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0:22

Welcome to The Referral with me, Dr. Curran.

0:24

I'm a surgeon in the NHS and this is

0:26

your weekly podcast where we talk about all

0:29

things medicine, science and health. We

0:31

chat to guest experts where we

0:33

debunk myths and offer you actionable,

0:35

insightful, evidence-based strategies to improve

0:38

your life. Today's topic is a very

0:40

interesting one. We're talking about an organ that's

0:43

invisible, but it's in plain sight. It's

0:45

the Swiss Army knife of organs. It helps

0:47

you regulate your body temperature. It

0:49

keeps you safe from microbes

0:52

and other bacteria and viruses. It's

0:54

part of your immune system. It helps you interact

0:56

with your environment. If you haven't guessed what it is,

0:59

it is the skin. We're going to be covering skincare

1:01

basics, essentials, and

1:03

talking about acne, which seems to

1:06

affect everyone at some point in their

1:08

life. And to join me to discuss this, we've

1:10

got a skincare expert, Dr.

1:13

Anjali Mato, who's a medical and

1:15

cosmetic dermatologist with her own clinic

1:17

in London's Harley Street.

1:19

There's absolutely no doubt that layer

1:21

upon layer of skincare product that people are

1:23

using in the morning and the evening is disrupting

1:26

skincare barriers. They're poorer

1:28

for it,

1:29

and their skin's no better for it, and their mental health is

1:31

worse for it.

1:32

Dr. Anjali Mato. Now,

1:38

you're a dermatologist, but tell me and tell

1:40

everyone watching and listening what you get

1:42

up to on a daily basis and an interesting fact

1:45

about what you do.

1:45

So, dermatologist,

1:48

we are trained to deal with over 3,000

1:52

conditions that affect the skin, the

1:54

hair, and the nails. And I think that's one thing

1:56

people don't realise about us. They think of skin, but

1:58

hair and nails also... fall into our remit.

2:02

I also subspecialise in laser

2:04

and a little bit of cosmetic work as well. So my

2:06

average day can vary from seeing

2:08

people with medical inflammatory skin conditions,

2:11

so things like acne, rosacea, eczema,

2:13

psoriasis, to doing mole

2:16

checks for skin cancers,

2:18

to doing laser treatments or a little bit of injectables

2:20

for anti-aging. So it's the whole gamut really of

2:22

skin conditions that can affect you on any

2:25

part of your body

2:26

at any age. Now you mentioned

2:28

acne as one of the

2:30

things that you deal with, and

2:32

acne is seemingly affecting everyone, sort of over 80%

2:35

of people who get it at some point in their lives.

2:37

Is that, would you say, a

2:39

bulk of the work and sort of the patients

2:41

you see in your clinic?

2:42

Yeah, and I think partly there is a

2:44

selection bias of what I see. I've been

2:46

quite open talking about my own issues with acne

2:49

growing up over the years. So I think there

2:51

is a degree of me attracting people because

2:53

I'm quite vocal about the links between acne

2:55

and mental health. But I think in addition

2:58

to that, yes, we see a lot of it because it's probably

3:00

the most common skin condition. It

3:02

does affect about 80% of people at some point.

3:04

What is acne and why do people

3:07

get it? So acne is

3:09

a multifactorial skin disease.

3:11

So what I mean by that is there is no one

3:14

single cause why it happens. So

3:16

it's a complex interplay between a number of

3:18

environmental factors and genetic factors.

3:21

So it's partly related to hormones

3:24

in the skin,

3:25

in particular what we call androgen hormones.

3:27

So testosterone, dihydrotestosterone,

3:29

DHT. Now even women produce

3:32

these hormones, although we classically think of those

3:34

as male hormones. So those hormones

3:37

can act on oil glands in the skin.

3:40

Our oil glands are in highest density on our face,

3:42

our back, our chest, our shoulders, which is why

3:44

those areas are where people are acne

3:46

prone. So the hormones,

3:49

the plump, juicy oil glands, chucking

3:51

out more oil, and then our skin

3:53

cells aren't behaving properly and they become

3:55

sticky and clumpy. The medical word

3:57

for that is follicular hyper-characterization.

3:59

But essentially what it means is the skin cells aren't

4:02

shedding or exfoliating properly. So

4:04

they form plugs or blocked pores. And

4:07

then bacteria which naturally live on the skin

4:09

surface, a bacteria called C. acne,

4:12

can then act on those blocked pores to create inflammation

4:15

and those deep spots. Just for

4:17

those people who are not so well

4:19

versed in skincare, they talk about acne

4:22

and you hear things like whiteheads, blackheads,

4:24

open-close comedones. What is that

4:26

simplified? What does all that

4:29

mean?

4:29

So these are all different

4:31

types of acne lesions. Okay, so

4:33

it's all acne.

4:34

It's all acne. But it's

4:36

almost the difference in acne which is inflammatory

4:39

and acne which is not inflammatory. So

4:41

generally speaking, it forms almost

4:43

like a process as acne progresses.

4:45

So when you've just got a couple of little blocked pores,

4:48

your skin's a little bit oily and your

4:50

skin's not exfoliating properly, you

4:52

will get comedones. So little blackheads

4:54

or little whiteheads. So these are the tiny little

4:56

bumps underneath

4:57

the skin. As acne

4:59

progresses, for some people, not

5:01

all, what will then happen is

5:03

the C. acne's bacteria then

5:05

becomes rather active on these blocked pores

5:08

and that's where you start to get the little raised bumps.

5:11

So this is where you get papules.

5:12

So the redness. Exactly. But

5:15

then as acne progresses, those little

5:17

red bumps become larger red

5:19

bumps. So they're quite deep. They're quite

5:21

painful. They last for several weeks at a time.

5:23

They're more likely to leave a mark or a scar.

5:26

So then they become nodules or cysts. So

5:28

they're a sort of pus containing inflammatory

5:30

now lesions. Exactly. But they're quite

5:32

deep underneath the skin. So they're just

5:35

a way really that we as dermatologists

5:37

use to classify the skin and the degree or

5:39

the severity of acne.

5:41

The truth is though, one person may have different

5:43

types of lesions at one point in time. And

5:46

when someone is suffering from acne, obviously

5:48

there's a percentage

5:50

of people who may just leave it alone and it resolves spontaneously.

5:53

There's a percentage of people who

5:56

try to pick at it and burst these

5:58

papules and lesions. You know, clearly

6:01

that's not a good idea to do

6:04

at home certainly anyway. It may

6:06

be okay for a dermatologist to do it, also a doctor

6:08

in clinic, but what are the actual

6:10

effects apart from pain

6:12

and scarring to then bursting

6:14

your own pimples

6:15

at home? Yeah, the main issue really

6:18

is infection and scar. Infection. They're

6:20

the big things that we'd be concerned about. And one

6:22

of the things that we do know with patients

6:24

who suffer with acne is there are also higher rates of

6:26

anxiety. And anxiety itself

6:29

can be related itself with things like

6:31

skin picking.

6:31

It worsens our acne as well. Yeah, so if

6:34

you ask somebody who's a bit anxious about your

6:36

acne and you're picking your skin, we've got a medical word

6:38

for that, acne excorié. So people

6:40

would rather than

6:41

have the bump, they would rather scrape the bump

6:43

away. So sometimes you see people

6:46

and literally they've taken away the top layers of their

6:48

skin and it's caused quite a lot of deep

6:50

scarring. So when I see that, for example,

6:52

so it's not a little bit of squeezing the odd spot, but it's

6:55

almost a compulsive desire to want to pick away

6:57

at the skin. You absolutely have

6:59

to work with a good mental health professional

7:01

as well as a dermatologist to get out

7:04

of the habit of that kind of picking of the skin.

7:06

Wow. I guess the more we figure out

7:08

about the genetic factors, we can

7:10

sort of try to stratify who will

7:12

be at increased risk of acne.

7:15

And a lot of people typically associate

7:17

acne with teenagers having

7:19

some hormonal fluctuations, but actually there's a

7:22

significant population of adults

7:24

and probably more adults now than ever with

7:27

acne in their 30s, 40s, 50s.

7:29

Yeah, it's interesting. So we actually inherit

7:31

the number of oil glands that we have

7:33

from our parents at birth, but those

7:35

oil glands are relatively inactive and it's

7:38

androgen hormones during puberty that cause

7:40

that spike, which is why you start getting acne

7:42

in teenage years. But if you look

7:44

at adults data, about 20 to 40%

7:47

of adult women will suffer with acne

7:49

and about 8% of men. So

7:52

it's significantly less in the male

7:54

population and that is thought

7:56

to be due to far less complex hormonal

7:58

patterns that are going

7:59

on. simple creatures.

8:01

We have one main hormone that we worry about

8:03

fluctuating. So I guess you

8:06

see it more in men who may abuse

8:09

steroids, who may then see

8:12

a significant fluctuation in the steroid

8:14

hormone and get steroid-associated

8:17

acne.

8:17

Absolutely. So bodybuilders are

8:20

the archetypal group

8:22

that you would think of that with. And what's

8:24

interesting is there are small studies on

8:26

bodybuilders aged between 17 to 25 years looking

8:30

at their whey protein consumption and

8:32

a link of potentially whey protein being

8:34

the driver for truncal acne, so

8:36

acne on the shoulders or the back. But

8:39

the issue there is often when

8:41

people are competing in those types of sports,

8:43

there are other things that may be also going on

8:46

in the body that may not just be whey protein, for

8:48

example, anabolic hormones,

8:50

which may be having a part to play. So this is where the data

8:53

can become a little bit murky to separate

8:55

out what's causing what.

8:56

And I think you just mentioned the whey protein

8:58

there, and there have been consistent

9:00

myths, but also some evidence

9:03

which point towards dairy

9:06

increasing the risk of acne. But again, the data

9:08

is circumstantial. It's

9:10

not a hard and fast dairy causes acne.

9:13

There's lots of limitations of studies

9:15

which have pointed to that because you can't blind

9:17

or randomize someone

9:21

to milk or not milk in a study

9:23

to actually figure out whether that's

9:26

the cause to factor in acne,

9:27

can you? That's right. And I think the other thing

9:29

is a lot of nutritional data is hard to interpret

9:31

because you're recalling bias in terms

9:33

of what people are telling you they've had 20 years

9:36

ago, 10 years ago. I mean, I can't remember what I ate

9:38

last week, let alone what I was eating regularly 10

9:41

years ago. So that doesn't help.

9:43

Now, that said, there probably is

9:45

a small select group of people

9:48

where dairy may have a part to play.

9:50

The problem is we still don't know exactly

9:53

how to stratify who those people would be.

9:55

So we rely on a clinical history and if somebody

9:57

says that's the case, I would absolutely respect

9:59

that.

9:59

that. But that said, if it was as simple

10:02

as dairy, I wouldn't have vegan patients.

10:04

And I certainly have vegan patients with acne.

10:06

Yeah. I've always been quite

10:08

vocal on the fact that I believe

10:10

that our current understanding of

10:14

the microbiome and the use of probiotics

10:16

for the microbiome is more hyped than

10:18

health at the moment. Agreed. And

10:21

you're nodding, which is good. And I feel as well

10:23

that people abuse the fact that

10:25

we know now about the presence of the microbiome

10:28

to then say, you can now put probiotic

10:31

supplements on your skin to maybe influence your

10:33

skin microbiome. Have you seen that sort of

10:35

stuff

10:36

in patients in your clinic and that

10:38

sort of myth being perpetuated? Yeah.

10:41

For gut and for topical as well,

10:43

both of them, absolutely. And often

10:45

the conversation that I will have is,

10:48

if we look at the gut microbiome specifically for skin

10:50

conditions, even if you have two

10:52

identical twins, identical

10:54

DNA,

10:55

their gut microbiomes aren't identical. Totally

10:57

different, yeah. So

11:00

how much variation is there going to be between one person

11:02

and the other? The second thing is a lot of probiotics

11:05

really just focus on bacteria. But

11:07

we know that our microbiome is not just

11:09

bacteria, it's yeast and it's fungus and it's

11:11

mold and it's viruses. So we're

11:13

not accounting for that either. So

11:15

I think we just live in a day

11:17

and an age where we just want to control as

11:20

many things as we can. And I feel

11:22

like diet is an easy thing that people feel

11:24

that they can control.

11:25

And

11:26

I think that's why often we go

11:28

down that route of maybe I should take this

11:30

supplement or that supplement, but we're better off eating real

11:32

food

11:34

than taking supplements. I mean, I totally agree with you

11:36

there on the supplements thing. And on that

11:38

line of diet

11:40

and skin, we'd

11:42

be remiss if we didn't mention there is

11:44

some association between that. What

11:47

are some things that you would typically recommend to

11:49

patients in terms of dietary factors

11:52

that could at least help to support their

11:54

skin health rather than a golden bullet

11:57

to change it? What would that be?

11:59

Yeah, so I always take top

12:02

line being there is no specific

12:04

diet that is good for your skin. There

12:07

is no superfood that is good for your skin. A

12:09

diet that is good for your skin is a

12:11

diet that's one that's good for your general health. It's

12:14

good for your gut and it's good for your heart and it's

12:16

good for your lungs and every other part of

12:18

your body. But the big ones that I get

12:20

asked about, so dairy, which we've slightly touched on.

12:23

So if we look at the clinical trial data that

12:25

we've got on dairy, the evidence

12:27

seems to be that low fat dairy

12:29

seems to be more of a problem than

12:31

full fat dairy. Now the question

12:34

there then becomes, is that because when you

12:36

remove the fat, you're left with the carbohydrates

12:38

or the sugars. So it's the sugar that might

12:40

be driving it. So if someone

12:42

says to me that every time they have

12:44

dairy, they notice a flare up, like I said,

12:47

I respect that and I will say fine. In that case,

12:49

you could be that select group, it's a problem, don't

12:51

have it in your diet. But if that's

12:54

not the case and they've noticed no kind of variation

12:57

in their skin, I would say, you know what, reintroduce

12:59

it and don't be scared of it. The

13:01

second thing that I find is people blanketly

13:03

cut out dairy because of what they read online

13:06

and they always switch to plant milks, which

13:08

is the natural alternative, but nearly

13:10

everyone switches to oat milk. Now

13:13

the reason for that is because it tastes good

13:15

and it tastes good because it's full of sugar.

13:18

It's got the highest glycemic index of

13:20

all plant-based milks.

13:21

And sort of lower glycemic index

13:23

foods are better for... For

13:25

skin. For reducing flare ups or potentially of

13:27

chronic skin conditions.

13:28

So acne in particular, particularly

13:31

adult acne, there seems

13:34

to be, again, limited data which shows

13:36

that if you consume foods that have got a high

13:38

glycemic index, so spike your

13:40

blood sugar levels very, very quickly, that

13:43

may potentially be one

13:45

of the things that might drive acne. Now it won't be

13:47

the cause, you've got to have the underlying tendency

13:49

anyway, but it may well be a trigger.

13:52

And again, that's not the case for everyone. So my approach

13:55

there is it doesn't mean you can't have sugar in

13:57

your diet, it just means that you just need

13:59

to be sensible.

13:59

about how much sugar you're having in your diet.

14:02

But what I don't think is great is cutting out dairy

14:04

blanketly and then putting oat milk in

14:07

everything, you've swapped something which probably

14:09

isn't a problem to something that we know has

14:11

got a high glycemic index and is more

14:13

likely to be a problem.

14:14

So I feel it's almost a bespoke, you know,

14:17

a bespoke approach, management approach for each

14:19

patient. I mean, what are some other sort

14:21

of basics apart from reaching

14:23

for medication from a lifestyle point

14:26

of view that you'd point people in the direction

14:27

towards? You know, in terms of the bespoke approach,

14:30

because we see a lot of acne, one of

14:32

the drivers for acne, particularly in women,

14:35

which I see a lot of, is a condition

14:37

called polycystic ovarian syndrome, PCOS.

14:40

It's underdiagnosed, it affects about 8 to 10%

14:43

of the female population and acne

14:46

is one of the features that's associated with it. So

14:49

often these patients will present to a dermatology

14:51

clinic and you will screen them for the first time and

14:53

find that. Interesting. If

14:56

I feel somebody has got other markers

14:57

of PCOS, so I will always ask about menstrual

15:00

cycles. I will always ask about hair

15:02

in general as well and family history,

15:04

all of that stuff is important. But

15:06

if there is any suggestion or that diagnosis

15:09

is made in clinic, I do find with

15:11

those people the glycemic index is quite

15:13

important. And I will also recommend,

15:16

again, in terms of improving insulin resistance,

15:18

resistance training and strength training at

15:21

least three times a week.

15:22

Have their body composition, lowering

15:24

the visceral fats, et cetera.

15:26

Absolutely. So I think for that particular

15:28

group, that's important. But then again,

15:30

from a practical point of view, we

15:33

know that the skin doesn't work in isolation

15:35

to other organs. How much sleep you're

15:37

getting is really important. How

15:40

much stress is in your life. Stress will

15:42

exacerbate chronic inflammatory skin conditions.

15:45

So a lot of this stuff, quite honestly, I think

15:47

we know we're just very bad at following

15:49

and we're looking for a magic bullet when

15:51

it's actually a lot of it is getting enough sleep,

15:54

managing your stress, making

15:56

sure your diet is diverse, making sure

15:58

that you're moving enough, you're doing resistance.

15:59

training, you're getting your heart rate up.

16:01

I feel now that cosmetic

16:04

dermatology with the rise of a lot

16:06

of wellness influences, both celebrities,

16:09

people like Gwyneth Paltrow, but

16:11

also people on TikTok

16:13

and Instagram, the sort of influencers who

16:16

have maybe left behind clinical

16:18

dermatology and are fully into the sort of

16:20

wellness fads, do you think the rise

16:22

of all of these things and celebrities online

16:25

promoting the use of dozens

16:28

of different products in your skincare routine

16:30

and us now bullying

16:31

our skin with

16:34

all of these various products that's

16:36

disrupting the natural skin

16:38

microbiome and resulting in all of these conditions?

16:40

Is that a contributing

16:41

factor, do you think? I think it's a huge issue. I

16:44

can tell you, having practiced

16:47

certainly as a consultant for nearly 10 years now

16:49

and the kinds of things I was seeing about 10

16:52

years ago versus what I'm seeing now, there's

16:55

absolutely no doubt that layer upon

16:57

layer of skincare product that people are using in

16:59

the morning and the evening is disrupting skincare

17:01

barriers. Clinic yesterday, I would

17:04

say probably about half the women that I saw were

17:06

using online products or

17:08

prescription online products for anti-aging

17:11

and it had disrupted their skincare barrier and

17:13

that is a massive issue.

17:15

On one hand, I think again, capitalist

17:17

society and fear of missing

17:20

out, we're told first of all,

17:22

you can't get old because getting old is terrible

17:24

and it's the worst thing that can happen to you. Therefore,

17:26

you need to be slapping all of these products onto

17:28

your skin. Secondly, you obviously

17:30

don't care enough about yourself if you're not using

17:33

all of these products. So there is a degree of

17:35

shame, I think, in friendship circles if

17:37

you're the one friend that doesn't seem to care about your

17:39

skin in the same way. So

17:41

I think there are multiple issues playing

17:44

into this at the moment.

17:49

So a lot of you asked me how I balance

17:51

brainstorming for my videos and writing scripts,

17:54

planning my book chapters, my newsletter,

17:57

stuff to do with my life as a surgeon.

17:59

as a doctor in the hospital, it was a struggle.

18:02

But recently I've been using Notion AI and

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it's essentially a workflow productivity

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tool. I've never used these before, but it's

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really simple. It's beautifully designed and it

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and I can juggle several projects simultaneously

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and I can write faster. It gives me

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AI generated prompts. I can write better.

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It picks up grammar mistakes and

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in seconds or minutes. So

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18:48

Why were medieval priests

18:50

so worried that women were going to seduce men

18:53

with fish that they'd kept in their pants? Who

18:55

was the first gay activist?

18:58

And what on earth does the expression sneezing

19:00

in the cabbage mean? I'll tell you,

19:02

it's not a cookery technique, that's for sure.

19:05

Join me, Kate Lister on Betwixt the

19:07

Sheets, the history of sex scandal in society,

19:09

a podcast where we will be bed hopping

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throughout time and civilization

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to bring you the quirkiest and kinkiest

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stories from history. What more could

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possibly want? Listen to Betwixt

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the Sheets today, wherever it is that you get your

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podcasts, a podcast

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by History Hit.

19:29

We've gone from, you know, if you look

19:31

back several hundred years ago, medieval

19:34

ages, where people didn't shower, didn't

19:36

have baths, and we don't know

19:38

what sort of skin conditions they had, to then

19:40

the invention of soap and then the

19:42

skincare beauty industry. And then us

19:44

now, especially if you look at, you know, Korea,

19:47

they are obsessed with skincare, even more

19:49

so than the sort of UK,

19:51

US, etc. And people

19:54

have 10, 12 step skincare

19:56

routines, which they're doing, spending a lot

19:59

of money

19:59

on. And even

20:00

if I look at myself, I never

20:03

thankfully suffered with lots of acne

20:05

as a kid growing up. I had occasional a

20:07

couple of spots here or there, which would

20:09

sort of go away. And my skincare

20:11

routine, even when I was younger, which I was kind of

20:14

conscious of those spots, it would

20:16

consist of these weird apricot scrubs

20:18

and this and that, and really harsh exfoliants

20:21

and cleansers. And now I've gone

20:23

to a point where my

20:25

skincare routine consists of wearing

20:27

sunscreen and moisturizer

20:30

and just washing my face a couple of times a day. And

20:33

just previously, before I've gone back

20:35

on that, I was taking retinoid

20:37

briefly, which I started for a month, but that

20:39

really caused an irritation of my skin. I was

20:42

wearing lots of these other, I was

20:44

doing an exfoliant, I was doing a scrub, I was doing this,

20:46

and my skin didn't like it. And since stopping all of

20:49

that and taking it down to basics, my

20:51

skin feels really healthy and I like

20:54

the way it looks.

20:54

And it's interesting because retinoids

20:56

and exfoliating acids like your glycolics,

20:59

your salicylics, your lactic acids, they

21:01

are the biggest culprits that I see for

21:03

skin barrier disruption.

21:04

Yeah. And they're all, I mean, your

21:06

skin produces lactic acid, it produces

21:08

all of those fatty acids as part of its

21:11

mantle.

21:11

So the skin naturally exfoliates. The

21:14

top layer of your skin, your stratum corneum sheds

21:16

every 28 to 32 days. Now,

21:19

there are some people that can benefit from exfoliating.

21:21

If your skin is very oily, you've

21:24

got those sticky, clumpy dead skin cells,

21:26

your acne prone, your blemish prone, there is a role

21:28

for that.

21:29

It doesn't mean everybody needs it. Yeah. And

21:31

I think this is the problem. I think there is this

21:33

idea that every new skin care ingredient that

21:35

comes out, you need to add it into

21:37

your skin care routine and you really don't. Simple

21:40

is better.

21:41

It's sort of this, also it

21:43

points towards the social inequalities because

21:46

these are quite expensive, like a small

21:48

tube of a certain

21:51

type of salicylic acid or something might

21:53

cost you a significant cost

21:56

of a meal in a restaurant potentially

21:58

sometimes. So most people

21:59

people may not be able to afford a 10, 12 step

22:02

skincare routine, but they feel like

22:04

they need to break their

22:06

wallet, break their purse to do that, to

22:08

fit into society's expectations.

22:10

I think one of the things that drives

22:13

me absolutely insane is the fact that

22:15

people are led to believe that their

22:17

skincare

22:18

in particular can fix actual

22:20

skin issues. Acne being a prime

22:23

example, rosacea being another, acne scarring

22:25

being another one.

22:26

Because if you had diabetes

22:29

or if you had epilepsy or you had any

22:31

other medical condition, you would go and see the relevant

22:33

doctor in that condition. Skin

22:36

is not given the same degree of respect.

22:38

It's an organ like every other part of

22:40

your body. And acne is not a cosmetic

22:43

issue. Rosacea is not a cosmetic issue. They are

22:45

medical issues with medical treatments.

22:47

And there are so many people

22:49

that I see, exactly as you've said,

22:51

they've spent an absolute fortune on skincare

22:54

at the expense of other things. And

22:56

it's not got their skin better because it's not a drug,

22:58

it's a cosmetic product. And

23:01

they're poorer for it. And

23:03

their skin is no better for it. And their mental health is worse

23:05

for

23:05

it. At what point does someone with acne,

23:08

should they seek treatment, medical intervention

23:11

in the form of racutane or

23:13

antibiotics for their acne? What's the

23:15

threshold?

23:15

So in the UK, I would say probably what

23:17

most people will do initially is they will try skincare.

23:21

So you can try skincare, which contains

23:23

things like benzoyl peroxide or

23:25

salicylic acid, face washes, moisturizers,

23:28

over the counter. And if you've been

23:30

doing that for say, month, month and a half,

23:32

give it about six weeks, things are not improving.

23:35

Or

23:36

your acne is getting worse or

23:38

more extensive. So it's starting to affect more body

23:40

sites.

23:41

Or if it's starting to scar

23:44

or affect your mental health and your confidence,

23:46

you feel like you don't want to go out, you feel like you don't want to

23:48

socialize, you're canceling your plans. At

23:51

that stage, probably most people would go and see their NHS

23:53

GP. Or that's when I would recommend you need

23:55

to get some kind of medical professional help.

23:58

At that stage,

23:59

is very likely to give you either prescription

24:02

creams or oral antibiotics,

24:04

or in a female patient, they might recommend a

24:07

contraceptive pill,

24:08

if appropriate.

24:10

At that stage, if those treatments

24:13

aren't working, so let's say you've been doing those

24:15

for about 12 weeks, and again, same parameters

24:17

apply. It's not improving, it's getting

24:19

more extensive, your mental health is getting worse or

24:21

there is scarring, at that stage

24:23

normally you'd be referred to a dermatologist.

24:27

And I know NHS dermatology waiting

24:29

lists very long at the moment, but at that stage,

24:31

then you would be considered for other treatments

24:34

in the NHS, such as isotretinoin

24:36

or roacutane, or possibly even

24:38

off-label spironolactone in a female patient.

24:40

Really? Now, in the independent

24:42

sector, obviously there is the

24:44

opportunity where you can go straight to a dermatologist

24:47

and you can have those treatments, and if it's a dermatologist

24:49

who also does cosmetic work, they may

24:51

also use peels or laser, particularly

24:54

if the acne is non-inflammatory. So

24:56

there are lots of options and lots of different routes,

24:58

but it does depend on whether that route is NHS or

25:01

independent. And if

25:02

someone experiences acne breakouts

25:04

and it resolves, and obviously, especially

25:07

in darker skin, there's a higher incidence of this

25:09

post-acne, post-inflammatory pigmentation,

25:11

where it leaves marks and scarring, what

25:14

are options, just at home DIY, that

25:16

someone could use to reduce the appearance

25:19

of this darkening

25:19

or pigmentation? Yeah, so

25:22

I always think with skin of colour,

25:24

you just have to treat the underlying issue

25:26

aggressively. Because actually the pigmentation

25:29

causes just as much distress as the

25:31

acne itself. So rather

25:34

than chase your tail with, okay, right,

25:36

I've got pigment, let me sort the pigment out, you've

25:38

got to stop the process that's causing the pigment. So

25:40

I still think goal number one should be sorting

25:43

the acne itself. In terms

25:45

of things you can buy over the counter,

25:47

things like glycolic acid,

25:49

lactic acid, they can help.

25:51

The problem is that over

25:54

the counter products, often the concentrations

25:56

are relatively weak, compared

25:58

to say maybe what you would do. do on a prescription

26:01

or in a clinic with a peel. So the results

26:03

are never going to be as good. So I think

26:05

that there is a risk potentially of

26:07

ending up spending a lot of money, but not

26:09

getting the results that you want when actually what you

26:11

should be doing is trying to tackle the acne first.

26:13

We've obviously spoken about

26:15

how people have really extensive

26:18

skincare routines nowadays. If

26:21

someone was starting out on their skincare journey

26:23

and was completely overwhelmed by the amount of

26:25

information and choice out there

26:28

from all these words like ceramides

26:30

to humectants to various

26:34

actives. What are, I don't

26:36

know, three basics for a skincare

26:38

routine? Like for example, myself,

26:41

the limited range of things I use,

26:43

a moisturizer, sunscreen, and

26:46

some sort of gentle foaming or hydrating

26:48

exfoliant. And

26:51

that's pretty much it. Is there

26:53

anything in addition to that which you'd recommend

26:55

to people?

26:56

So I think that's probably actually a pretty good

26:58

day-to-day routine. Cleanse in the morning,

27:01

moisturize sunscreen. If you are naturally

27:03

quite oily skinned, you may not need to use a

27:05

moisturizer and a sunscreen because sunscreens

27:07

come in a moisturizing base and simply cleanser

27:10

and sunscreen may be enough. In the

27:12

evening, you do need to make sure you cleanse properly

27:14

because you need to ensure that the dirt,

27:17

sweat, pollution, grime, sunscreen,

27:19

all the stuff you've come into contact with during the day is properly

27:22

removed from your skin before you go to sleep.

27:24

Including makeup as well. That too. A

27:26

lot of people sleep with their makeup on.

27:27

I think people are getting better at not

27:30

doing that. But yeah, that night

27:32

cleanse is important. And then if somebody

27:34

is worried in general about kind of

27:36

like anti-aging, I suppose, or

27:38

premature skin aging, then you could cleanse,

27:41

you could use a vitamin A product, and then you could moisturize

27:43

afterwards.

27:44

So apart from wearing

27:46

sunscreen, which can limit photo

27:48

aging and aging of the skin, and

27:51

retinoids, which probably is the closest

27:53

thing we have in dermatology to an anti-aging

27:57

treatment, what are some

27:59

other anti-aging products that you've

28:01

seen and that you'd recommend that actually

28:03

work and that have some evidence behind them.

28:06

So I think if we're going to be completely

28:09

academic about it, the difference between a cosmetic

28:11

and a drug. So when I say cosmetic, I mean something

28:14

you could buy over the counter in a

28:16

shop.

28:16

A cosmetic is not

28:19

legally allowed to change the structure

28:21

or function of your skin. So

28:23

if you think about that definition, how

28:26

much can skincare really

28:27

do? I think the second

28:29

thing that's really important to recognize is your

28:32

skin is a barrier and it's a really

28:34

good barrier. It is really good at

28:36

keeping things out.

28:38

So I'm not saying that skincare doesn't do anything at

28:40

all. It's not as binary as that.

28:43

But if we're asking what skincare

28:46

products have got a little bit of evidence behind them, well,

28:48

absolutely your sunscreen, your vitamin A, there

28:50

is some data behind using antioxidant serums

28:53

as well. In particular, vitamin C. Vitamin

28:55

C has probably got the most data behind it. As a

28:57

topical agent to

28:58

put on the skin. As a topical agent. So vitamin C

29:00

serums. Okay. They can be used underneath

29:03

your sunscreen. And not

29:05

only can they help your sunscreen work better,

29:08

they can also reduce oxidative

29:11

damage. So sunlight creates

29:13

these harmful molecules known as free

29:15

radicals, which will damage the DNA, the proteins,

29:17

the fats in your skin. And vitamin C

29:20

topically can help reduce that. The

29:22

difficulty though is there is a massive

29:25

difference between formulations and

29:27

companies aren't necessarily

29:28

carrying out clinical trials because they don't

29:31

need to. So it's very hard to

29:33

discern which is a good vitamin C and

29:35

which is not because it breaks down very quickly

29:37

because it's an antioxidant. The minute it's opened

29:39

up to air,

29:40

it's going to break down and

29:42

it's going to destabilize. So

29:44

my kind of general tips for when you pick a vitamin C

29:46

serum are firstly, it needs

29:48

to be in a dark bottle. So sunlight

29:50

is not breaking it down. The second thing

29:53

is you really want a system of vitamin

29:55

C delivery where you're just not opening it up the

29:57

whole time. So oxygen is getting in every

29:59

time you. open it and breaking the product down because

30:02

there may well be a decent percentage of vitamin

30:04

C at the time it was packaged in the factory.

30:06

But six months later when you open it and then you're opening

30:09

it and using it every day, you don't

30:11

know if the potency is the same.

30:12

But you see now there's a whole subset

30:15

of anti-aging wellness

30:18

people online really wanting to extend their lifespan

30:20

and health span as well and skincare has come into

30:23

that as well. You see a number of people

30:25

claiming you can put period

30:27

blood on your face to do that or you

30:29

put a punny on your face. I mean

30:33

clearly a lot of this stuff is harmful and probably

30:35

can worsen your skin. Is

30:37

there anything else apart from those three that you'd

30:40

recommend for more youthful skin?

30:42

So I think that for youthful skin

30:44

probably not. I mean peptides, the peptide

30:46

data, if you actually start looking into

30:48

it, peptides are a massive group

30:51

of compounds. And just because

30:53

one may have some activity doesn't mean the other one does.

30:55

Same with growth factors in skincare. Growth factors

30:58

don't work in isolation in your skin. That's not how the human

31:00

body works. It's not a single kind of ingredient

31:03

that you put in and it's suddenly going to be miraculous.

31:05

The thing there is your average wellness influencer

31:07

is genetically blessed with great skin. They

31:10

could be the person that quite frankly could sleep in

31:12

their makeup every night and they would have no issues with

31:14

their skin.

31:15

It's not everything else they're doing. The second

31:18

issue is there's another group of wellness influencers

31:20

that are quite happy to work with brands and say it's that

31:22

brand that's fixing their skin. When you

31:24

know full well they were in your clinic yesterday having a

31:26

whole load of other stuff done, which you obviously

31:29

can't say for confidentiality and obvious other reasons,

31:31

but you know for a fact it's certainly not that skincare

31:34

product that got their skin better or looking that way.

31:35

Certainly some conflicts of interest there. Indeed. So

31:38

Angelie, we've got a segment in the podcast it's

31:40

called If It Ducks Like A Quack where

31:42

we try to debunk quackery

31:45

nonsense and medical myths that are commonly

31:47

seen online and people

31:49

promote them and almost believe them, they become

31:52

true. So I'll read out a few of them now and

31:54

get your thoughts on them.

31:59

So again, we briefly mentioned

32:02

this about acne and the psychological effect

32:04

it can have. And I suspect this is tied to

32:06

it as well. A myth that acne

32:09

is caused by bad hygiene.

32:11

People with acne are not dirty people. If

32:13

anything, people with acne are probably cleaner than

32:15

people that don't have acne because they're constantly washing

32:17

their face and they're constantly washing their skin because

32:20

they're worried about the oil production that goes along with it.

32:22

And

32:22

that probably worsens their acne because they're drying

32:25

out their skin and resulting in more

32:27

sebum production. So it's not so much

32:29

more sebum production, but there is a risk of damage

32:31

to the barrier function of the skin itself. Now

32:34

that said, again, there's always gonna be a little

32:36

bit of, but there is an exception. So the

32:38

exception is, for example, if you do a

32:40

lot of exercise and you've had

32:42

a sweaty workout and then you

32:44

don't shower immediately after your workout and you

32:46

decide to go and sit and have a coffee and sit around

32:48

in your gym kit, it is possible to

32:50

get truncal acne or chest acne because

32:53

the sweat, the heat, the occlusion, compression

32:56

from sports bras or tight-fitting clothing or lycra

32:59

can potentially drive spots. So- Blocking

33:02

the pores. Indeed. So I think in that scenario,

33:04

it's not dirty. It's just from

33:06

a hygiene point of view, you probably wanna make sure you're showering

33:08

straight after a sweaty workout.

33:09

Yeah, yeah, brilliant. And then, so the

33:11

other one, you don't need to moisturize

33:14

if your skin is oily. What do you feel about that?

33:16

So I disagree with that. So oil

33:19

in skin is very different to water or

33:21

hydration in skin. So

33:23

the first thing I would say is just because your skin's oily doesn't

33:25

necessarily mean it's hydrated. So there is always

33:27

benefit in using a moisturizer. You may

33:29

wanna use something that's oil-free or gel-textured,

33:32

which is a bit lighter so the skin

33:34

doesn't feel sticky or tacky or

33:36

anything like that. But no, I think moisturizers

33:39

are sensible. The second thing I would say is if

33:41

you're acne prone, people are usually using treatments

33:43

of some sort, be that your salicylic or benzoyl

33:46

peroxide's over the counter or prescription

33:48

treatments. Those treatments work by drying

33:50

the skin out. So you then have to

33:52

replace the moisture.

33:53

I mean, you can still have oily

33:56

skin, but a dry component that

33:58

is under hydrated to your skin.

33:59

lead to it, maybe looking more sunken

34:02

and not as plump. Indeed. So

34:05

clearly you need to... Moisturiser should be a component

34:09

of your skin. But also there are different

34:11

types of moisturiser. You can get these occlusive

34:14

ones, ones which maybe have humectants

34:17

which can hold more water. So if

34:19

you have oily skin, is there a certain type

34:21

of moisturiser that may be more beneficial?

34:23

Yeah, so as a general rule, most moisturisers

34:25

do contain a combination of occlusives,

34:28

humectants and emollients. If

34:30

one is oily or blemish prone, you're

34:33

better off going for a slightly more humectant-based

34:35

moisturiser, say something like hyaluronic acid.

34:37

Which traps water rather than, you know,

34:40

blocks it as a barrier.

34:41

Indeed. So you wouldn't want to be using something

34:43

super occlusive because you're more likely to block your pores.

34:45

If somebody's got a very dry skin,

34:48

so they're eczema prone or psoriasis prone, or

34:50

they just naturally have dry skin, particularly in the winter

34:52

months, which can be quite common, you probably want

34:54

to go for something that's a little bit more emollient

34:56

or occlusive based. So your squalanes,

34:59

your glycerins, for example, rather

35:01

than purely relying on hyaluronic acid.

35:03

Stop that water loss across the

35:05

skin barrier and keep it in. Indeed.

35:07

Brilliant. So I mean, we probably can talk about a whole

35:10

host of myths about skincare. But

35:12

thank you very much for joining me and enlightening everyone

35:14

on skincare essentials and acne

35:17

as well.

35:25

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35:27

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36:53

Now, before I let you go, you had a question for

36:55

me. I

36:57

did. And my question is, do you think social media is

36:59

a good place for giving medical advice?

37:02

That is a very interesting question. And I think there is some nuance

37:05

to be added there. I don't

37:07

think it's a good place to give advice. I think

37:09

you can give generic advice about

37:13

physiology, about mechanisms of how the

37:15

body works. So for example, you

37:18

can talk about anatomy. You can talk about fiber. You

37:20

can talk about the gastrocolic reflex. You

37:23

can talk about advice that would be

37:25

applicable to the average human body. But

37:28

if you're giving then advice on someone who's

37:30

suffering from IBS type C, who's got a uterine

37:35

prolapse, I think it's a good place to give advice.

37:38

And I think it's a good place to for

37:41

very niche personal medical conditions, because

37:43

I think that could be to the detriment of

37:47

the patient. And I've seen personally in some of the videos

37:49

I've seen, I've seen people who are suffering

37:52

from IBS type C, who's got a uterine prolapse. And

37:56

I think it's unreasonable to offer virtual advice online

37:58

specifically for

37:59

make some of the comments that I see, there's

38:02

a lot of people out there and sometimes

38:04

quite heartbreaking asking questions, very

38:07

specific niche questions, because

38:10

they connect with people they follow online,

38:13

and they have more trust in those people than their

38:15

own medical professionals. And that raises the question

38:17

is, what are the medical professionals they are facing

38:20

on a day to day basis physically? What are they

38:22

doing wrong or what are they not doing enough of

38:24

that their trust has been eroded? And

38:28

what are these people online doing that's

38:29

garnering more trust? So I think

38:32

the question is, it's not a place

38:34

for specific medical advice. And I think it would be dangerous

38:36

to do. But I think it is a good

38:39

place to improve

38:40

someone's health literacy. And

38:42

you know, for example, a lot of the stuff you do debunking

38:45

skincare myths, providing evidence

38:47

based information between diet

38:50

and skin or, you know, different types of

38:52

sunscreen. So I think that's good debunking

38:54

things and stopping people falling prey

38:57

to people who might want to sell them some, you

39:00

know, dodgy skin supplement or

39:02

you need to put this, you know, yogurt cream

39:04

to improve your skin probiotics. So I think

39:06

it's good for that, but not good for specific

39:09

advice.

39:09

So I guess my follow up to that would be, to

39:12

all the people that are listening to this,

39:14

how can they find or

39:16

vet a credible social

39:19

media account that is run by a medic? Are

39:21

there any top three things they should be looking out

39:23

for?

39:24

When I see someone online, I'm sort

39:26

of looking at their name and qualifications

39:29

that they, you know, produce and verify.

39:31

So you can look them up online and they'll be associated

39:34

with either a hospital, a private

39:36

clinic, they're on a GMC

39:38

register, if you're based in the UK, you look them up and they're,

39:41

you know, they're registered with a license to practice.

39:43

And there's a lot of people who may not have an active

39:46

license to practice. So it's questionable whether

39:48

they should be giving any advice online. There are

39:50

many of them online. And also to see, have

39:52

they got any conflicts of interest? Are they

39:54

selling something or aligning themselves with a brand

39:56

or product and then giving you a discount

39:59

code?

39:59

think that's a very dangerous

40:02

territory because as a doctor

40:04

there's

40:05

one aspect where you need to be beyond reproach,

40:07

you need to be neutral and apolitical. If

40:10

you are, as a

40:12

person who deals with guts and a

40:14

GI surgeon,

40:16

if I promote probiotics

40:19

and then give someone a discount code, I

40:21

am leveraging my credibility, expertise

40:23

and authority to say, guys you should

40:25

trust me and buy these probiotics because I'm

40:27

a GI surgeon, I'm saying they work, here's

40:29

my discount code. That's a huge conflict

40:32

of interest and potentially a probity

40:34

issue I would say and it's actually very hard

40:37

to verify whether someone is actually a real

40:39

doctor or not online. There's not

40:41

a lot of transparency.

40:42

Yeah I agree, it's a real problem. Yeah, Dr.

40:45

Angelina Li-Marto, thank you so much for coming on

40:47

and sharing the sort of myths, the secrets

40:50

and all evidence-based stuff about skincare

40:53

and acne. Thank you.

40:54

Thank you for having me.

40:57

So thank you to Dr. Angelina Li-Marto, that was a really

40:59

interesting insight into skincare and acne.

41:02

Just before we go, we have a crowd science

41:04

question from Nat in

41:07

Landello in Wales. She's asked,

41:09

hi Dr. Curran, love the podcast,

41:11

I wanted to get your take on collagen

41:13

supplements. You're often saying that supplements

41:15

are a waste of money and that we can get what we need

41:17

from a healthy diet. Are there many

41:19

foods that contain collagen that could

41:21

be included in your diet? And

41:24

are collagen supplements a scam to

41:26

rinse people like me trying to hang on

41:28

to their youth? Thanks Nat. So

41:31

the collagen supplements you get in pills or

41:33

powders or shots or whatever you buy

41:35

is actually a different type of collagen

41:38

to that found in our bodies. Pure

41:40

collagen would be very difficult for us to digest

41:42

so the ones that you see in these supplements are

41:45

partially digested. They are hydrolyzed

41:47

collagen which makes it easy for us to consume

41:49

and digest. But unfortunately there is very

41:52

very little evidence to suggest that collagen

41:54

supplements that you can buy and then consume

41:57

can have any noticeable impact on

41:59

a scientific diet.

41:59

cellular basis on the skin.

42:02

I will say one thing, there was a review of 19 studies

42:05

containing more than a thousand participants which

42:08

suggested that taking collagen supplements

42:10

seemed to reduce the appearance of

42:12

skin aging if taken for more than 90 days. But

42:15

when you break it down, the individual studies

42:17

in the 19 studies, there were a very small

42:19

number of participants. And another limitation

42:21

is that often a lot of these studies are funded

42:23

at least in part by companies

42:25

that produce collagen supplements. That's

42:27

a conflict of interest. The claims by people who

42:30

sell collagen supplements and people who are supportive

42:32

of collagen supplements significantly

42:34

outweigh any evidence that's actually there in

42:36

the literature. The claims made by sellers

42:38

of collagen supplements or supporters of

42:41

collagen supplements surpass any evidence

42:43

available or proven in the literature as

42:45

of right now. Now, that's a great question, hope it

42:47

helps you and other people who may be considering

42:50

purchasing collagen supplements. And

42:52

in this week's CrowdScience Extra episode, we've

42:54

got a question from Kay in Singapore who

42:57

asked if the radiation from infrared,

42:59

Bluetooth and our mobile phones are

43:02

affecting us negatively in any way. And

43:04

remember, if you wanna get in touch and have your

43:06

question featured in this episode of CrowdScience

43:08

Extra, get in touch at thereferralpod.com.

43:12

Thanks for listening to this episode of The Referral.

43:14

So remember, I am a real doctor, but I'm

43:16

not your personal medical doctor. So if you require

43:19

any specific medical advice, please contact

43:21

your own healthcare professional. And remember,

43:24

nothing on this show is intended to provide

43:26

or replace any specific medical advice that

43:29

you'd otherwise receive from your own doctor.

43:31

This has been a Sony Music production. Production

43:33

management was Jen Mistry. Videos by

43:36

Ryan O'Meara. Studio engineer was

43:38

Teddy Riley.