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Stress and the skin: the brain-skin feedback loop

Stress and the Skin

The relationship between stress and disease has been well described with many conditions proven to be triggered or exacerbated by stress. Well known examples are hypertension, migraines and epileptic seizures. However, does stress worsen skin conditions? The answer is a resounding ‘Yes’.  In fact, this has been clearly demonstrated during the pandemic over the last 18 months, when mounting emotional stress has triggered some skin diseases and caused other stable skin conditions to flare up.

While from clinical experience we are certain that a relationship does exist, are there any clear underlying mechanisms to support this?

Indeed, there is…. in embryology the skin and brain are derived from the ectoderm layer. As a result, it doesn’t seem a stretch to believe that the same cells and pathways found in the central nervous system (CNS) are also found in the skin.

What is Stress?

Stress is the body’s natural response to physical, mental, or emotional pressure from events in our life. When the amount of stress we perceive overwhelms our coping mechanisms, hormones are produced to adapt our body to cope with the stress. In the short term these can cause changes to blood pressure, heart rate, blood sugar levels and mood. In the long term, with prolonged stress there may be more lasting changes impacting our overall health as well as skin health.  These hormones are sometimes called ‘stress hormones’ and there are various pathways between the brain and the endocrine system releasing these hormones. 

The main pathway is the HPA axis (hypothalamic- pituitary-adrenal axis). Stress causes the hypothalamus in the brain to produce CRH (corticotrophin releasing hormone) which in turn causes the pituitary gland in the brain to release ACTH (adrenocorticotrophic hormone). ACTH enters the blood and cause the adrenal gland to secrete cortisol and glucocorticoids. Cortisol is considered our main ‘stress hormone’ and remains elevated in those with chronic stress. Interestingly the skin also has a peripheral HPA axis and CRH, ACTH and cortisol are released by various cells in the skin. 

Other important stress hormones, adrenalin and noradrenalin, neurotrophins, substance P and prolactin are released by cells of the brain and endocrine system as well as the skin. The result is that the skin is both a producer and a target of these hormones that mediate a range of effects impacting the course of many skin conditions. 

Skin and Stress

What are the effects of these stress hormones and which skin conditions do they impact?

In a nutshell ‘Stress hormones’ impair the skin barrier function, immune function, wound healing and fibroblast function.  These hormones also increase inflammation, sebum production, melanogenesis (pigment production) and angiogenesis (blood vessel production). Most of these hormone mediators have more than one effect.

Inflammation in particular seems to feature as the major contributing factor in the exacerbation of disease in general in the body as well as the skin. Stress seems to worsen inflammation by various mechanisms. 

As a result of these hormonal effects stress can aggravate conditions like psoriasis, eczema, acne, urticaria and rosacea or trigger new onset of a skin condition. Chronic stress can even accelerate the ageing process!

Atopic eczema/ Atopic dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterised by a defect in skin barrier function and a faulty inflammatory response.  Stress exacerbates AD by impairing the integrity of the skin barrier leading to trans epidermal water loss (TEWL). Stress causes release of hormones in the skin that increase inflammation and worsen eczema. Impaired barrier function also means that more irritants can penetrate the skin and further worsen inflammation. Common scenarios demonstrating the effect of stress on eczema include worsening of eczema during exams, pregnancy and conditions affecting general health and wellbeing

Psoriasis

Psoriasis is a chronic skin condition in which there is overproduction of keratinocytes and inflammation which leads to itchy, red, thickened psoriatic plaques.  

It is well known that psoriasis is worsened by stress, though the exact mechanism is still not quite certain. One theory is that activation of the HPA axis by stress causes increased ACTH and cortisol promoting proliferation and inflammation. Another is that increased substance P released by nerve fibres in the skin of patients with psoriasis triggers an inflammatory response.  High levels of cortisol have also been found in the blood and in psoriatic plaques of patients with psoriasis. 

Rosacea

Rosacea is a skin condition characterised by vascular hyperreactivity and resultant dilated blood vessels and inflammation. Rosacea sufferers flush in response to various stimuli like hot drinks, spicy food and emotional stress. Stress hormones increase inflammation, and skin sensitivity. Histamine released from mast cells in stressful situations also causes flushing.

Urticaria

In more than 50 % of cases the cause of urticaria or hives can’t be identified, but psychological factors have consistently shown to trigger episodes of urticaria. The most likely mechanism is anxiety causing the release of cortisol and adrenalin leading to inflammation as well as release of histamine from unstable mast cells.

Over production of sebum and/ or Acne

Stress does not directly cause acne but can worsen it. Stress causes the adrenal glands to produce more adrenalin, cortisol and androgens that in turn stimulate the sebaceous glands to produce more sebum. The follicles become blocked with sebum and dead surface keratin. This blocked follicle is the perfect environment for acne bacteria in the follicle to proliferate and trigger inflammation around the follicle resulting in acne or breakouts on the skin. CRH receptors on sebocytes promote sebum production. In addition ‘picking of acne spots” during times of stress also worsens acne.

Skin barrier function

The stratum corneum which is the uppermost layer of the skin has a combination of proteins and lipids that create a ‘seal’ on the skin. The skin barrier functions to prevents bacteria and irritants from entering the skin and maintains hydration by preventing water loss (TEWL) from the skin. 

Though the exact mechanism in unknown, studies have shown that stress, including reduced sleep can alter the protein and lipid content of the stratum corneum. This leads to impaired barrier function with consequent dehydration and a dry flaky skin. Untreated, this can trigger an inflammatory response and dermatitis.

Impaired wound healing

Fibroblasts and keratinocytes (skin cells) are key players in the process of wound healing which is regulated by various chemical mediators. There is evidence to demonstrate that elevated levels of cortisol and epinephrine which occur during periods of stress impair wound healing by affecting the functions of these cells.  Psychiatric conditions like anxiety, depression and dementia have been associated with delayed wound healing, presumably due to psychological stress in these patients.  The risk of skin infection during wound healing is also increased during periods of stress due to impaired immune function in the skin. An infected wound is slower to heal.

Wrinkles and fine lines and hyperpigmentation(chronic stress)

We know that genetics, lifestyle and environmental factors affect the ageing process, but emotional and psychological stress can be a big contributor towards ageing. While short periods of stress can sometimes benefit us chronic stress leads to suppressed immune function with increased susceptibility to infections, inflammation and skin cancers. 

The skin immune function protects against both ultraviolet (UV) damage and infection and consequently protects from skin cancers. With suppressed skin immune function there is a greater chance for skin cancers to occur. 

As we age our DNA shortens with each cell division. This process is called telomere shortening.  Chronic stress has been shown to further reduce the length of our telomeres, accelerating ageing.

Stress reduces the production of healthy fibroblasts which synthesize collagen and elastin and the extracellular matrix. This results in thinning of the dermis, loss of elasticity and resultant fine lines and wrinkles.

CRH causes increase in Alpha MSH which promotes pigment production in melanocytes which explains why skin hyperpigmentation can increase during periods of chronic stress, severe illness and even lack of sleep. 

What is the way forward?

There is more than enough circumstantial evidence to support the connection between the skin and brain. It seems that stress management should be an integral part of management of most skin conditions

The first step is to be able to identify our triggers of stress, then to start managing them as best we can. This is a difficult task as stress shows up in many ways and does affect the body as a whole. Most people may not even perceive that they are experiencing emotional stress and find it difficult to accept as a reason for their worsening skin condition. Doctors and dermatologists take care to first exclude all possible explanations for exacerbation of disease before considering stress as a cause.

Make an appointment with Dermatologist Dr Kesiree Naidoo to assist you with any stress related skincare conditions or contact one of our medical skincare specialist to help you with a customized skincare routine. For a complimentary Skin Assessment, click here.

Dr Kesiree Naidoo: 021 531 1107 / [email protected] / www.kesireenaidoo.co.za

Medical Skincare Specialists : 021 023 2501 / [email protected] / www.skinsmart.co.za 

References

  • Inflammation & Allerfy – Drug Targets, 2014, 13, 177-190
  • Brain-skin Connection: Stress, Inflammation and Skin Ageing
  • Ying Chen* and John Lyga – Global R&D, avon products, 1 avon place, Sufferen, NY 10901, USA
  • 2014 Bentham Science Publishers
  • Experts explore the underlying mechanisms of the link between the brain and the skin, feature: By Allison Evans, assistant managing editor, December 1, 2020
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How to restore & maintain your skin this winter

How to Restore & Maintain your skin this winter

Winter is fast approaching, so it’s high time to revisit the impact that winter weather has on the skin and look at what we can do to keep our skin hydrated and healthy in the colder months.

Here are a few essential tips to restore and maintain your skin this winter.

1.   Antioxidants and Sunscreen

A powerful and sometimes forgotten step is including a topical antioxidant in your skincare regimen. Prevention from the effects of sunlight and environmental factors, often referred to as the exposome, is vital even in winter. Antioxidants are our first line of defence when it comes to protecting our skin from outdoor exposure.

Additional oral antioxidant supplements keep our immune system healthy and functioning. Antioxidants including pure vitamin C, vitamin E, ferulic and phloretin help fight off free radicals during the day and form a reservoir in the skin to repair existing damage to skin cells.  

Applying sunscreen every day is vital. Whether it is summer or winter, ultraviolet light and visible light damage our skin cells, accelerating the ageing process and causing unwanted hyperpigmentation. No matter the season or the activity, sunscreen should always be applied and kept close!

2.   Keeping Hydrated

As the cold season approaches, the use of indoor heating such as air conditioning, heaters, fireplaces, and electric blankets increases. The resultant heated air leads to moisture loss, causing dry, flaking skin and irritation. Use an appropriate moisturiser to restore the skin barrier and prevent further trans epidermal water loss and skin dehydration. 

3.   Avoid Hot Showers

Excessively long, hot showers can irritate the skin’s surface layers, causing damage to the skin barrier and leading to moisture loss (trans epidermal water loss). Hot showers can also trigger or worsen skin conditions such as eczema or dermatitis. It is better to have lukewarm showers and avoid long periods in hot showers or baths. Equally important is a skincare routine for the body and face to help support and maintain skin barrier function. 

4.   Winter Skincare Routines

Our skincare needs need fine-tuning with the change of season. Our skin will need lighter moisturisers or even fewer steps in our routine during the summer because we secrete more sebum during the warmer and humid seasons and less during the colder, drier seasons.

It is not uncommon to change your skincare routine during winter by adding additional products or ingredients or even using a moisturiser that can provide more nourishment or moisture. 

We lose more moisture during winter due to the colder, drier air and indoor heating and heaters. It is a good idea to take a gentler approach when choosing a cleanser to avoid stripping the skin of its natural oils. If you are not used to using active ingredients or exfoliating your skin, winter is an excellent time to start! Exfoliation will remove the dead skin cells that sit on the skin’s surface. 

Introducing ingredients like AHAs (Alpha Hydroxy Acids) to the skin will improve the skin condition by removing dead skin cells, accelerating the cell turnover process, and improving the skin’s moisture. Retinol increases epidermal turnover to create newer and healthier functioning skin cells. Ingredients like lipids, ceramides, and fatty acids keep your skin’s barrier healthy and functioning correctly by supporting the skin barrier, while hyaluronic acid is vital for hydrating and holding hydration in the skin. It is essential to consult a dermatologist or skincare therapist regarding the use of the different ingredients and skincare products. 

5.   In-clinic Skincare Treatments

Winter is also a safe time to do your in-clinic treatments such as chemical peels and micro-needling, as it allows a quicker recovery time. That’s because even though we are continually exposed to ultraviolet rays, the sun’s rays are not as intense in winter as in summer. Sunscreen and sun protection is always essential.

Our skin needs more attention during winter and will benefit from extra professional care. With the dead skin build-up on our skin during winter, chemical peels provide an exfoliation to revitalise the skin and allow better product penetration. Certain facial treatments can calm and soothe dry and sensitive skin caused by over-exposure to harsh weather.

As the change in seasons draws closer, now is the perfect time to consider the impact that winter weather has on your skin and ensure that you adjust your skincare routine for these changes. If you notice persistent concerns unrelated to the change in temperature or need assistance with choosing the best products for you, book an appointment with your dermatologist. 

Winter Best Sellers

Cleansers

Obagi Gentle Cleanser
NeoStrata Facial Cleanser
La Roche Posay Cleansing Oil

Moisturisers

NeoStrata
Bio-Hydrating Cream
SkinCeuticals Triple Lipid Restore
Obagi Hydrate Luxe
Cream

Exfoliators

NeoStrata Exfoliating Wash
SkinCeuticals Glycolic 10 Renew Overnight
NeoStrata Smooth Surface Glycolic Peel Pads

Exfoliation combined with hydration

SkinCeuticals Retexturing Activator
NeoStrata Renewal Cream
Isdin Ureadin Ultra 10

Anti-oxidants & Sunscreens

SkinCeutical Serum 10 AOX
La Roche-Posay Pure C10
Obagi Vitamin C 10%
Heliocare 360 Fluid Cream SPF50
Anthelios Hydrating Cream SPF50
Anthelios Hydrating
Body Lotion SPF50+
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Anti-oxidants in Skincare

SkinCeuticals Anti-oxidants

What are anti-oxidants, what do they do and

which ones are best?

Skin ageing is a complex process driven by a combination of genetic and environmental factors. Essentially it is a manifestation of the decline in optimal functioning of the skin. Traditionally we make the distinction between intrinsic and extrinsic ageing. Intrinsic ageing occurs with the passage of time and is thought to be determined by genetic make-up while factors causing extrinsic ageing are generally environmental factors such as exposure to sunlight and air pollution, and, lifestyle choices, such as diet and smoking. Extrinsic factors often accelerate the natural process of intrinsic ageing.

 The effects of intrinsic ageing and extrinsic ageing merge and it’s not often possible to tell apart.

SkinCeuticals Anti-oxidants

What are reactive oxygen species and antioxidants?

Basic cellular metabolic processes in skin cells generate free radicals which are mainly reactive oxygen species (ROS). To add to this ultraviolet light and a growing list of other environmental factors as mentioned above cause direct DNA damage and ‘stress’ the skin also producing ROS.  These high energy oxygen molecules cause damage to skin cell membranes, cell proteins and cellular DNA inducing inflammation that further damage skin cells and precipitate skin diseases.  Of course nature did not leave us without any help at all…

Antioxidants are molecules that donate or remove electrons from reactive oxygen species (ROS), neutralising them and preventing them from causing damage. The body has its own internal antioxidant systems to ‘scavenge’ harmful free radicals, but these become less effective as we grow older upsetting the balance and creating ‘oxidative stress’. In addition to these our internal DNA repair mechanisms become less efficient. When the skin is subject to excessive DNA damage, these repair mechanisms become overwhelmed leading to skin cancer.

The effects of environmental factors on the skin

There is overwhelming, well documented evidence for the role of ultraviolet light, specifically UVB (290-320 nm) and UVA (320-400nm) in causing skin ageing and skin cancers.

 Recently there is growing evidence that visible light (400-700 nm) infrared radiation (above800 nm) and other atmospheric factors such as air pollution (smog, ozone and particulate matter) cause skin cell damage and oxidative stress similar to that caused by UV light and are therefore implicated in premature skin ageing and skin diseases

Visible light and infrared cause similar damage to UVA. Long term exposure induces the breakdown of collagen and elastin in the dermis, while simultaneously preventing the production of new collagen and elastin. The overall effect is thinning of the dermis, loss of elasticity, wrinkling and volume loss.

Visible light and infrared are also responsible for stimulating melanocytes and worsening hyperpigmentation. This effect is especially found in darker skins. Visible light seems to have no effect on melanocytes in light skin.

Visible light is responsible for inflammatory skin conditions like actinic dermatitis, photoallergic skin reactions and porphyria.

Ozone is an environmental toxin that is unable to penetrate the skin. Chronic exposure can however lead to depletion of antioxidants with resultant skin damage and inflammation. Studies have shown that pre-treatment of the skin with antioxidant can prevent the resultant sun damage. We know that conventional sunscreens provide protection from UVA and UVB. The lack of protection against these other environmental aggressors represents a gap in the current sun protection and antiaging strategy.  Antioxidants have been proven to fill this gap and together with sunscreens provide a more comprehensive strategy of environmental protection. By boosting our own antioxidant mechanisms topical and oral antioxidants possibly also improve intrinsic ageing.

The benefits of topical antioxidants

Antioxidants are naturally present in the skin as part of our inbuilt skin protection system. Some of these are vitamin E, catalase, superoxide dismutase, glutathione peroxidase and Vitamin C. As mentioned, these antioxidants decline with age and are depleted by UV exposure. Antioxidants can be taken orally to benefit the skin and body, but we are unsure of how much oral antioxidants needs to be taken to actually reach the skin. The skin is in a unique position to absorb topical antioxidants directly to replenish declining reserves.

 Regular application of topical antioxidants creates a reservoir in the skin to boost our declining natural antioxidant mechanisms. In this way antioxidants provide us with an ‘active’ protection against skin cancer, photo-ageing, and inflammation.

Antioxidants are multi-functional, in that they prevent sunburn, stimulate collagen production and improve the appearance of fine lines, wrinkles and dark spots, thereby reversing the effects of environmental damage.

Topical antioxidants serums have the added benefits of stabilising melanocytes and assisting in the treatment of hyperpigmentation, and promoting the formation of barrier lipids to improve skin barrier function and hydration.

Antioxidants are also anti-inflammatory, thus assisting with management of acne and resultant post inflammatory hyperpigmentation (post acne marks), while providing younger skin with comfort and hydration.

It’s not too late for those who already have sun damage and a history of skin cancers. While antioxidants cannot treat skin cancers, they can help to prevent further DNA mutations and new skin cancers and improve the appearance of dry, sun damaged skin by boosting barrier lipid production and collagen repair.

What are the best topical antioxidants?

The best studied antioxidants are vitamin C and vitamin E. The potency of an antioxidant is determined by its ORAC (oxygen radical absorbance capacity) value.

Vitamin C also known as L-ascorbic acid is one of the most potent, and frequently used antioxidants. It has been extensively studied and proven to have powerful beneficial effects on the skin. Vitamin C is found in high concentrations in the skin, but this decreases with age and sun damage, hence the benefit of topically applied product. Other than being an antioxidant, Vitamin C is a cofactor in collagen production, improves wound healing and inhibits melanin synthesis, thus improving fine lines and wrinkles, targeting pigmentation and lightening dark spots.

Vitamin C is unstable in light so the correct formulation in essential to preserve efficacy.

The optimal concentration of Vitamin C in a product is 15% which is comparable to the quantity in the skin. Combination preparations with a lower dose of Vitamin C and other antioxidants seem to increase the overall antioxidant potential of the product by improving stability. Some of these combinations include Phloretin, Vitamin E and Ferulic acid.

Vitamin E otherwise known as tocopherol is another well studied skincare ingredient. Besides being a potent antioxidant, it is known for its natural moisturising and anti-inflammatory properties. It also inhibits melanin production and can help with hyperpigmentation. Unlike Vitamin C which can be used alone, Vitamin E is best used in combination formulations.

Resveratrol which is derived from the skin of red grapes is both antioxidant and anti-inflammatory. It is particularly suitable to reduce sun damage in patients with rosacea and sensitive skins

When in combination antioxidants work synergistically multiplying their antioxidant potential.

A few other potent topical antioxidants include green tea polyphenols, ferulic acid, phloretin and silymarin.

The major limitation is adding these ingredients to skincare products so that they remain stable and effective throughout the period of use. Not all products that contain antioxidants are equal. For this reason, higher concentration of antioxidants in the formulation does not equate to better. There seems to be a cap on the concentration that should be in a product and anything beyond this lends to instability of the formulation. Certain combinations may be antagonistic rather than synergistic. Antioxidants must be used in conjunction with a good sunscreen, and as part of a comprehensive anti-ageing routine.

Written by Dermatologist, Dr Kesiree Naidoo


References:

  • The role of antioxidants in photoprotection: A critical review Lucy Chen, BA,a Judy Y. Hu, MD,b and Steven Q. Wang, MDa New York, New York, and Hermitage, Tennessee
  • Atmospheric skin aging—Contributors and inhibitors David McDaniel MD, FAAD1,2,3,4 | Patricia Farris MD, FAAD5,6 | Giuseppe Valacchi PhD7,8
  • Topical L-Ascorbic Acid: Percutaneous Absorption Studies Sheldon R. Pinnell, MD,* Huanshu Yang, MD,‡ Mostafa Omar, PhD,† Nancy Monteiro Riviere, PhD,‡ Holly V. DeBuys, MD,* Linda C. Walker,* Yaohui Wang, MD,§ and Mark Levine, MD§ *Duke University Medical Center, Durham, North Carolina, †PhytoCeuticals, Elmwood Park, New Jersey, ‡College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, and §National Institute of Diabetes & Digestive & Kidney Diseases, NIH, Bethesda, Maryland
  • A topical antioxidant solution containing vitamins C and E stabilized by ferulic acid provides protection for human skin against damage caused by ultraviolet irradiation John C. Murray, MD, James A. Burch, Robert D. Streilein, Mary Ann Iannacchione, Russell P. Hall, MD, and Sheldon R. Pinnell, MD Durham, North Carolina.
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Sunscreens

Sunscreens - shedding new light on an old topic

SHEDDING NEW LIGHT ON AN OLD TOPIC.

Are there any good reasons NOT to wear sunscreen? Surely not…

We know well enough of the dangers of skin cancer, which may not only be deadly as the dreaded melanoma, but also disfiguring and requiring numerous visits to the doctor’s office for multiple interventions. In addition, excessive sun exposure causes photo ageing and hyperpigmentation which is distressing to women and men alike.

Sunlight is certainly not all bad, and generally induces a sense of well-being, decreases the appetite, improves libido and assists with the synthesis of vitamin D.  South Africans are a sun loving society that embraces an outdoor lifestyle. While moderate and responsible exposure to the sun is good for your well-being, it is not possible to tan without damaging skin cells, leading to accelerated ageing, and increasing your risk of skin cancer.

As we head into 2021 hoping for a better year than the last, I thought we would relook at some of the controversies surrounding sunscreens and shed some light on new innovations and considerations concerning sunscreen use.

With conflicting information in the media many people are confused about whether they should be wearing sunscreen and uncertain of the product to choose. This can lead to them wearing no sunscreen at all. Let’s set the record straight.

The first point to make clear is that there is overwhelming scientific evidence that excessive sun exposure causes skin cancer and methods of sun protection including sunscreens can prevent this. Recent sunscreen studies conducted in Australia estimate that the current sunscreen recommendations have decreased the incidence of skin cancer by 10-15 %.

Sunscreen and Vitamin D

Possibly the current biggest controversy surrounding sunscreen use relates to Vitamin D deficiency. Reports have been conflicting. A review article published in the British journal of Dermatology last year sought to evaluate the available studies and concluded that there was not enough evidence to suggest that sunscreens decreased the production of Vitamin D. The original study that made this claim was done with an artificial light source different to what people are normally exposed to in the environment. Subsequent studies with real life circumstances could not prove a decrease in Vitamin D production with sunscreen use.

The only limitation of this review was that it didn’t take into account the newer very high protection sunscreens currently being used.

Remember that sunscreen does not fully prevent exposure to sunlight. To get maximum sun protection from a sunscreen one would need to apply 2mg/cm squared and reapply every 2-4 hours. Most people do not wear sunscreen in large enough quantities. Some of the analysis even suggested that there is still enough UV R exposure to produce adequate vitamin D even while using sunscreen.

Interestingly there are some people who do not produce enough Vitamin D even with large amounts of sun exposure, and some people with minimal sun exposure with normal Vitamin D levels. There seem to be as yet unidentified factors influencing Vitamin D synthesis.

More importantly you can get enough Vitamin D from oral supplements and diet without exposing yourself to an increased risk of skin cancer.

Sunscreen and its impact on the environment

UV filters oxybenzone,  camphor derivates, octocrylene, and octinoxate  have caused much recent controversy as they have been shown to accumulate in the water sources of the world and suspected of being responsible for the bleaching of coral reefs. They are not easily removed by conventional water treatment methods. As a result of this several states in the united states have banned these sunscreen ingredients. Of note is that the study that claimed the adverse effects on coral reefs used much larger concentration of oxybenzone than is actually found in even the busiest beaches in the world. However this is certainly a warning and has led sunscreen manufacturers to seeking alternative ingredients in their formulations.

It doesn’t however warrant a blanket boycott of all sunscreens. If anything, there is a shift towards using more physical or mineral blockers in sunscreens like zinc oxide and titanium dioxide which is recommended for sensitive skin and children.

Sunscreen and its relation to Frontal Fibrosing Alopecia

On that note physical blockers or mineral sunscreens have also been controversially linked to frontal fibrosing alopecia which is a condition that is caused by progressive fibrosis of the hair follicles of the frontal hairline resulting in hair loss and a receding hairline. Small quantities of titanium supposedly from titanium dioxide containing mineral sunscreens, have been found in the hair shafts of patients with frontal fibrosing alopecia. There is no conclusive proof yet that the sunscreens are the actual cause for frontal fibrosing alopecia.

Is sunscreen an endocrine disrupter?

Oxybenzone has been identified as an endocrine disrupter affecting the endocrine systems in rats and fish.  But for this to affect humans, one would need to apply an unrealistically large amount of oxybenzone to the skin for decades to absorb the quantities of avobenzone needed to cause any real danger. To date there have been no proven significant negative effects from oxybenzone in humans.

What about SPF ? The burning question is whether a higher SPF provides greater sun protection?

To recap, SPF or sun protection factor is actually only a measure of protection against UVB. An SPF of 30 means that you will be able to stay in the sun 30 times longer without burning, than you would be able to without wearing the sunscreen. This does not equate to 30 min and varies amongst individuals, as we all burn at different rates depending on our skin type.

SPF is measured in a test environment which is nothing like real life.It does not take into account sweating, environmental factors and the varying application by the sunscreen user.

In a test environment sunscreen is applied very thickly, at 2mg of sunscreen per square centimetre which is the minimum needed to get the protection labelled on the sunscreen.

Several investigations  have found that sunscreen users rarely apply sun screen adequately and evenly.The quantity that is actually applied by people is closer to 0.5mg per square centimetre. So we are never really getting the same protection as on the label.

Using a lower SPF sunscreen at quantities lower than 2mg per square centimetre actually reduces the overall sun protection factor.

However a recent study published in the Journal of the American Academy of Dermatologists (JAAD) confirmed that realistic usage of a higher SPF sunscreen of SPF 70 and above may provide enough sun protection to protect against photo ageing and skin cancer.

Another point worth emphasising is that while it is true that SPF15 filters out 93.3% of UVB, SPF30 96.7% and SPF50 98.3%, making it seem that there is very little benefit in using the higher SPF, one needs to consider that only the amount of UV light reaching your skin is important. If you look at it this way then SPF 15 allows 6.7% of UVB to reach your skin while SPF 50 allows only 1.7% of UVB. Its not about what you are filtering out, but rather about what you are allowing to reach your skin.

Why should you consider tinted sunscreen?

Tinted sunscreens containing ‘light reflectors’ protect against visible light which causes erythema in light-skinned individuals and hyperpigmentation in dark-skinned individuals. Visible light is the light that we see and makes up 44 % of the electromagnetic spectrum reaching the earth. Conventional broad spectrum sunscreens do not protect against visible light. For a sunscreen to do this it must be opaque and visible on the skin. The newer generation of physical sunscreens made with nanotechnology use small particle sizes of zinc oxide and titanium dioxide to decrease the “white” appearance of the sunscreen and make them more aesthetically suitable for use. Ironically these fine particles can no longer reflect visible light. Tinted sunscreens containing shades of iron oxide and titanium dioxide in various combination are not only able to blend with different skin tones, but are also able to reflect visible light. In this way they can protect against disorders of hyperpigmentation like melasma, post inflammatory hyperpigmentation and lichen planus pigmentosus.  Iron oxide pigment can also be found in tinted powder or brush on sunscreens which can be conveniently reapplied during the day.

Sunscreens treating early skin cancer

The latest research in sun screen technology has seen the development of a new generation of ‘active sunscreens’ containing DNA repair enzymes. These sunscreens have very high SPF and are in the unique position to be seen as potential treatment of early skin cancer (not melanoma) rather than just preventative treatment like regular sunscreens.  Skin cells have their own mechanisms to repair DNA damage caused by UVR, but with excessive sun exposure these mechanisms are overwhelmed which can lead to permanent DNA mutations causing skin cancer and photo ageing.  Scientific studies have shown that sunscreens containing photolyase and endonuclease can enhance the DNA repair mechanisms in damaged skin cells and reduce the lesions of early skin cancer in sun damaged skin. These novel sunscreens may also protect against photo ageing and prevent the breakdown of collagen in the dermis by decreasing the enzyme matrix metalloproteinase.

Conclusion

The science behind sunscreen technology and skin cancer prevention is by no means stagnant and while new challenges emerge regarding the potential dangers of ingredients, science will continue to forge ahead bringing new solutions and replacing old ones.

At the current time sunscreens remain our best solution to the prevention of skin cancer and photo-ageing.


References

  • The effect of sunscreen on vitamin D: a review*
    R.E. Neale iD ,
    1 S.R. Khan,1 R.M. Lucas iD ,
    2 M. Waterhouse,1 D.C. Whiteman iD 1 and C.M. Olsen iD 1
  • Population Health Department, QIMR Berghofer Medical Research Institute, 300 Herston Rd, Herston, QLD, 4006, Australia
  • 2 National Centre for Epidemiology and Population Health, Australian National University, Australia
  • Linked Editorial: Wolf. Br J Dermatol 2019; 181:881–882.

  • High-SPF sunscreens (SPF $ 70) may provide
    ultraviolet protection above minimal recommended
    levels by adequately compensating for lower
    sunscreen user application amounts.
    Hao Ou-Yang, PhD,a Joseph Stanfield, MS,b Curtis Cole, PhD,c Yohini Appa, PhD,a and Darrell Rigel, MDd
    Los Angeles, California; Winston Salem, North Carolina; Skillman, New Jersey; and New York, New York

  • Photoprotection beyond ultraviolet radiation: A review of tinted sunscreens
    Alexis B. Lyons, MD,a Carles Trullas, MSc,b Indermeet Kohli, PhD,a Iltefat H. Hamzavi, MD,a and
    Henry W. Lim, MDa
    Detroit, Michigan; and Barcelona, Spain

  • DNA repair enzymes in sunscreens and their impact on
    photoageing—A systematic review.
    Hanna Luze1,2 | Sebastian Philipp Nischwitz1,2 | Iris Zalaudek3 | Robert Müllegger4 |
    Lars Peter Kamolz1,2

  • Review of environmental effects of oxybenzone and other sunscreen active ingredients.
    Samantha L. Schneider, MD, and Henry W. Lim, MD
    Detroit, Michigan
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Collagen : Inside and Out

Collagen Helix 3D Image

All you need to know about the Collagen craze.

written by Dr Kesiree Naidoo

3D Collagen Strand/Helix
3D Collagen Strand/Helix

Before we begin, what is collagen?

Why is it important and why is there a sudden surge of interest in collagen?

Collagen is a protein composed of three chains of amino acids, wound together in a tight triple helix. Each of these chains are over 1400 amino acids long and form ‘ropes’ that strengthen the tendons and sheets that support our skin and internal organs. Collagen provides structure to our bodies, protects and supports the softer tissues and connects those tissues to the skeleton.

There are many different types of collagen in the human body and at least 25% of the body consists of collagen. Each type of collagen has a particular function in the body. Collagen type 1, 2 and 3 make up 80-90% of the collagen in the body.

Type 1 Collagen is considered to be the strongest and the most abundant type of collagen that is found in tendons, ligaments, organs and the dermis of the skin. It is very important for wound healing and gives skin its strength and firmness. 

Type 2 Collagen primarily helps build cartilage and connective tissue. The health and function of our joints depends on type 2 collagen.

Type 3 Collagen is usually found with type 1 and is a major component of the extracellular matrix that makes up our organs and skin. It also helps give skin its firmness, forms part of the walls of blood vessels and is an important component of the heart tissue. 

Type 4 Collagen has the important job of forming the basement membrane of the skin and the epithelial tissue that surrounds organs, muscles, fat, nerves and blood vessels. In the skin the basement membrane lies between the epidermis and dermis and forms a protective barrier to the outside environment. 

So why the big fuss?

As we age the collagen in our body, including the skin, degrades and deteriorates by at least 1% annually. This is due to various intrinsic factors like genetics, cellular and metabolic processes and hormones, as well as extrinsic factors like excessive light exposure, radiation, chemicals, toxins and pollution.

Collagen supplementation is relatively new, and was initially met with scepticism as collagen is a protein and it is still not clear how an oral collagen can bypass the digestive system to be available where it is needed. But slowly the critics including myself are being convinced that while it is still not clear how it works, collagen supplementation may be possible. Certainly, the evidence is growing and the results are visible in my practice.

It is becoming apparent that starting collagen supplements from as early as age 30 will help slow down this degeneration.

What is the difference between a protein and peptide?

Peptides are short chains of amino acids which are the building blocks of proteins.

A chain of less than 100 amino acids is called a peptide while a longer chain is called a protein eg. collagen.

Does topical collagen benefit the skin ?

The skin being external is in a unique position to benefit from both topical applications as well as oral supplements.

The tricky thing is that collagen molecules are too large to penetrate the skin topically and reach the dermis. The skincare industry has instead focused on Ingredients that can ‘boost’ collagen production in the dermis. Topical anti-oxidants, retinoids , signaling peptides and carrier peptides have been shown to enhance the skin’s own production of collagen by acting as messengers that stimulate collagen production pathways. 

Additionally, hyaluronic acid which is a component of the dermal matrix in which collagen fibres lie can be applied topically with some demonstrable benefit. 

Hyaluronic Acid acts as a sponge which draws water to it and plumps up the epidermis to make the skin look plumper, hydrated and less wrinkled. Hyaluronic Acid also promotes healthy collagen by keeping the dermal collagen hydrated and nourished. 

Signal peptides also known as matricins or collagen stimulators are important for wound healing. But some are also antioxidants, anti-inflammatory and pigment regulating.

Signal peptides slow the ageing process by stimulating the proliferation of fibroblasts leading to increased production of collagen and elastin in the skin. They also inhibit the breakdown of collagen and elastin.

Carrier Peptides in the skin transport trace elements like copper and manganese which are important for wound healing and collagen synthesis.

Copper Tripeptide is the most well-known and best studied carrier peptide which also functions as a signal peptide. Copper Tripeptide is a versatile ingredient in skincare as it has antioxidant and anti-inflammatory benefits. It aids in regeneration of new skin and improvement in wrinkles and skin moisture.

Some of our favourite topical collagen boosting products are: 

Should you take oral collagen supplements?

Oral collagen supplementation is usually in the form of hydrolyzed (broken down) collagen. Most collagen supplements are derived from high protein foods like beef, pork and fish, respectively called bovine, porcine or marine collagen.

To aid oral collagen supplementation, collagen proteins undergo a process called enzymatic hydrolysis breaking down the large collagen protein into water soluble, easily digestible and easily absorbable peptides and amino acids. 

Peptides may be oligopeptides, tripeptides or dipetides depending on how the collagen is broken down. Further these peptides are made of predominantly amino acids proline, glycine and hydroxyproline. 

Some argue that you could supplement your collagen by simply increasing your protein intake or making a nutrient rich bone broth to add to your meals. Oral collagen supplementation seems to be a hassle free, quick and effective way to increase your collagen. In addition to this other vitamins and minerals like vitamin C, copper and manganese which are essential for collagen production may also be supplemented. 

Oral collagen has various emerging benefits for the body. It has been reported to improve hair growth, strengthen nails and assist with joint problems, whilst plumping up the skin. When oral collagen is used in conjunction with topical collagen boosting products this enhances the skin’s natural production of collagen.

Oral collagen supplements come in various forms ie. liquid, powder or capsules.

Absortion varies according to the formulation. The jury is still out regarding which form has the best absorption and bioavailability. Choose a product that you prefer to ensure that you take it regularly and are able to reap the benefits. 

Dr Kesiree Naidoo recommends:

Proactive Liquid Collagen. It comes in two flavours, strawberry and lemon and contains Vitamin C, amino acids like Proline, Glycine and Arginine and Hyaluronic Acid. All the things that you need to enhance, optimise and activate collagen production. 

This month we have also launched the Beauty Network Collagen powder which can be added to a smoothie or coffee.

As dermatologists we would like a vast amount of scientific evidence to validate our recommendations to our patients. This is not always possible as evidence takes time to accumulate and emerges with more use of the supplement.

There are numerous studies that demonstrate that oral collagen supplements do reach the skin with measurable benefit. The problem is that there are so many products, not all of them are of the same quality and the studies reporting efficacy are not always of the product that is available . So we do need more evidence and we need some measure of the quality of the products that are available.

My advice is, that if the supplement is safe, you can certainly try it and hopefully become part of the growing evidence that collagen supplementation is possible and beneficial.

For further information or if you have any queries pop us an email at [email protected]


  • Resources : Oral Collagen Supplementation : A Systematic Review of Dermatological Applications
  • Franchesca D. Choi BS R Ph, Calvin T. Sung BS, Margit L.W. Juhasz MD, Natasha Atanaskova Mesinkovska MD PhD.
  • University of California, Irvine, Kaohsiung Medical University Taiwan, University of California Riverside School of Medicine.
  • Nikita Jhawar BS1 / Jordan V. Wang MD, MBE, MBA2 / Nazanin Saedi MD2
  • J Cosmet Dermatol. 2019;001-3
  • J Drugs Dermatol. 2019;18(1):9-16.
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The Causes and Treatment of Adult Acne

acne

The Causes and Treatment

of Adult Acne

written by Dermatologist, Dr Kesiree Naidoo

Acne

Adult acne also known as late onset or post adolescent acne has been the anguished subject of many dermatology room consults worldwide. Its diagnosis is almost always followed by questions like ‘Why do I still have acne now? ‘or ‘Aren’t I too old to get Acne’ or sometimes statements like ‘I’ve never had acne before’ or ‘I’ve always had a perfect skin till now’.

Sadly, adult acne is a continuous challenge, especially as it is difficult to treat with an often prolonged and recurrent course. It has become increasingly more common in recent years for leading dermatologists to question whether there are different factors playing a role as opposed to those causing adolescent acne. 

Adult acne is defined as acne that affects men and women over the age of 25. It is by far more common in women than men. Adult acne may persist continuously from adolescence, recur after age 25 or in fact occur for the first time after the age of 25 years old. So, to answer those questions ‘Yes, you can still have acne beyond adolescence’ and ‘yes it can be for the first time’. Most cases of adult acne persist from adolescence and only around 20 % occurs for the first time after the age of 25. Hence the term adult acne seems more appropriate than late onset acne.

Traditionally it is believed that the main factors causing adult acne are genetic and hormonal, with predominant involvement of the lower third of the face. Flare-ups are typically premenstrual supporting the role of hormones. Most patients complain of deep seated and painful nodules with very few comedones (blackheads and whiteheads). The acne nodules are usually sparse, but can lead to significant scarring.

There are now considered to be 2 predominant forms of adult acne, inflammatory and retentional:

Inflammatory acne is the most common type accounting for 50-60% of cases. The skin is not always oily, and in fact may be normal to dry making it sensitive to topical treatments generally prescribed in adolescent acne. The acne spots can be on multiple areas and not just the lower third of the face.
Retentional acne is the other predominant subtype and is characterised by increased sebum or oily skin and multiple comedones (blackheads and whiteheads).

What causes adult acne?

The fundamental factors causing acne whether adolescent or adult are:

  1. Genetic predisposition. As many as 40% of acne sufferers have a family history of acne. This may be related to the size, number and activity of sebaceous glands which are genetically determined.
  2. Increased androgenic hormone (testosterone, dehydroepiandrosterone sulphate and dihydrotestosterone) stimulation of the sebaceous glands leading to an oily skin. The levels of the androgen need not be higher than normal. It is the sebaceous glands that are more responsive to normal levels of circulating androgens. Oestrogen inhibits the secretion of androgenic hormones and inhibits sebaceous gland activity. An age related decline in oestrogen tips the balance towards androgenic stimulation.
  3. Excessive sebum production by sebaceous glands. While this is largely driven by androgenic hormones, there are other factors that also stimulate the sebaceous glands.
  4. Abnormal follicular keratinisation leading to blocked pilosebaceous unit (hair follicle unit) and the formation of a comedones. The skin cells in the hair follicle do not shed easily. They accumulate and together with the increased sebum from the sebaceous glands block the opening of the follicle. This in turn contributes to the inflammatory response.
  5. Propionibacterium acnes or cutibacterium acnes which live normally in the sebaceous glands proliferate with increased sebum production worsening the inflammatory response and acne
  6. an inflammatory response primarily to Propionibacterium or cutibacterium acnes which release enzymes that trigger the inflammatory cascade. These cause papules and pustules in acne that we commonly refer to as  ‘pimples’.

There are however other factors or triggers that may be more significant in causing adult acne and these need to be further evaluated:

Ultraviolet light exposure- excessive sun exposure causes thickening of the stratum corneum and accumulation of dead surface skin cells. There is stimulation of the sebaceous glands producing more sebum. Both these processes lead to comedones and acne

Stress- a stressful lifestyle with poor sleep patterns can cause acne by its effects on the pituitary adrenal axis and resultant release of corticotrophin releasing hormone, neuropeptides and proinflammatory cytokines which stimulate the sebaceous glands and worsen the inflammatory response.

Obesity and insulin resistance is associated with hormonal imbalance and acne.

Endocrine disorders – There are numerous endocrine diseases that cause acne by increasing the activity of androgens, stimulating the sebaceous glands or inducing abnormal keratinization. The most common cause is polycystic ovarian syndrome aka PCOS. Other conditions include congenital adrenal hyperplasia, hypothyroidism, Cushings syndrome and various other adrenal and ovarian tumours. Acne also occurs in menopause due to the decline in oestrogen and resultant increasing effects of male hormones.

Smoking – causes acne by stimulating the sebaceous glands and inducing abnormal keratinization. The acne associated with smoking is typically a non-inflammatory, comedomal acne. There are mainly blackheads and whiteheads without significant papules and pustules.

Diet -does diet worsen acne? There is not much scientific evidence, but studies have shown that high glycaemic index foods increase insulin and insulin like growth factor 1(IGF1) which stimulate the production of androgens and sebum.

In addition, diets rich in dairy products and muscle building supplements with whey protein have also been found to worsen acne. Anabolic steroids used by weight lifters and body builders can cause a severe scarring acne affecting the face and body.


Damage to the skin barrier – Over washing of the skin leading to a damaged epidermal skin barrier which in turn causes water loss through the skin and worsens the inflammatory cascade.

Greasy cosmetics – Occlusive makeup, Vaseline and other thick greasy creams block the follicles and cause acne in those that are susceptible. This problem is sometimes seen in actors and models or those requiring heavy make up as part of their job. Hair products that spreads onto the hairline can cause acne in the affected areas.

Medication- Some drugs can cause acne as a side effect. Examples of these drugs are progesterone only contraception (includes commonly used injectable contraception) benzodiazepines, mood stabilisers like lithium and blood pressure medication like ramipril. There is also some speculation as to whether hormone releasing intrauterine contraceptive devices and contraceptive implants possibly trigger acne in some women who are predisposed. Anabolic steroids used by weight lifters and body builders can cause a severe scarring acne affecting the face and body.

Are there any tests needed to diagnose adult acne?

Acne is a clinical diagnosis and lab tests are not needed to make the diagnosis. Even though androgenic (male) hormones are one of the main pathogenetic factors causing acne there is usually no increase in hormone levels. It is rather the balance between androgenic hormones and oestrogen that causes acne.
Investigations may be required if endocrine disorders associated with acne are suspected, though these conditions will usually have other signs and symptoms to warrant further investigation.
Polycystic ovarian syndrome (PCOS) commonly presents with acne as well as other signs of hyperandrogenism (increased male hormones). It is the most commonly suspected cause of adult female acne. PCOS will need laboratory investigations and abdominal imaging and a visit to the gynaecologist or endocrinologist.

How is acne treated?

This is the most difficult part.

Adult acne is challenging as it typically responds to treatment, but frequently recurs once treatment is stopped. Acne is also of varying severity and is sometimes not even present at the time of the dermatology consult. This is frustrating for both the patient and the dermatologist. Prolonged courses of treatment are often needed as well as rotating different treatment options, and off course maintenance treatment is essential, which often involves a good skincare regimen. We also have to take into account the possibility of pregnancy and breastfeeding which decreases treatment options. Adult patients tend to have a drier skin compared to adolescents which does not always tolerate topical prescription acne medication. There is really no one size fits all approach and each person needs to be evaluated individually and treated accordingly.  
I am often asked for ‘the best treatment ‘or the ‘strongest treatment’. Patients are sometimes under the impression that it is possible to ‘treat acne and get it right the first time’. Sadly, the truth is there is no quick fix for adult acne. If there were.

  1. You would probably know about it
  2. Doctors would give it to you and there would not be more than that 1 treatment option
  3. You would not see so many people walking around with adult acne

Treatment options can be broadly divided into topical, systemic treatments, skincare and procedures.

Topical Acne Treatments

Topical treatments are best suited to mild to moderate acne and sporadic lesions. In this case they can be used as a spot treatment as needed. Topical treatments are also an important part of maintenance treatment.

Retinoids

Retinoids used for topical treatment include 0.1% adapalene gel( Differin, Dapta), and tretinoin( Retin -A, Ilotycin -A,Retacnyl) 0.05% cream and 0.025% gel.

These treatments are also fundamental to adolescent acne. Gradual introduction is recommended. Interestingly retinoids are also anti-ageing and prevent skin cancer. As mentioned, these topical treatments cause dryness and irritation of the skin in the first few weeks of use. They also cause photosensitivity. They must be used with a good moisturiser for skin hydration and comfort and with sunscreen over moisturiser in the daytime. Retinoids are not suitable during pregnancy and breastfeeding.

Topical antibiotics

Topical antibiotic treatments include clindamycin and erythromycin which are both safe to use in pregnancy. These work by reducing Propionibacterium/cutibacterium acnes as well as having a direct anti-inflammatory effect.
Antibiotics used alone whether topical or oral can create resistant strains of Propionibacterium/cutibacterium. For this reason, it is important to use antibiotics with either topical retinoids or benzyl peroxide to prevent antibiotic resistance.

Benzoyl peroxide

Benzoyl peroxide has been used for decades and is especially beneficial to an oily skin type as it causes further dryness and irritation with normal to dry skin. It also makes skin sun sensitive and bleaches clothing and towels. Benzoyl peroxide (5%) is recommended as first line therapy in mild adolescent acne and is safe to use in pregnancy.

Azelaic acid

20% Azeleic ( Skinoren) twice daily is effective in mild to moderate acne and especially suited to a dry skin as it is not irritating. Azeleic acid is also effective in reducing post inflammatory hyperpigmentation caused by acne lesions. It is safe to use during pregnancy and breastfeeding.

Topical combination treatments

Adapalene0.1% combined with 2.5% benzoyl peroxide (Epiduo) is an effective treatment for mild to moderate acne. It needs gradual introduction to minimise skin irritation. I recommend initiation of treatment twice a week for the first week, 3 times per week for second week and then every day once tolerated.  It should be used at night with a good moisturiser to relieve dryness and sunscreen in the day.

This combination is also good for oily skin and excellent at reducing post inflammatory hyper-pigmentation.

Benzoyl peroxide 5% and clindamycin1% (Clindoxyl) is a topical treatment combining an antibiotic with benzoyl peroxide. This gel can therefore be used alone without resistance developing. It is suitable to treat both inflammatory lesion (papules and pustules) and non-inflammatory lesions (blackheads and whiteheads)

Systemic treatments

Systemic or oral medication is best for moderate to severe acne and widespread acne where it is difficult to treat all affected skin with topical medication.

Antibiotics

Adult facial acne responds very well to oral antibiotic treatments, but the problem is recurrence once the course is completed. Antibiotics should always be used in combination with a topical retinoid or benzoyl peroxide as the combined treatment prevents resistance, and has a synergistic effect which speeds up the response to treatment.

First line antibiotics for adolescent or adult acne are the tetracyclines. Commonly used in this class are lymecycline (Tetralysal ) and doxycycline. The once daily acne dosage greatly improves compliance.
Other antibiotics that can be used are erythromycin and sulfamethoxazole/trimethoprim combination (Purbac)

Hormones

Hormonal treatments are highly effective in treating adult female acne (they cannot be used in men).

As mentioned earlier they work even when there is no measured androgen excess and
have the added benefit of being suitable for long periods of use. For this reason, they are also a very good maintenance treatment.

When would I choose to prescribe a hormonal treatment?

First of all, the patient must not be pregnant, attempting to fall pregnant or breastfeeding and must be willing to take hormonal treatments. They work best when there is skin oiliness and premenstrual flare ups of acne and should ideally be combined with a topical retinoid, benzoyl peroxide, azelaic acid or antibiotic.

Cyproterone acetate

Cyproterone acetate is an anti-androgenic progesterone found either combined with oestrogen in the oral contraceptive pill (Diane -35, Minerva, Ginette) or alone at varying doses (Androcur).
It works by blocking the androgen receptor on the sebaceous glands preventing excessive sebum production. Side effects include mood swings, breast tenderness, fluid retention, nausea and vomiting.

Spironolactone

This potassium sparing diuretic also works by blocking the androgen receptors on sebaceous glands. It may cause increased potassium levels in those susceptible eg renal failure. It is however safe to use in young healthy women. It may be combined with the oral contraceptive pill, with the intrauterine contraceptive device or topical retinoids for added benefit.

Other combined oral contraceptive pills with antiandrogenic progesterone(drospirenone) eg Yaz, Yasmin. It is important to exclude risk of thromboembolism ie heart attacks and strokes when prescribing the oral contraceptive pill

Isotretinoin

Isotretinoin (roaccutane, oratane, acnetane, acnetret) is usually reserved for severe or resistant acne where other treatments have failed. It is also used in acne with significant scarring which deserves a more aggressive treatment approach. Isotretinoin works by reducing the size and activity of the sebaceous glands, improving keratinocyte shedding and reducing inflammation. Even though the results are undeniable, isotretinoin has many side effects which make many patients reluctant to take it unless absolutely necessary. The biggest problem with prescribing it in females is the risk of teratogenicity, which makes contraception essential in females at least while on the medication and 2-3 months after stopping treatment. Isotretinoin does not affect fertility. Other side effects include dryness of the lips, eyes, nose and other mucous membranes, dermatitis, joint and muscle pains. Isotretinoin can cause raised liver enzymes and raised cholesterol and triglycerides so baseline blood tests are needed before treatment and during the treatment period. Isotretinoin may also be associated with depressed moods. Despite all this it is still used frequently in adult acne especially after repeated courses of antibiotics and topical treatments prove to be unsuccessful. As with all other treatments of adult acne there is frequent relapse once treatment is discontinued. There are therefore many off label low doses used which are effective in treating acne while the patient is on the medication.

Cosmeceutical skincare

Acne treatments frequently cause dryness and skin irritation and may damage the epidermal skin barrier. This leads to increased transepidermal water loss (TEWL) and worsening of inflammation through triggering of the skin’s innate immunity. It is important to moisturise the skin and maintain the integrity of the epidermal barrier so that the treatment can be continued and the skin is comfortable without burning and peeling.

In addition to this cosmeceutical skincare has many ingredients that can help in the treatment of the acne. Ingredients like salicylic acid, lactic acid and glycolic acid help shed dead surface skin cells unblocking the opening of the hair follicle unit. This reduces the earliest lesion of acne, the microcomedone. Acne facewashes and toners can help reduce oiliness of the skin. Ingredients in skincare will also assist with reducing and treating post inflammatory hyperpigmentation and scarring which often remains long after the acne has been treated. Sunscreens protect against post inflammatory hyperpigmentation and counteract the sun sensitivity caused by many acne treatments.

 It is important to note that skincare is ideally used together with prescription treatment in the case of active acne or plays a role in maintenance once the course of treatment is complete. A supportive skincare regimen is especially important in adult acne as the skin is not generally oily and thus more in need of hydration.  Visit a dermatologist early for skin assessment and advice as delay in starting treatment can cause scarring to develop.

Procedures

Steroid injection of acne nodules is used for resistant painful inflammatory nodules or scarring nodules that fail to subside despite treatment. Injections can be carried out even during the course of treatment.

Comedone (blackhead and whiteheads) extraction may be necessary to speed up response to treatment. Open comedones(blackheads) are easier to remove, while closed comedones (whiteheads) may sometimes need very careful light cautery to open up the lesions. This will reduce the amount of inflammatory acne lesions forming and prevent trauma to the skin caused by picking if the patient is impatient and wants quicker results.

Chemical peels

Superficial chemical peels aid in superficial exfoliation and removal of dead surface skin cells which contribute to forming acne lesions. They are useful for acne with multiple comedones ( blackheads and whiteheads), to reduce inflammation in mild inflammatory acne and to improve post inflammatory hyperpigmentation and scarring. Glycolic, lactic, salicylic and pyruvic acid peels have been used.

Photodynamic therapy (PDT)

PDT has been used as an alternative treatment for acne. Amino levulanic acid (ALA) in a 10- 20% concentration is applied to the skin and red or blue light is shone on the skin to activate it. This treatment works as it’s anti-inflammatory. ALA penetrates into the follicular unit and on activation destroys Propionibacterium / cutibacterium acnes.

Dermal needling

This treatment is effective at remodelling the dermis and treating acne scarring and post inflammatory pigmentation effectively. It is best to start after active treatment is complete with a course of 6-8 sessions.

Conclusion

Adult acne is a challenge because its chronicity and significant impact on the quality of life of those that suffer from it. It perhaps becoming more and more prevalent. We don’t fully understand what causes it, though it seems the same pathogenetic mechanisms causing adolescent acne are at the root of it, with a whole range of contributing factors. It is critical to consult with your dermatologist sooner than later to discuss what treatment course is best suited to you. The management of adult acne is complex and there is no one size fits all perfect treatment, but acne can be controlled and managed with the correct guidance and tools.

You can have a look at our FREE online skin assessment that will help you get started , if you however would like to rather book a consultation to see Dr Kesiree Naidoo or the Skinsmart medical therapist, please do not hesitate to contact us on 021 531 1107 or email us on [email protected] or alternatively at [email protected]

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Ageing Gracefully

We’re never ready for it but ageing is inevitable.
We’re ageing both inside and outside but the skin, which is the largest organ in the human body, suffers from the added onslaught of environmental factors more than any of our internal organs.

Certainly, we all care more about what is visible than what is not seen. As a result, ageing of the face, neck and chest area is considerably more bothersome to most even if we may suffer from a myriad of other systemic diseases. The truth is that a healthy and beautiful exterior appearance
represents overall well-being, and looking good makes people feel better psychologically and emotionally.

An even more interesting observation is that most patients want to look ‘better’ for their age and not necessarily ‘younger’.

So yes, we’re going to age, and yes how quickly we age is largely determined by our genetic make-up, but is it worth trying slow down the inevitable?

No matter how old you are there is always something that can make a difference if you should want to do so.

Where do I start with anti-ageing?

Let’s start with Skincare
Our skin changes as we age and while most of us did very little in our youth, we will need to do more to maintain a healthy skin as we grow older. Remember that most of your efforts with anti-ageing skincare also help to protect the skin from skin cancer.

As we age our skin is more susceptible to drying and easily becomes irritated and sensitive. A dry, dehydrated skin has a more wrinkled, dull appearance.

Maintenance of the skin barrier with a suitable moisturiser prevents dehydration and penetration of organisms, allergens and irritants that can cause inflammation of the skin.

Antioxidants and calming botanicals reduce inflammation which also prevent melanocyte stimulation and resultant hyperpigmentation.

The epidermal turnover rate decreases leaving dead surface skin cells and resultant poor texture and loss of skin radiance. Chemical exfoliation with glycolic acids helps to improve epidermal turnover. There is also resultant signalling to the dermis to improve collagen and elastin formation.

Advanced skincare formulations allow penetration of selective active ingredients into the dermis where we need them to work to prevent breakdown of collagen and elastin as well as stimulate the formation of new collagen to ultimately decrease the appearance of wrinkles.

Antioxidants combined with sunscreens neutralise free radicals for optimum sun protection. There is much evidence to prove the benefits of topically applied antioxidants to reduce skin cancer risk and decrease the breakdown of collagen and elastin in the dermis by scavenging free radicals.

Vitamin C, B3 (niacinamide), and E are the best-known antioxidants with good penetration into the skin. Antioxidants have significantly greater antioxidant properties when combined than alone.

Niacinamide is a powerful anti-ageing ingredient that regulates cell metabolism and cell regeneration. It has also been shown to reduce redness, improve hyperpigmentation and skin elasticity.
The optimal concentration in skin care in 5%.

Green tea polyphenols and numerous other botanicals have varying antioxidant properties that have proven a useful benefit in anti-ageing skincare.

Retinols (Vitamin A) have often been described as the ‘gold standard’ for anti-ageing. They stimulate the formation of collagen and elastic fibres to reduce wrinkles and fine lines and improve skin elasticity as well as increase and regulate cell turnover to improve skin texture. Retinols have antioxidant effects, reduce the signs of UV induced sun damage, improve hyperpigmentation and uneven skin tone.

Retinols, peptides and growth factors have numerous benefits which include stimulating collagen production ultimately leading to a plumper dermis and a healthier younger looking skin.

Sun protection includes responsible sun behaviour and sunscreen of at least SPF30. The sun is responsible for photo-ageing which is an accelerated form of ageing visible on sun exposed areas of our skin. New sunscreens with DNA repair enzymes have been shown to reduce the number of
precancerous lesions with regular use.

Anti-ageing ingredients are often found in combination to assist with incorporating more that one ingredient in a skincare regimen.

Most dermatologists and skincare therapists make use of a skincare pyramid which can be seen as a stepwise method of introducing anti-ageing skincare, starting from the basics at the bottom of the pyramid, which include sunscreen, antioxidants and DNA repair enzymes, and gradually adding more active ingredients based on tolerance and response.
We are also guided by your individual goals as in ‘what you are looking to improve the most’.

Anti-ageing Procedures
Chemical peels may be superficial, which include alpha and beta hydroxyacid peels and 10-30% TCA (trichloroacetic acid) peels; medium depth peels like 30-50 %TCA; or deep peels which include >50% TCA and phenol peels.
Superficial chemical peels are suitable for most skin types and have minimal downtime. It is important to go to a reputable therapist as not all peels are suitable for all skin types.

Dermal needling or collagen induction therapy makes use of fine needles to penetrate the skin, to break down old collagen in the dermis and stimulate fibroblasts to produce new collagen. Active ingredients for anti-ageing may be applied to the skin and ‘needled in’ for optimal benefit.

IPL (Intense pulsed light), lasers and radio-frequency devices are aimed at targeting various skin structures like blood vessels, collagen and pigment to improve the appearance of ageing skin.

Hyaluronic acid fillers injected superficially into the dermis can activate and stimulate fibroblasts to produce new collagen and inhibit the enzymes that break down collagen. More robust hyaluronic acid fillers injected deep onto bone or into deficient fat pads in the face can have a significant lifting effect and improve volume loss, simulating a face lift. This is often referred to as a non-surgical face lift.

Platelet rich plasma (PRP) is derived from whole blood which is spun down in a centrifuge. The plasma contains growth factors which is injected into the skin to stimulate collagen synthesis.

Botulinum toxin is injected into muscles to stop contraction. In this way they prevent repetitive creasing of the skin which in time would lead to a permanent wrinkle or furrow. The best benefit for this treatment is seen on the frown lines, forehead lines and crow’s feet. Injections need to be repeated every 3- 4 months and in time there is significant improvement in skin wrinkling. The treatment does not work on static lines.

There are various options to include anti-ageing procedures in your skin treatment plan. Chemical peels and dermal needling are usually added as a course of treatments after preparing the skin with a homecare regimen. Filler treatments are carried out according to a pre-discussed plan.

Is anti-ageing all about products and procedures?
In general, a healthy lifestyle with responsible sun protection is important to slow skin ageing.

A well-balanced diet is a great source of nutrients and oral antioxidants which also benefit the skin.

A good exercise routine, alleviates stress which through various mechanisms not fully understood, worsen disease and make us age faster. Perhaps less stress and anxiety makes us frown less with resultant less wrinkles.

Smoking increases the breakdown of collagen and elastin in the dermis leading to a more wrinkled skin.

There is a growing body of evidence that all forms of atmospheric pollution is detrimental to the skin and body, causing premature ageing, skin cancers and hyperpigmentation.

Though this seems like an exhaustive list, it is by no means complete!
Consult with your dermatologist or skincare therapist and come up with a treatment plan that you are comfortable with.

What you are able to achieve also depends on how much time, effort and budget you are willing to invest.

Start early, start simple, start somewhere…

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The Magic of Serums

Serums are often the ‘wonder product’ of most skincare brands, and the go-to product for most dermatology and specialist skincare clinics. With so many different options, it isn’t always easy to know which product to choose or even how these can fit into your skincare regimen.

So, let’s shed some light on the matter …

What are serums and why are they so special?
Serums are lightweight liquids or gels containing the highest quality, highest concentration of active ingredients specially formulated to enable the product to penetrate the epidermis to reach the deeper dermal layers of the skin. The sophisticated delivery systems ensure faster and efficient absorption of the product and consequently less wastage.

To be able to guarantee stability of these high quality ingredients while they are on the shelf, to ensure maximum benefit when the product is applied, is nothing short of scientific genius and the reason why serums are often more expensive.

In fact serums are generally the most expensive part of a skincare regimen and this is often the reason most patients are hesitant to use them.

It’s important to remember that very little product is required as the delivery systems are often superior to creams and lotions. With proper use and correct storage most serums actually end up lasting longer than creams or lotions and are ultimately more cost effective.

Where do serums fit in my skincare regimen?
Serums are best applied after cleansing and toning when the product can achieve maximum penetrance into the skin without being hindered by other products. There may be exceptions to this rule.

Serums may be used morning or night depending on the product.

Remember serums do not always give enough moisturise or hydration so you may still need to apply a moisturiser after the serum especially if your skin is dry.

Which serum should I choose?
Serums are often used to target specific skin types or skin concerns. A product range may have a variety of serums with different concentrations of active ingredients to suit different skin types . For example, an oily skin may benefit from a higher concentration of Vitamin C while a dry sensitive skin may only be able to tolerate a low concentration.

Serums may fall under the ‘prevent’ , ‘treat’ or ‘hydrate’ categories of a skincare brand.

Antioxidant serums containing combinations of Vitamin C, E and other ingredients will help prevent and reverse damage caused by sun exposure.

Various skin concerns like hyperpigmentation, acne, rosacea and dryness are targeted by appropriate ingredients found in different serums.

Since most serums contain superior active ingredients either alone or in power combinations, you may find a single serum effective for numerous skin concerns.

Can serums be combined?
Absolutely! Since most of us have more than one issue going on at once, it’s often necessary to treat more that one problem. So if you want an anti-ageing serum , and also a treatment for hyperpigmentation you may use more than one serum. In this case, you may apply one and wait a few minutes before applying the other or use them at different times of the day. Sometimes a single serum can fulfill all your needs.

Have a look at our Skinsmart product recommendations below where we try to help you find what you need, or complete our free online skin assessment here.

– Skinsmart Suggestions –

For hyper-pigmentation or uneven skintone:

*SkinCeuticals Discoloration Defense
*Neostrata Illuminating Serum

For skin redness and rosacea-prone skin:
*Neostrata Redness Neutralising Serum
*SkinCeuticals Phyto Corrective Serum

For hydration:
*SkinCeuticals Hydrating B5

For ageing and fine lines:
*Neostrata Tri-therapy Lifting Serum
*Neostrata Firming Collagen Booster
*SkinCeuticals HA Intensifier Serum

For prevention of free radical damage:

*Obagi C Clarifying Serum
*SkinCeuticals Phloretin CF
*SkinCeuticals C E Ferulic
*Neostrata Antioxidant Defense Serum

For skin barrier repair:
*SkinCeuticals Retexturing Activator
*Neostrata Bionic Face Serum

For mature skin prone to acne:
*SkinCeuticals Blemish + Age Defense Serum

If you are still unsure of what you need, email us at [email protected]. Our qualified medical therapist can give you the right advice for your skin concerns.

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Skinsmart 5 Steps

Everyone wants ‘flawless skin’.

A beautiful skin reflects good health and well being and makes us feel confident and attractive. We constantly look for the ‘holy grail’ of skincare to give a smooth, radiant, even-toned skin that is free of blemishes.

However. while we aim for perfect skin most of us have some imperfections and uneven tone that is ‘normal’, which we should learn to accept as part of our uniqueness.

While aesthetic procedures like botulinum toxin (Botox) , fillers and cosmetic surgery may improve sagging, wrinkling and volume loss, they do not address skin quality (clarity, texture and density) that significantly contributes to the ageing appearance of skin.

As we grow older the rate of epidermal turnover slows from around 28-40 days in youth approaching 50-60 days in the elderly. The resultant dry, dead skin cells sitting on the surface result in poor skin texture and do not reflect light well leading to reduced skin radiance. Dead skin cells block the follicles with the resulting appearance of enlarged pores,

With age there is an overall decline in the production of collagen and elastin leading to reduced density or thinning skin. The skin sags and is also prone to easy bruising.

Of course there are other factors besides ageing that affect skin health like sun exposure, environmental pollution, smoking and diet.

The great news is that there is plenty of evidence to support that a long term, well tailored skincare regimen can have a significant effect on the overall quality of a person’s skin.
Active ingredients in skincare can target specific skin concerns and improve the structure, function and appearance of your skin.

Patients are often reluctant to change their skincare unless they are guaranteed better results. My response is that if you’re looking for a change it means your current regimen isn’t doing enough for your skin. You have to be open to new products and procedures if you want to achieve better results.

Another common complaint that patients have is that they are accustomed to having great skin in their youth without any effort, and grudge the fact that they need to invest time and money in skincare. Beyond a certain age, good skin takes some effort to maintain and this all depends on your genes and how well you looked after your skin when you were younger.

In 2020 we revisit the Skinsmart 5 steps to once again put you on the right path to a smooth and radiant skin.

Step 1: Cleanse and tone
Cleansing removes impurities and dead surface skin cells leaving the skin more radiant.
Gel cleansers are better suited to oily skin while cream cleansers are best for dry or sensitive skin.
Rough, sun damaged skin would tolerate and benefit from a cleanser with a chemical exfoliator like glycolic acid.
A toner may be useful for oily skin to reduce oil and the appearance of large pores.

Step 2: Prevent
Antioxidants like Vitamin C and E help prevent DNA damage caused by sun exposure.
Vitamin C has a host of other benefits including stabilising melanocytes to prevent hyperpigmentation, calming inflammation in acne and locking in moisture.
Vitamin E also acts as a moisturiser.

Step 3: Treat
Active ingredients in skincare may repair existing damage, promote cell turnover, inhibit melanogenesis and stimulate the production of collagen and elastin.
Exfoliating the skin with a chemical exfoliater increases the epidermal turnover rate improving radiance and texture. Glycolic and lactic acids are examples of chemical exfoliators. They are preferable to physical scrubs which are more likely to cause damage to the skin barrier.
Retinol in skincare can stimulate collagen production to improve skin density (thickness), and improve epidermal turnover to treat hyperpigmentation and restore radiance.

Step 4: Hydrate
Moisturisers hydrate the skin and restore defective barrier function.
Most contain a combination of occlusives and humectants which prevent water loss from the skin, and draw water into the skin respectively.
Ointments and creams are best for dry skin, while gels and lotion are best for oily skin.
Moisturisers on Skinsmart almost always contain active ingredients targeting different skin concerns.

Step 5: Protect
Sunscreen is your most important antiageing product.
Dermatologists recommend daily sunscreen use as the final step to your skincare regimen. Use an SPF of 30 to 50.
Sunscreens protect the skin from skin cancer, slows skin ageing and help prevent hyperpigmentation and sun spots.
Some innovative new sunscreens have DNA repair enzymes which have been proven to reverse early sun damage.
Makeup should be applied over your sunscreen.

There is a skincare regimen well suited to every skin type and specific treatments to target individual skin concerns.
Our Skinsmart skin assessment is there to assist you with finding the right routine for your skin concern as it is based on the Skinsmart five steps, recommending products specifically for your skin, for every step of your skincare regimen.

Whether you’re wanting just a basic routine to start or a more intensive one, start by taking your Skin Assessment here

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Pregnancy and your skin

Pregnancy and your skin

Congratulations you are pregnant and while you’re expecting a beautiful glowing skin that we’ve come to associate with pregnant women, there may be a few unexpected surprises leaving you less than happy! To begin with pregnancy can affect not just your skin, but your hair and nails too.

Most body changes observed in pregnancy are regarded as physiological or normal and result from hormonal, vascular, metabolic and immmunologic alterations which are necessary to sustain a healthy baby.

Not all changes are bad and the good news is that most of these physical changes regress in the first six months after delivery anyway.

Some women experience healthier and better looking skin in pregnancy. The ‘pregnancy glow’ results from a combination of 50% more circulating blood volume giving you a brighter or flushed appearance, and a hormonally driven increase in sebum production making the skin more shiny.

Other common vascular changes are reddening of the palms (palmar erythema), spider veins and varicose veins. Most of these changes can be attributed to the effects of oestrogen and an increase in the circulating blood volume.

Stria gravidarum (stretch marks) are caused by changes in the connective tissue or literal ‘stretching of the skin’ in pregnancy. Stretch marks usually develop on the belly, hips, buttocks, breasts, or thighs during the later stages of pregnancy when the body is rapidly growing. Most stretch marks fade to pale or flesh-coloured lines and shrink after delivery, although they usually do not disappear completely.

Higher levels of oestrogen prolong the growth phase of the hair, resulting in less shedding and thicker, healthier looking hair especially in the third trimester. Unfortunately the hair may quickly go into the resting phase after delivery leading to a depressing loss of hair within the first 6-12 months after delivery. This condition is known as telogen effluvium and thankfully full regrowth is the norm.
Some may experience increased hair growth or hirsutism on the upper lip, chin and cheeks which luckily usually abates after delivery.

Pregnant women may develop harder, thickened nails, while others find that their nails are softer or more brittle. These changes are temporary, and the nails should return to normal.

Melasma also known as ‘mask of pregnancy’ is probably the most disturbing form of hyperpigmentation in pregnancy affecting as many as 90% of women. Other forms of hyperpigmentation include darkening of the areola, linea nigra (vertical pigmented line than runs down the middle of the abdomen) and darkening of pre-existing moles (melanocytic naevi). Hyperpigmentation is thought to be related to increased oestrogen, progesterone and melanocyte stimulating hormone. Fortunately the hyperpigmentation of pregnancy regresses in most cases. There are numerous treatments for Melasma but many of these are not suitable in pregnancy.

Eccrine glands activity increases in pregnancy with increased sweating making pregnant women heat intolerant and contributing to discomfort in the third trimester.
Increased androgens boost sebum production with a resultant oilier skin. Fortunately an oilier skin does not always mean acne. Acne breakouts usually occur during early pregnancy. Remember that not all treatments and products are safe to use during pregnancy and its important to check if your pre-pregnancy treatments are still suitable.

Besides these physiological or normal changes in pregnancy, pregnant women are also susceptible to common skin diseases or skin concerns.
Dry or sensitive skin may occur for the first time during pregnancy or be part of an ongoing problem.
Pre-existing skin conditions such as eczema, psoriasis and rosacea may improve or worsen.

While you are pregnant you may need to change your existing skincare regimen for one that doesn’t contain ingredients that are unsafe or have high irritation potential. In general vitamin A and its derivatives, including retinol, are not safe for use.
If you would like our advice on whether you can still use any of your existing creams, please email us or alternatively book an appointment with our medical therapist or dermatologist.