Sandy Skotnicki and Christopher Shulgan
Dr. Skotnicki's Clinic
The Product Elimination Diet
Dr. Carroll's Clinic
The Canadian Dermatology Association
CDA Recommended Skincare Product List

Mashup [0:00] Christina found this magical world where doctors are happy and patients are pleasant, and no one is screaming, or stealing surgeries. Everyone just rubs each other all day long. Do you know how much easier our life would could be if we could just rub lotion - *record skipping sound* - Ladies and gentlemen of the class of 99, wear sunscreen - I believe in taking care of myself. I use a deep pore cleanser lotion, then a honey almond body scrub, then I apply an herb mint facial mask. I always use an aftershave lotion with little or no alcohol, because alcohol dries your face out and makes you look older - I have a horn growing out of my head. Okay. It came to a point where I couldn't squeeze it anymore, and that's called a pilar cyst - My skincare routine. My morning skincare routine. - Skincare routine.

Eryn Tong [0:58] What's the largest organ in your body? If you get skin, you'd be correct. Open up any magazine, Instagram influencer account, or morning talk show, you'll see an ad for the top 10 products you must use for beautiful glowy skin.

Eryn Tong [1:11] Or walk down the aisle at Shoppers or at Sephora, and you're greeted with a million types of creams, oils, serums, shampoos and cleansers.

Richie Jeremian [1:17] We're constantly inundated with advertising on the most essential products, or the best skincare routines, with very little across the board consensus. It's hard to know whom to trust and what actually works. This is understandable because at the end of the day beauty is a business, and one that is valued at just over half a trillion US dollars globally.

Eryn Tong [1:37] I'm Erin.

Alexandra Mogadam [1:37] I'm Alex...

Richie Jeremian [1:39] I'm Richie. Welcome to Episode 56 of Raw Talk.

Alexandra Mogadam [1:54] On today's episode, we went out of the laboratory and into the lavatory to find out more about our largest and most visible organ. We delve into the field of Dermatology which is uniquely situated at the intersection of medicine, cosmetics and surgery. We went searching for the most evidence based information so you don't have to. The first thing we tackled is our society skincare slash bathing practices. This is something that is ingrained in our culture. But where did these routines come from? Are they actually beneficial from a medical or beauty perspective?

Dr. Sandy Skotnicki [2:25] Everything you read in the magazines everything you're told, pediatricians, family doctors, and physicians know that we don't need to clean as much. So we tell that to patients, but we're going against a huge marketing that says get the body washes, put on the lavender, the bath bombs, mango shampoo...Like they're all chemicals and the skin has to deal with them, and it's not necessary, especially in children. As far as how do you deal with in the drugstore, read my book.

Eryn Tong [2:54] That was Dr. Sandy Skotnicki, a dermatologist specializing in allergic contact dermatitis or skin allergies, and has been practicing for the last 22 years. She's the founder of the Bay Dermatology Center, an Assistant Professor in the Department of Medicine at the University of Toronto, and she teaches at St. Michael's Hospital. As you may have just guessed, she recently published a book called Beyond Soap.

Richie Jeremian [3:14] She was propelled to write this popular science book because of the skyrocketing prevalence of unexplained skin reactions we're seeing nowadays, and because there's a lot of misinformation about skin health in the general public. It's a fascinating read and incredibly practical, and we highly encourage you to get your hands on it. She helps us turn a more critical eye towards what we as a society seem to know about skin, skincare, beauty products, anti aging, and even our hygienic practices, which we've certainly never questioned ourselves before.

Alexandra Mogadam [3:42] One particular quote in the book that struck us was, "the washing practices that keep us healthy and hygenic are a lot less rigorous and the washing processes we've been socialized into thinking keep us clean."

Dr. Sandy Skotnicki [3:52] I interviewed quite a few physicians and basic science researchers in particular, Dr. Sally Bloomfield in London. She is a professor emeritus of the London School of Hygiene and Tropical Medicine, and she was very generous with their time. A lot of that comes from her, and that was an aha moment for me too. I mean, hygiene is basically what we need to do to decrease the transmission of disease. In this day and age, in North America or westernized countries, its washing your hands. The washing of your hair and your body, and all that, is being clean, and we've sort of mixed them up. People think that washing their body every day with a detergent or soap is actually good for you, and it's not. I think if you talk to Europeans all Europeans know that. It's interesting because I don't think they've been bombarded as much with the advertising as we have. It's very true, we over wash ourselves, over clean ourselves, and it's not about hygiene.

Eryn Tong [4:53] This blurred line between hygiene and cleanliness is an interesting one. It definitely got us thinking, when and where did we learn to adopt out current washing and bathing practices? Are they truly for the purposes of hygiene? Dr. Sally Bloomfield, as Dr. Skotnicki just mentioned, has coined the societal phenomenon as a cleanliness obsession.

Richie Jeremian [5:11] At some point, we've moved away from hygenic customs to protect ourselves from infectious diseases into an over obsession with cleanliness. In other words, a complete absence of dirt and feeling fresh and smelling nice. These are really more about societal desires rather than for health purposes.

Alexandra Mogadam [5:28] So why is over washing or over cleaning our skin and hair not good for us from a biological perspective, what is really happening to our skin when we put on cleansers, oil, serums, creams, eye creams, etc.

Dr. Sandy Skotnicki [5:40] One of the most important analogies I think I use in the book, right off the bat, is the sort of brick wall analogy, its much more complex than that, but it obviously this is for the public. I think even for me, it was a bit of a aha, so we have this incredible permeable membrane, our skin, which is basically evolved with us over 200,000 years. It is our gateway, and so if you think of it like a brick wall, the cells are sort of the bricks of the outer skin. Then the mortar is your natural oils or lipids, and the act of washing, just water itself, decreases the mortar. When you add in soap and cleansers, being much worse because it's alkaline, there's a pH thing that we haven't talked about yet, but essentially, washing with soap cleanser and water decreases that mortar. So you get a leaky wall. It's kind of like the leaky gut analogy. What happens is you can let in chemicals easier, allergens, irritants, now pollution. People who scrub their face thinking they're doing a good thing and then they go out, and it's the pollution that can go through the leaky brick wall. So modern day skincare does that to the brick wall, it damages it. I was watching a series on the TV about sort of 1960s, and they all use cold cream. I mean we've known, and the soap industry knows as well, because soap is very damaging It's high alkaline, and it removes the mortar more. So that's why there's been this transition to cleansers, but with everybody wanting to go more natural, they want to go back to natural soap. It's not good, mostly because it's not pH balance. We haven't talked about the microbiome, but the microbiome is exploding. I find it fascinating, because my degree is Microbiology and Immunology. The skin is acidic, it has a pH of about 5 to 6, 5.5. Interestingly, internally we're more neutral, we're more around 7.4. So the skin is acidic, partly because we now know the pH maintains that brick wall, and the microbiome, which needs this acidity to grow, has something to do with that. We don't understand what it is because in diseased skin, like eczema and psoriasis, the microbiome was less diverse and different, and we don't know why that is.

Richie Jeremian [8:03] If what Sandy is saying is sounding familiar, you may have already listened to Episode 48 on autoimmune diseases. We explored concepts like the leaky gut and the microbiome in the context of diseases like Crohn's and type one diabetes, definitely go back and check it out. We were interested to hear the microbiome is just as important on our skin as it is in our gut. We asked Sandy to unpack the role of the microbiome and the health of our skin.

Dr. Sandy Skotnicki [8:28] Well, when you think about it, it kind of grosses you out a little bit. Some interesting facts, we have more microbial genomic material, which is DNA, then human DNA. So right off the bat, that's staggering, right? You got to wonder, what's it been doing? Or what have we been doing to it? The microbiome is on the skin and in the gut. There's more bacteria than human cells, fungus and viruses as well, it's not just bacteria, and no two people's microbiome is the same. The microbiome can help protect us and train our immune system. There's studies to show that in mice that are born into sterile environments, their immune system doesn't develop. So you need the microbiome on you to train your immune system. The question is, have we been altering it with our modern day skincare? The microbiologist I interviewed for this book, agree that we're probably doing something but it's so early. The research is in its infancy. I think it's interesting that wasn't the point of my book but with my research I was like, wow. Nobody puts the pH of their products on the label, and if we're alkalizing our skin that's damaging the barrier, and changing the microbiome.

Richie Jeremian [9:53] Now that we have a better understanding of what's happening to our skin on the micro level, let's zoom out and look at how our skin might affect our mental well being.

Alexandra Mogadam [10:01] Let's be honest, we all care about our skin and are at least somewhat invested in it, because it really is our most visible orgon. It's how we present to the world. We wanted to learn more about the intrinsic connection between how we feel on the inside, and how we look on the outside from a dermatologists perspective.

Dr. Sandy Skotnicki [10:17] Just in my clinical practice, I think when people are more happy with themselves, they take better care of themselves. If you take better care of yourself, all of those take somebody who thinks they're worthwhile to take care of. If you don't have the self worth, then it all affects your aging, because you're not going to age as well because you're not taking care of yourself. I find that the whole Botox thing with young people very frustrating, because there is a body dysmorphia there. They're looking at these people on Instagram that have all been photoshopped. So when I have 20 year olds come in asking me for Botox, I do sit down, have a discussion with them. You know, I've changed my tune a little bit. As I'm getting older, I used to be very staunch and like, "you don't need this", but they're going to go somewhere else and do it. So yeah, I try to gauge if there's any issues that I may refer them, but I sometimes will give them like two units of Botox around the eyes just to make them feel like they're doing something. I know if I don't, they're gonna go somewhere else and someone else might take advantage of them. I don't know if that's right or not, but that's my conclusion. There's this huge stress on young people to look a certain way, and be a certain way and some of that comes from the company's like, "Botox is preventative, you have to start it early". You can start it in your 30s you don't need to start it in your 20s, and nobody needs Botox. The whole cosmetic aspect with dermatology bothers me sometimes. I mean, I do do it. But I think I tried to do I have a full service practice, I'm not just cosmetic. I do all dermatology, I see kids, I see elderly, I see skin cancer. I offer it. I see a lot of moms, they bring bring their kids in, they'll have a mole check and they'll go "can you give me a little Botox"? I'm like, "sure". It's like hair dye. I kind of liken Botox nowadays, to hair dye. Because in the 50s, it was like, "oh, that's dangerous, that's a chemical. Why are you doing that?" So it's the unknown kind of thing. I mean, there's nothing wrong with doing something that isn't harmful to you that makes you feel good, and doing it appropriately by a trained physician or injector. But I struggle with it a little bit.

Eryn Tong [12:31] The idea of keeping an eye on patients who may be seeking extraneous cosmetic treatments isn't unique to Dr. Skotnicki. Dr. Julia Carroll, another Toronto dermatologist echoed her sentiments. Melissa caught up with Dr. Carol over the phone.

Dr. Julia Carroll [12:44] Over the years, I've referred the odd patient on to a psychologist for like very extreme cases. I've actually ended up managing quite a lot of those patients on my own in the meantime, because it's very hard. Just because of resources, it's hard for them to get into see a psychologist, so I try to keep them sort of connected with me and under my wing. Particularly there's a condition called body dysmorphic disorder where people are obsessed with a part of their skin, or something they see in their body. What they see is in their mind more dramatic than then what everybody else sees for them. So it's in that sort of same category as like anorexia or bulimia, where there's like the inside view doesn't match what the rest of the world will see. So some of those patients, I'll try to sort of just keep under my wing because I don't want them to fall prey for somebody who's going to sell them something or do something that's unreasonable just for financial advantage. So I try to coach them into seeing how they truly look and then try to get them some help there. But that's pretty uncommon. I would say the majority of patients that come that are younger, if they ask about cosmetic concerns sometimes we'll sort of get to the bottom. I always ask about their family, how their parents age, whether they had acne when they're younger. So we go through all those things. If there's a legitimate concern, I'm okay to treat it but usually we'll look at some preventative measures and skincare, maybe some chemical peels, things that we can do that are going to make them feel that they're being preventative and helpful for their skin, but not really jumping into the more advanced cosmetic treatments.

Richie Jeremian [14:24] Both Dr's Carroll and Scotnicki are members of the Canadian Dermatology Association, and Dr. Carroll is actually the Ontario director on the CDA board. When we started doing research for this episode, we were overwhelmed by the wealth of conflicting information out there on skin health, and we suspect that most of you listeners are as well. As you may have guessed, Dr. Scotnicki advocates for less is more approach to skincare. You'll hear about hers and Dr. Carroll's own routine must haves in a little bit. But for those of us who aren't dermatologists, how can we wade through the information overload and figure out what's accurate? The Canadian Dermatology Association seemed like a good place to start.

Dr. Julia Carroll [15:03] So I am the Ontario director on the board of the Canadian Dermatology Association. So I basically bring the concerns of Ontario physicians, and somewhat Ontario patients, to the Canadian Dermatology Association Board. Then I served on a number of committees as well. So I serve on the Clinical Practice Guidelines Working Group, I actually chair that group. Then I'm also in the Pharmacy and Therapeutics Committee and the Education Committee. So, within the CDA, there's lots of subcommittees and we do a lot of a lot of projects. You know, really our goal is to advance science and the art of medicine surgery as it relates to skin, hair, and nails. It's not just skin. Its skin, hair and nails. It really encompasses dermatology. So if we look at professional development for our members, we also support patient care. We provide a lot of public education, particularly when it comes to sun protection, but also other aspects of skin health. We want to really just promote a lifetime of healthy skin hair and nails.

Melissa Galati [16:03] Right? So how do you go about achieving that goal other than having those resources available on your website, for example?

Dr. Julia Carroll [16:11] So there's lots of different things that we do, some of the fun things we do is we have Sun Awareness Week. So that's a week, it's in June, and we really try to get the word out from a CDA level, but also our members across Canada will put a push out. So sometimes that could just be something local that you do in your office with your patients to talk about sun protection, and skin cancer, and a lot of us do media around that topic as well. There's World Melanoma Day that we participate in. So we go to Parliament Hill, and the focus there is really trying to change the behavior of Canadians regarding sun protection. Recently, myself and a number of women who were involved in an outreach program, where we actually went into shelters to educate women and children on skincare and give them an economical options of things they can do to improve things like acne, eczema, melasma. Things that might affect them outwardly, but would also, you know, affect them inwardly when they're at a vulnerable time in their life. Maybe they're out for a job search or just trying to get some things organized, so we gave them some tips there. We've made public service announcement, particularly on psoriasis or indoor tanning. So there's a great series of videos called "tanning is out". It just talks about the perils of indoor tanning, and tanning in general. Then we have some interesting product recognition programs. So for us, theres a lot of products out there and we're the experts in those products. So we wanted a way to communicate that to patients in a broader way. So there is a CDA symbol that is on products, there's a particular one for sunscreen. Sunscreens have to be broad spectrum, a minimum SPF of 30. they have to be minimally fragrant, low irritation, and then we don't want them containing the most common allergens that we see. Then there's a similar program just for skincare products outside of sunscreen. So that's just the tip of the iceberg of what we do.

Alexandra Mogadam [18:10] So the CDA is heavily involved in advocating for greater understanding of skin, hair and nail health. But what defines the nitty gritty of what goes under the umbrella of health? Dermatology exists at a unique intersection of medicine and cosmetics. When does something like acne, for example, stop being medical and start becoming cosmetic.

Dr. Julia Carroll [18:29] I'm going back to acne specifically, I think that's a great example. But I think it's really important to just stay off the top that acne is not just a cosmetic concern, it's a disease like it has chapters in textbook. So it really is a disease. Some of the sequelea might be more cosmetic. I think that's the interesting thing is that, you're right in that there is this gray zone, and it sort of where does one end and the other begin? So when I'm talking to teenagers or young adults about, or their parents, about acne and about trying to get them on certain treatments, sometimes they'll sort of say, "ah, you know, it doesn't bother me." Or the parents are a little hesitant to do something might be a little bit more aggressive. Then I'll sort of point out that you don't know the decisions that you or your teenager are making because of the acne that they have. So you know, if they have really bad acne on their back, like classic back-nee we call it, or they have that big pimple on their cheek, like what decision are they making? What's that going to do further on their life? Are they quitting the swim team? Are they not trying out for ballet? Or are they opting out of social events with their friends? If you just don't know what the dolphin effect of that is, you don't know that the person that quit the swim team might have gone on to get a scholarship to university, and then that might have led to them going into medicine or law. You don't know. So, you want to give people in this vulnerable time in their life, like all the support that they can. For me, what I can give is, I can help them treat and control their acne so that's one less thing that's gonna impact their confidence.

Richie Jeremian [20:09] Like it or not, most of us care about the way we look. Our skin is how we present to the world. So maybe it's no surprise that people are hyper analytical of their skin. Dr. Carroll explains it this way: If we were able to see our internal organs, liquor liver, for example, we might be more aware if some aspect of it changed and more likely to see a liver specialist. It's why dermatologist see a range of cases from medical to cosmetic.

Dr. Julia Carroll [20:35] So I don't think gap is the best term because that seems like there's a grip on one side and a grip on the other side. I think it really is a spectrum because, with the acne example, the disease is acne, and maybe the cosmetic issue is more acne scars. But really if someone has horrible acne scars, I still think that should be under medical. A lot of where the division goes is what is covered, for example, in Ontario under OHIP and what is not. It's not even a decision the dermatologist can make. But a lot of it just really is a spectrum. It's interesting, because if you look at the cosmetic treatments that we have, a lot of them came from the medical world. For example, Botox was used in medicine long before it was used in the world of cosmetic dermatology. The same can be said for this interesting injectables that we have. The majority of products that we have come from medicine first, and then we find out they have a cosmetic use. So you know, it's really a mix, like most people that come to me with a medical concern, there's a cosmetic concern as well. They don't like the medical thing because of the way it makes them look, or sometimes feel, but it's very intertwined.

Eryn Tong [21:50] We wanted to know more about how the Ontario Medical Association (OMA) makes decisions about what procedures are covered under OHIP. Are dermatologists involved in these decisions?

Dr. Julia Carroll [21:59] One of the ways that we define what's cosmetic and not cosmetic is often just based on what OHIP covers, and what OHIP doesn't cover, but there are dermatologists that are involved at the OMA level. So the medical association do have some say in what is on the schedule of benefits and what is not. So it's always a balancing act, right you're looking at you have this pot of money, and that the amount of money that as dermatologists you can spend for health care for your patients. So you have to look at what is gonna be funded with those funds and what is not. You know, for example, skin tag removal is something that used to be funded years ago, or vein injections. Those are no longer funded by the government so those are considered cosmetic. I think you have to decide whether that's the right word or not, but I think that's where there's a clear delineation of this is covered by OHIP and this is not covered by OHIP. Many of the things that are not covered by OHIP would fall under a more cosmetic concern.

Richie Jeremian [23:06] The delineation of what's defined as cosmetic versus medical under OHIP mostly corresponds to procedures like skin tag removal, as Dr. Carroll mentioned., with the exception of OHIP plus which covers individuals under 25 and over 65. Prescriptions aren't covered in Ontario, which means that if you're not covered under private insurance that you've purchased, or your work or spouse provides, you're essentially paying out of pocket. But like many other specialists, Dr. Carroll often advocates for her patients who may not have the financial means to obtain treatment.

Dr. Julia Carroll [23:39] We advocate for our patients all the time. We will usually, if they have insurance, we will start by advocating with the insurance company. So sometimes it's just as simple as filling out a form. But we'll take a look at, the good example is like psoriasis, and edema, so we'll look at the impact that it's having on their life. There's a quality of life assessment that we do, we'll look at the severity of the disease and how much of their body it's covering. Then we can look at other things as the disease, for example say psoriasis is also affecting their joints. We can look at what medications have they tried in the past, and what medications are not suitable for that particular patient, then perhaps advocate for one of the newer medications. So we can advocate to their insurance company. For some of the medications drug companies specifically will have something called compassionate release. So you can advocate to the company and say, "look, I have a patient and they have psoriasis, they have a eczema, they have hidradenitis suppurativa is another condition. A lot of those companies will actually release the drug at no charge, or depending on the patient means, less charge to the patient so the patient can get treated. I've seen that go on for years, or they'll be treated on a very expensive medication, or the company will simply just give it to them. If the patient doesn't have insurance that there's no compassionate release available, there's also government programs that you can work with, like Trillium, that you can help get the patient some coverage through the government. So there's usually a way. Then a lot of us are involved in clinical trials. So sometimes you can get patients into clinical trials and thats the way to get them medication that's covered.

Alexandra Mogadam [25:21] So it's more difficult than we thought to parse out what treatments are medical or cosmetic, and dermatologists spend a lot of time advocating in cases where conditions are seriously affecting a patient's well being. But some procedures are pretty clear cut. Botox and fillers, for example, easily fall into the cosmetic camp. Since the wait times to see dermatologists are often pretty long, we wondered how Canadian dermatologists are dividing their time.

Dr. Julia Carroll [25:44] Interestingly, we actually have just finished a survey at the Canadian Dermatology Association of our members to find out exactly where people are spending their time, and what type of practices people have. It turns out interestingly, in Canada that 85% of dermatologists still have a general dermatology clinic so they see all comers. There are 5% of our dermatologists who are only cosmetic, which I was surprised with. It's much smaller than that I assumed. Then there are a few very specialized types of dermatologists. For example, there's a subspecialty called Mohs surgery, which is a type of skin cancer surgery, some people only do that. Then there's a lot of people that say only do hair transplants, but the majority of our members see it all. So they will see everything from baby to octogenarian, they see men and women, they see skin cancer, they see psoriasis and eczema, and then they're probably doing a little bit of filler, Botox, laser, as well. It really probably depends on sort of the demand that's coming their way from their community, and then also what they have an interest in. Just like if we're doing an English major, their going to have a particular era, or a particular author. It's similar in dermatology, people find their niche, or they're doing research in a certain area. So all those things play into how the dermatologist is getting split up their day. Then the other thing is a lot of us as dermatologists are educators as well. So we're teaching at the university level. We're lecturing conferences, so there's a large component of trying to educate the up and coming group. We know that one in three dermatologists are planning to retire, I think in the next five to 10 years.

Eryn Tong [27:29] Although we focused a lot on skin well being and cleanliness, you'll be amazed to learn that dermatology is a huge field that encompasses so much more than just skincare. These include many diseases such as skin cancer, psoriasis, rosacea, vitiligo, hair loss, eczema, dermatitis and chickenpox. There are many different treatment options including biopsy surgery, cryo therapy, dermabrasion, injections, hair restoration, and so much more. So it should come as no surprise that, just as with any other specialty, one of the backbones of improved care for patients is the dissemination of research knowledge into the clinic.

Richie Jeremian [28:01] Durham is highly interdisciplinary and covers many fields of science and medicine. This includes physiology, microbiology, endocrinology, rheumatology, histology, and several others. As such, the Toronto community has a healthy group of dermatologist researchers who are hard at work and driving for discoveries that impact the lives of patients. One of these groups is located at Sunnybrook Hospital and specializes in the epidemiology of skin diseases, hair conditions, as well as rare skin disorders, the treatment of burns and skin lesions and even skin related side effects from chemotherapy. They treat patients of all ages, including a focus on pediatric dermatology. Another major center is Women's College Hospital, which has clinics that are specialized in Mohs surgery, wound care, melanoma and pigmented lesions. Women's College Hospital also has a multicultural academic dermatology clinic for patients with non-caucasian skin. Collectively, these two centers treat over 80,000 patients a year, and both place a huge emphasis on patient education. Furthermore, closely affiliated with the centers is the UofT dermatology residency training program that allows highly motivated medical students to gain the clinical and research skills they need to excel as dermatologists.

Alexandra Mogadam [29:18] Dermatology also has many ties to industry. This includes privately funded research, particularly around the development of drugs, cosmetics, and treatments. This makes it all the more important to take a critical lens when interpreting industry research findings. To put this in perspective, a 2016 study published in JAMA Derm has identified that dermatologists in North America receive millions of dollars each year for consulting, product endorsement, research collaborations and speaking engagements. Another study found that although physicians disclose their ties as mandated by law, the majority chose not to report the exact amounts received. This finding highlights the potential for conflict of interest that must be disclosed. But on the bright side, there is a trend towards increased transparency, which ensures that physicians continue to act in the best interest of their patients. This is all to say that research can come from many different sources and can be used to improve care, increase knowledge, and also to bring new innovations to the market.

Eryn Tong [30:13] Now to answer the question you've all been waiting for, what did the dermatologist actually recommend to us? We ask Dr. Scotnicki to unveil her secrets and walk us through her own skincare routine.

Dr. Sandy Skotnicki [30:24] Yeah, and I'm very forthcoming with what I do, which is not a lot. I think in the book, I talk a little bit about aging and genetics. I mean, 60% of our skin, unfortunately or fortunately, is genetics as far as aging and looks. Then, whether we smoke and how much sun we get is the vast majority. Product is a very small amount. I don't really wash myself very often, I never use soap, I only use cleanser, which I don't have any financial- I use Cerave or Cetaphil. I only wash my bits, like underarms, groin, feet maybe. If I have a workout or something, I just shower, I don't use soap again, or cleanser again, maybe just under the arms. I wash my hair only twice a week because I use dry shampoo. Actually it's a funny story, my youngest son, when I was writing the book, he didn't tell me this, but he stopped using everything. He didn't use any soap, any cleanser, any shampoo. He told me this after about six months, and he was fine. Absolutely fine. Absolutely. Of course, he washed his hands. That's the extreme. I interviewed a fellow, a couple people, who hadn't done that. I think if you understand the brick wall analogy, you need to use moisturizer. You need to use product because we're damaging it when we wash. Same with your hair. So if you wash less, you have less damage. People will write me on Facebook, and email me and say, "you know my life's changed, I don't need to use any moisturizer," because you're damaging it. As far as face care, I never washed my face, I use a micellar cleanser, which I put it on the pad and use that. So I never put water on my face anymore. I use a sunscreen in the morning that's tinted that has titanium. So titanium is a physical block for pollution. It's also sunscreen, and you get some tint so it's a makeup. At night I use bit of retinol and some vitamin C. And that's it. Yes, most dermatologists they all use sunscreen and retinol. Part of the reason there's other products is because of marketing, but also some people can't use retinol. I talked about that in the book. So there's other categories like peptides, and growth factors which are the newest kid on the block with the science a bit lacking. I don't think that you need to do a lot. But sunscreen is paramount. The most important.

Richie Jeremian [32:46] What did Dr. Carroll have to say?

Dr. Julia Carroll [32:48] Sunscreen, sunscreen, sunscreen...

Melissa Galati [32:55] ...It's good that you guys are completely unanimous on that everyone. That's the first thing everybody says...

Dr. Julia Carroll [33:01] The intersting thing about sunscreen is, we all love our sunscreen, but I also think it's important for people to know that sunscreen is really your third line of defense when you're talking about sun protection. So first is avoiding, so you don't want to put yourself out there in the middle of the day, you're better off seeking shade. The second tip is just covering yourself. So protective clothing and hat and then sunscreen. You know, we all say "sunscreen, sunscreen". But really that's just part of the picture. Back to your question about products. I would say my three non negotiables are- and we're talking about your classic patient who's looking at preventative aging. It's different if someone has acne or someone has rosacea, someone has melasma. The core product that we all believe in, I think the first is sunscreen. The second is something exfoliating so tretinoin is a prescription product that is helpful for chemical exfoliation. It also increases collagen production. I can spot from across the room, someone who's been a very diligent tretinoin user. You can just tell by their skin, you can say, "you've been using a retinoid for 20 years." How can you tell? I can just tell. Then there's baby versions of that, there's retinols if you can't handle something in that tretinoin family, use glycolic acid. So just something that's turning your skin over is helpful. Then antioxidants are really important as well, because even with sun protection and sunscreen, some of the ultraviolet damage is going to happen in your skin. So antioxidants do help mitigate some of those harmful rays that get in and the damage that they cause. Particularly they cause free radicals. So the antioxidants do help to mop up some of those free radicals.

Melissa Galati [34:45] How are the antioxidants usually marketed as?

Dr. Julia Carroll [34:49] Vitamin C is the classic one. So it's l-ascorbic acid, and L stands for left. So their market is vitamin C product. I think that it's important for people to know is like, there's a ton of marketing hype out there. So there's a lot of "me too" products that will say they have things and they just have enough to say it in the bottle. But is it enough that's doing something? Not always. So you know, for example, in the vitamin C's, we like a 10 to 20% range of vitamin C. Under 10, it's probably not doing anything over 20, it's probably irritating, or it's not worth any more. So it's important to look on the backs of the bottles and look at the ingredient list and the percentages to make sure that you're getting enough of the active ingredient to make it worth the money and worth the time to apply it.

Melissa Galati [35:37] In terms of the the retinoids that you were talking about before, do people have to come and get prescription for those? Or is there something just like products that they can buy at Shoppers Drug Mart, for example, that are lighter versions of them, perhaps?

Dr. Julia Carroll [35:53] The gold standard is the prescription retinoid, but there are retinols that are available in drugstores, there's lots of different companies that make those. Also sometimes I suggest to patients that's a good place to start. Then they can kind of work through the different percentages. If they do find they have no irritation, then I can give them a prescription as well. So it just depends on what they want. People want to go right for the bug guns.

Richie Jeremian [36:16] Dr. Carroll talked about the importance of antioxidants. The reason why antioxidants are important is because they offset oxidative stress, one of the major chemical processes that contribute to you guessed it...aging.

Dr. Sandy Skotnicki [36:33] Basically, we age because of oxidative stress. Every time you breathe, you're aging, because oxygen causes super oxygen radicals which damage us. So we're aging solely every time we breathe. So anything that decreases oxidative stress... the studies on nutra sort of supplements, eating collagen or taking high doses of vitamin C, all those there's some promise to them. The biggest one actually, I just did a article on, is on collagen. So collagen is our most common protein, it gives a structure and it decreases as we age, it breaks down. So if you eat collagen, the fish are sort of marine collagen, like the skin or the bones. There's been some actual double blind randomized control studies that it can help decrease aging. It comes back to common sense again, eat well, exercise, get your sleep, drink water. I mean, it's all stuff we already know. People that live in bigger cities age more because of pollution. They've shown that in the skin, several studies actually showing more brown spots and people that live in polluted areas. I don't know about the oxidative stress for that. Sunscreen is a cornerstone. So I talked about that really interesting study in the book that Olay did with Procter and Gamble that looked at exceptional agers. It was actually insane. I mean, you're a researcher, they did genomics, full genomics on all these people. It's like, a lot of money. They basically took non medical people, and they had them rank- I think was 200- let's just say stay for ease, how old they were. Anybody that was ranked at a younger age then they actually were, they then took those people, so they call them "exceptional agers", and they looked at their full genomics. They tried to see if there was any pattern. All the genetics that they sort of found that were different in these exceptional agers were about how the skin could protect themselves itself against UV radiation. So they had enzymes that could decrease the damage and improve medium dimers of the DNA in the skin, etc, etc. So, you know, it comes down to again, genetics, and in Asian and African American skin, you're ageless because your skin is more able to protect itself against UV radiation. The long answer to that is sunscreen is the cornerstone of anti aging treatment.

Alexandra Mogadam [39:05] Okay, that's all the skincare tips that we have for this episode. Remember, less is more and...

Dr. Julia Carroll [39:11] ...sunscreen, sunscreen sunscreen.

Alexandra Mogadam [39:15] The episode team learned a lot from today's guest and we hope you did too.

Eryn Tong [39:19] Thank you to our wonderful guests, Dr. Sandy Scotnicki and Dr. Julie Carroll for answering all of our burning skincare questions. If you're interested in learning more about them or skincare in general, we've compiled a list of resources in the episode description, including Dr. Scotnicki's book 'Beyond Soap' and CDA resources.

Richie Jeremian [39:36] Content development and hosting for this episode was done by Alex, Aaron, myself and Melissa. Audio engineering was done by Max, and until next time, keep it hygenic not clean.

Melissa Galati [39:47] Raw Talk podcast is a student presentation of the Institute of Medical Science and the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the faculty of medicine, or the university. To learn more about the show, visit our website rawtalkpodcast.com and stay up to date by following us on Twitter, Instagram and Facebook at Raw Talk Podcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.

Richie Jeremian [40:21] One of the major chemical processes that contribute to you guessed it...

Eryn Tong [40:25] dun dun dunnn....

Richie Jeremian [40:25] ...aging.