Gluten and Inflammatory Skin Conditions

In the dermatology world, the link between diet and inflammatory skin disease (such as eczema and psoriasis) is still being navigated. There was a recent article on this published in the February 2020 edition of The Dermatologist.

A study by Dr. Aaron Drucker and colleagues showed little to no correlation between gluten consumption and the development of inflammatory skin conditions. This may not apply to individuals who are gluten-sensitive of gluten-allergic.

Eczema is closely linked with food allergies, and the role that food allergies play varies significantly from patient to patient. Food allergies can manifest immediately (minutes to hours) after ingestion or may take up to 48 hours to occur. Eggs, milk, wheat, nuts, seafood, and soy remain the front-runners in terms of foods that trigger allergic reactions.

Botox for Scars?

Botox truly is the wonderdrug of my generation. Who would have ever thought that a toxin could be manipulated to provide so many incredible health benefits?

I recently came across an article discussing the utility of Botox injection in improving the outcome of surgical scars. The conductors of one of these studies did a split-face study and examined the difference between injecting half of a scar with Botox and the other half with saline and found that the Botox-injected half healed with a finer, better-contoured, less-noticeable scar.

We have also used Botox in practice to treat high-movement areas prior to a skin surgery or skin cancer removal. Think about a skin cancer that is located on the forehead. By injecting Botox into the forehead muscles ahead of time, allowing 2 weeks for the Botox to settle in completely, and then performing the surgery, we have essentially created a static, non-moving surgical site that stays at rest through the critical phase of wound healing. Less movement of the area leads to less stress and strain on the delicate collagen fibers that are forming to heal the site.

In my practice, the most ideal situation involves injecting Botox 2-4 weeks before the surgery to allow ample time for the Botox to fully take effect in relaxing the muscle fibers around the treatment area. However, if this is not an option, studies have shown that injection of Botox same day as surgery or shortly after still has significant clinical effect. The effect of scar improvement is not applicable to mature scars as the collagen generation and scar development is already established, in contrast to a fresh surgical site.

Update on Sunscreen: What You Need to Know

In light of the recent FDA discussions regarding testing and labeling of sunscreens, I have had numerous questions from patients, friends, and family members regarding sunscreen usage: what is safe? what sunscreen would you recommend? are sunscreen ingredients harmful to me or my children?

Here is the rundown regarding the recent reports:

Initial discussions on the topic of chemical sunscreens began over a year ago. Now, a more recent clinical trial in January 2020 brought this topica back into focus and demonstrated that 6 chemical sunscreen ingredients are likely absorbed through the skin and into the bloodstream at levels above the FDA’s recommended 0.5ng/mL. We do not know what the clinical effect, if any, is of the absorption of these ingredients into our bodies. It is important to understands as well, that the conditions in which the sunscreens were applied (in high amounts, with multiple reapplications, do not necessarily translate to how sunscreen in applied in real-life scenarios.

The most recent study focused on avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate.

Sunscreens are regulated by the US FDA as over the counter drugs, rather than cosmetics; in most other countries, sunscreens are regulated in the same category as cosmetics.

In 1978, the FDA began to regulate sunscreen in the US. This included an advisory panel that insured that the 21 active sunscreen ingredients that were listed were safe and effective; additionally, regulations were made regarding labeling and determination of sun protection factor (SPF).

In 1999, the 21 safe and effective sunscreen ingredients were narrowed down to 16. Further labeling requirements, including a maximum protective factor of SPF 30 were enacted.

In 2011, the same 16 safe and effective sunscreen ingredients were listed, and testing methods to determine broad-spectrum coverage and water-resistance were established. The maximum SPF increased to 50+; sunscreens were no longer allowed to make labeling claims of being “waterproof” or “all-day protective.”

Over the past couple of decades, sun-protective habits have changed. In the 1970s and 1980s, sunscreen usage was often limited to beach vacations or the occasional all-day sporting event. In more recent years, we have developed a better understanding of the link between sunburns and sun exposure with skin cancer risk. Additionally, the known effects of sun exposure on photoaging of the skin encourages many to practice daily sun protective measures in the quest for delaying the aging process and keeping skin youthful and healthy in appearance. This knowledge has driven a change in sun-protective behavior with many individuals using sunscreen daily. And the sunscreen industry has responded to consumer concerns by developing sunscreen products with broad-spectrum (UVA and UVB) protection and higher SPFs. The refinement of effective sunscreen research and development means that penetration of sunscreen ingredients has evolved…so if we are getting more penetration of “stronger” sunscreen ingredients, could this lead to toxicity within our bodies? The media quickly delved into this topic, utilizing limited and early research to suggest that sunscreen use could lead to changes in hormones, effect on reproduction, and cancer.

In 2016, the FDA outlined requirements for establishing over the counter safe and effective sunscreen ingredients; these included safety testing, cancer and reproductive testing in animals, and confirmation of safety in children. Although many of these recommendations were already implemented by sunscreen manufacturers, one significant change with this ruling was the requirement for human absorption studies; i.e., when you apply a sunscreen to your skin, how much of it is absorbed? This, of course, depends on the total body surface area to which it is applied, the vehicle in which the active sunscreen ingredient is packaged, and the absorption properties of the actual sunscreen ingredient. These studies will be costly and will likely be limited to a finite number of active sunscreen ingredients; they could take many years to complete. The end result is a probable narrowing of available sunscreen ingredients from which consumers may choose and a higher cost for those sunscreens based on supply and demand.

Here are the current proposals:

  • Only 2 active sunscreen ingredients, zinc oxide and titanium dioxide, are currently considered safe and effective.
  • Sprays, oils, lotions, creams, gels, pastes, ointments, butters, and sticks are approved; powders require further investigation
  • Maximum SPF will increase to 60+
  • Labeling will require listing the active sunscreen ingredient on the front of the package/bottle
  • SPF 15 or higher is required to provide broad-spectrum coverage consistent with SPF

Bottom line (Dr. Casey’s recommendations): Sunscreen is an integral component of sun protection. When applying sunscreen to large areas of skin, stick with safe and effective ingredients: I prefer zinc oxide due to its comprehensive broad-spectrum coverage (UVA and UVB protection) but titanium dioxide is also effective. Be knowledgeable regarding sunscreen additives that may be irritating or sensitive to the skin.

Wide-brimmed hats, staying in the shade, avoiding sun between 10:00am and 3:00pm, and sun-protective clothing are excellent ways to protect your skin without the worry of sunscreen absorption.

Avoid sunburns!

And finally, protecting your skin from the sun has proven and established benefit in the prevention of skin cancer, the most prevalent cancer in the United States.

Much of the information in this post was obtained from the excellent article “Sunscreen Regulations and Advice for Your Patients” by Vincent DeLeo MD in the May 2019 issue of Cutis (vol 103 No 5 pp 251-253) and updated to include information from “Talking Points for Counseling Patients on Sunscreen Use” in the February 2020 edition of The Dermatology

Your Skin’s Circadian Rhythm

Most of us are aware of the circadian rhythm in our bodies that occurs over the course of a 24 hour period. But do you recognize that your skin also experiences a similar circadian rhythm?

Circadian rhythm is the body’s inherent physiologic, behavioral, and metabolic processes that occur over a 24-hour period; it is significantly influenced by light and our surroundings.

Melatonin is the primary compound involved in regulation of our circadian rhythms; levels of this substance fluctuate throughout the course of the day at lower levels and tend to increase at night. Melatonin is an antioxidant and is linked to hair growth, controlling ultraviolet damage in skin cells, and healing of wounds.

When our circadian rhythm is interrupted, the result is a disruption in the natural biologic routines of our bodies. Within the skin, this can manifest as increased water loss, unhealthy proliferation of skin cells, and interruption of the ability of our skin to repair DNA damage (which typically occurs at night). As dermatologists, we take this cycle into consideration when determining when to apply certain products to the skin, i.e. sunscreens in the morning and repairing serums at night).

This information underscores the importance of adequate sleep in maintaining optimal skin health. Our skin cells actually contain clock genes which ebb and flow in regard to water loss from the skin to the surrounding environment, blood flow, growth of new skin cells, and skin temperature. Our skin loses more water at night when it becomes more permeable. This can cause our skin to feel dry, dehydrated, irritated, or itchy; and we may be more aware of this at night or when we wake up in the morning. Alternatively, night time is an ideal time to apply creams and serums that we want to penetrate into our skin to achieve maximum result.

Blood flow in our skin increases in late afternoon and evening; this can also affect absorption and efficacy of topical creams, lotions, and medications that are applied to the skin during this time with increased absorption and diffusion into the surrounding tissue as blood flow increases. Our skin temperature is also regulated in a cyclic way with temperatures in the skin reaching a peak in the afternoon and then dropping at night.

Skin cell proliferation peaks around midnight in healthy skin cells. Cancerous skin cells lose this rhythm and may continue to proliferate in a more unregulated way. Oil producing glands also show a rhythmic pattern with minimal activity in the very early morning and increased activity at midday.

The fact that our cortisol levels fluctuate throughout the day is well-recognized with a natural trough in the evening. As cortisol levels drop, we may experience increased skin sensitivity, itching sensations, and greater inflammation in our skin.

Numerous studies support the conclusion that when our natural sleep/wake cycles are interrupted, there is an increased cancer risk. This is demonstrated in individuals whose careers require nighttime work such as night shift workers, pilots, and flight attendants.

Consideration of your skin’s circadian rhythm is important to optimize skin health and also increase efficacy of skin care products in achieving the best results for your skin.

Source: Lyons, Alexis B et al. Circadian Rhythm and the Skin: A Review of the Literature. Journal of Clinical and Aesthetic Dermatology. Sept 2019, vol 12 (9): 42-45.

Sunscreen Use in Grade-School Aged Children

We’ve come a long way regarding consistency in sunscreen use…but we still have far to go. An article this summer in Pediatric Dermatology examined more than 5000 fifth graders and found than fewer than 25% almost always wore sunscreen. And the percentage fell to 6% for non-Hispanic black children that were surveyed.

Sunscreen use in the 5th graders correlated with other preventive health behavior such as regular flossing,

As a dermatologist and skin cancer expert, it is frustrating to see these numbers. When it comes to skin cancers, prevention truly is the best medicine. We know that consistent and early-established sun-protective measures have a significant impact on decreasing skin cancer incidence.

We also know that preventive health habits are sustained much more effectively when they are ingrained at an early age. Which leads to the question of why we are not taking a more active role in educating our children, from a very young age, about how to protect and nourish their amazing skin.

Barriers to proper sunscreen habits are multi-factorial and may include: lack of parent knowledge, socio-economic barriers, an absence of sunburns in themselves or close family members, lack of established habits, suboptimal education regarding skin health, and unwillingness of children to adopt these habits. I would argue that if we can establish the ritual of simple and regular sunscreen use from a young age, that children are more likely to incorporate this important habit into their daily routine.

Sun protective education is an opportunity for all health care providers, teachers, other educators, and parents to come together to establish a foundation for lifelong healthy skin. By doing this, we continue to raise awareness about the skin cancer epidemic and hopefully have a significant impact on decreasing these numbers.

My practice is centered on skin cancer treatment and skin rejuvenation. When I examine the skin of my patients under the microscope, it tells the story of decades past. The effects of sun and inflammation lead to pigmentation, broken down collagen, and abnormal skin cell proliferation. I firmly believe that we can change the trajectory of the skin cancer incidence by educating our young people and help them incorporate healthy sun protective habits into their daily routine.

Oakes, Kari. Sunscreen use in grade schoolers: Wide racial, ethnic disparities seen. Pediatric Dermatol June 2918 38-39

Correnti CM et al. Pediatr Dermatol. 2018. doi: 10.111/pde. 13550.

Healthy Skin is not Just Superficial

This is an exciting time in the world of dermatology as we discover more about the link between our skin and our internal health. Recognizing more about this relationship underscores the importance of keeping our skin as healthy as possible…and the potential benefits that we will see in our overall well-being as a result.

There are numerous studies proving the relationship between inflammation in our skin and inflammation within our bodies. For example, when our skin becomes really inflamed, the inflammatory cells and cytokines that are formed can be enough to create inflammation within our body. We know that inflammation in our body can lead to chronic conditions such as heart disease and can stress our other organs and immune system as well.

So how can we minimize inflammation in our skin? One simple way is establishing consistent habits such as avoiding harsh and irritating cleansers that inflame our skin; keeping our skin well-moisturized to provide the support and flexbility that it needs to behave optimally; and being consistent about effective sun protection. We know that sun exposure causes inflammation within the skin which then causes damage to the collagen and other structures in our skin…as possibly beyond.

Starting optimal skin care habits as children is the most ideal approach to a lifetime of healthy skin. Simple routines such as gentle cleansers, consistent moisturizers, and sun protection are the foundation of lifelong beautiful skin (and likely a healthier body in general). As our skin matures, we lose some of the natural moisture component of our skin. We also start to lose elasticity and firmness in our skin through the breakdown of collagen and elastic fibers…this process is accelerated by inflammation.

When our skin is not adequately moisturized, the skin barrier is compromised…microscopic cracks allow bacteria and viruses to enter the skin. A similar process can occur from skin care products that produce dryness or irritation to our skin. Our skin cells in turn produce cytokines to fight these bugs, leading to inflammation and further recruitment of other immune system cells.

Find a skin care regimen for you and your children that works for you. Ceramide containing creams and lotions (such as Cerave) are an effective way to keep the skin barrier strong and resilient. Avoidance of harsh soaps and antibacterial gels that can irritate the skin is important. Daily sun protection with a broad-spectrum SPF 30 or higher is a must.

Sun Protection Among Racial and Ethnic Minorities

This morning, I had an interesting conversation with a beautiful friend of Lebanese background who has lovely skin that always tans. We were discussing healthy skin and sunscreen habits, and she made the comment that when she was younger, her mother told her that she didn’t need to worry about sunscreen. As her mother put it “our skin doesn’t need that.” She never sunburned, but she is now regretting the significant sun damage that her skin sustained over the decades of her youth.

An article this summer in the Journal of the American Academy of Dermatology reviewed sun protection among racial and ethnic minorities. The authors sent out a survey to 3665 women and 5287 men; 82% were white non-Hispanic, 11% Hispanic, 3% black non-Hispanic, 3% Asian non-Hispanic, and 1% other non-Hispanic.

The black, Asian, and Hispanic populations surveyed were less likely to use sunscreen compared to the non-Hispanic white adults. However, these 3 groups were also more likely to wear long sleeves and shelter themselves on sunny days.

The results support the previous finding that despite skin cancer being the most commonly diagnosed cancer, it is often underrecognized among members of minority populations. Additionally, morbidity and mortality of skin cancer is often greater in racial and ethnic minorities compared to white adults.

There may be underlying cultural habits, personal preferences as well as an under-appreciation of the importance of sun protection in all skin types that is responsible for the findings. As a society in the US, we are evolving towards greater awareness and better habits when it comes to sun protection. But we still have a long way to go. I’ll be the first to admit: I’m far from perfect…I’ve had more blistering sunburns than I can count in my lifetime; I used tanning beds; I rarely applied suncreen in the first 2 decades of my life. And our daughters have had sunburns in their lifetime. And they don’t always put sunscreen on before going outside. We’re pretty good about good sun protective habits, but we could be better.

As an expert in skin cancer and skin health, I have seen a significant number of skin cancer in individuals with darker skin types and ethnic minorities. Education about the importance of sun protection in all skin types is a priority among all providers in dermatology. And the responsibility lies on us to educate the next generation and establish consistent and effective sun protective habits.

McKenzie C, Kundu RV. J Am Acad Dermatol. 2019 June 19.

Why Dirty Skin is Healthy Skin

We’re trying to reverse the thinking that cleaner is better. Our society has moved towards an era of antibacterial wipes, hand sanitizers, disinfecting solutions…we’re constantly scrubbing, cleaning, wiping. So what is the impact of all of this cleanliness on our skin?

The truth is, it’s really bad for your skin.

Our skin is colonized by a diverse, specific, and intricate collection of bacteria…actually between 10,000 and 1,000,000 units per square centimeter…that is unique to each of us. There are also yeasts and parasites that exist in a symbiotic relationship with those bacteria. When we interrupt this delicately orchestrated balance of organisms, it can lead to sensitivity, irritation, infections, and inflammation. That collection of bacteria and yeasts also works to protect our skin from all of the environmental stresses (ultraviolet radiation, pollution, etc).

In the field of dermatology, we are seeing an increase in the incidence of sensitive skin, eczema, inflammation and related conditions. In our households and daily lives, we might be experiencing an increased drive towards cleanliness: long hot shower scrubbing at our skin, anibacterial soaps and skin products, exfoliating products. Many days in my practice, I get questions from patients about why their skin is more sensitive. When we “overclean” our skin, we essentially strip it of all of those protective organisms, the probiotics. These organisms help with regulating everything in our skin from ceramides that help provide a protective barrier, to anti-inflammatory properties, to temperature regulation.

What can we do to protect the intentional and effective balance of bacteria, yeast and parasite on our skin to optimize skin health? Here are the tips that I give to my patients

  1. Avoid hand sanitizing gels, lotions, and creams
  2. Wash with gentle soaps and cleansers such as Dove, Cetaphil cleanser, or Cerave cleanser
  3. Avoid antibacterial wipes
  4. Avoid harsh and aggressive exfoliating products
  5. Take warm, not hot, showers or baths
  6. Bathe once daily at the most
  7. Moisturize all of your skin regularly with a gentle and effective moisturizing product such as Cerave or Cetaphil

Skin and Allergies

Understanding and appreciating your skin as a barrier is essential to maintaining skin and body health.

The skin’s role in our immune system must be recognized. The skin is essentially the “first line of defense” between our bodies and the external environment. As such, our skin is exposed to many potential harmful exposures including pollution, irritants, ultraviolet radiation, chemicals, and natural compounds. When the barrier of our skin isn’t working at full capacity, the potential for these external factors to harm our skin and “irritate” our immune system increases. This can result in allergies, skin infections, inflammation, eczema, and contact dermatitis.

Think of your skin as the filter between your internal body and the world around us. In a sense, the skin is the means by which the external environment communicates with our internal selves. The skin is a complex organ, comprised of the stratum corneum that sits above the epidermis, the epidermis, dermis, and subcutaneous fatty tissue.

The skin barrier includes the microbiome, physical elements, chemicals, and immune layers. The microbiome is a very active and dynamic community comprised of living bacteria, yeasts, viruses, fungi, mites, parasites, and other organisms that are constant communication with each other, our internal body, and the world around us. The skin microbiome has been actively discussed in recent research regarding skin health as we start to recognize the complexity of this entity, and the importance of protecting and nurturing it to keep our skin and our bodies healthy. The chemical layer has natural moisturizing factors and other chemicals that maintain the pH of our skin. The physical part of our skin barrier is just that: the cells and connections among them that actually form what we recognize as tangible skin. Finally, the immune portion of our barrier is made of microscopic immune cells that are essentially scouring our skin like little police peacekeepers.

Our skin has a remarkable ability to stay balanced and stable in regard to all of these elements. The microbiome communicates closely with the immune cells. When the microbiome is disrupted, the skin barrier is consequently threatened. In practice, this translates to an awareness of keeping our skin clean and healthy, without stripping or harming the little organisms that are so essential for keeping our skin, and our bodies, in balance. While we want to wash away dirt, oil, and other skin irritants, we also need to support the helpful community of bacteria, fungi, etc on our skin. Similarly, our chemical skin barrier stays balanced when we maintain an optimal skin pH between 4-6. The physical barrier of our skin actually protects us from the entry of foreign substances such as chemicals, irritants, harmful bacteria, etc. Thy physical barrier must stay strong, without cracks, breaks, or openings that would allow foreign materials in. And the immune portion is closely integrated within all of the other components of the skin barrier, communicating among the external pathogens, and the other cells of our skin and our bodies.

In dermatology, we recognize the following:

  1. When the skin barrier is disrupted, this can lead to allergic sensitization
  2. When the skin barrier is repaired, this may prevent allergic sensitization
  3. Allergies can develop through skin sensitization
  4. When the skin barrier is compromised, allergies can develop
  5. Skin barrier disruption can result in contact dermatitis
  6. Proper skincare plays a critical role in keeping the skin barrier strong, healthy, and protective

Emollients can aid in repairing the skin barrier by restoring water and lipids and also promoting ceramide synthesis. When the lipids are replaced, inflammation is reduced. Barrier creams and ointments essentially create a protective layer over the skin, thereby preventing entry of environmental irritants and also preventing the loss of water from within our skin into the external environment.

There is also increasing recognition regarding skincare products that support of the microbiome of the skin. These washes, creams, and serums regulate inflammation to support the healthy natural flora of the skin. Prebiotics may be added to skincare products and may have a role in creating a diverse and optimal microbiome. The ideal skin mositurizer would avoid preservatives that can damage the microbiome, have an neutral pH to support the skin pH of 4-6, avoid allergens and fragrances that could aggravate the skin. As with most things in life, there is give and take that is required in each of these categories in order to create an effective, sustainable, cosmetically elegant and attractive product.

Strugar TL et al. Connecting the Dots: From Skin Barrier Dysfunction to Allergic Sensitization, and the Role of Moisturizers in Repairing the Skin Barrier. J Drg Dermtol 2019 18(6): 581-586

Melatonin and Your Skin

What do you think of when you hear “melatonin”? For most of us, we associate melatonin levels with our constantly cycling circadian rhythms. Melatonin is available as a supplement to help regulate sleep cycles; i.e. for those that have difficulty with insomnia or falling asleep, melatonin supplementation may help.

But melatonin has many other roles. It is an effective antioxidant, protecting our cells from damage from the free radicals that we encounter daily. And due to its lipophilic properties, melatonin is able to more easily travel through the membrane of cells, delivering its antioxidant properties directly into the DNA and mitochondria of cells. Melatonin also plays an important role in the homeostasis of the skin.

So what does this mean for our skin? Early studies have shown that topically applied melatonin actually suppresses ultraviolet-B induced inflammation, and this effect is compounded when melatonin is combined with other antioxidants such as vitamins C and E. Melatonin also has proven benefit in healing wounds(1) and suppressing eczema flares(2).

All of this translates to significant anti-inflammatory and antioxidant properties of melatonin, in topical or supplement form, on our skin. And antioxidant properties lend to an anti-aging effect by fighting against the damaging agents that our skin encounters daily.

Our melatonin levels decrease as we age. So it is important to recognize the potential benefit that supplementation, whether oral or topical may provide to us as our instrinsic levels start to decline.

  1. Ozler M et al. Scand J Clin Lab Invest. 2010 Oct;70(6)447-52.
  2. Kim TH et al. J Pineal Res. 2009 Nov;47(4):324-9