Resilient Skin for Stressful Times with Dermatologist Jerry Potozkin MD

I'm a big, big believer in the mind-body connection, and I think that oftentimes our physical states can impact our mental states. So I like to get my body moving. I like to exercise. Historically, I've never been a big meditator. I've, you know, I'll sit there and I'm like, after 2 minutes, I'm like getting antsy. I remember one day I was really stressing out and I clicked on a panic and anxiety 15-minute guided meditation on Insight Timer. That really helped me a lot. There are a lot of great meditations on there.

This is RxChill Pill. Now is the time to stay well. Each episode teaches your brain how to become resilient with amazing stories, knowledge from experts, and short meditations you can do anywhere, anytime to elicit your relaxation response. I'm your host, Dr. Juna Bobby MD, resilience and stress management physician and mother of two amazing kids. Today I'm here with Dr. Jerome Patoskin, MD. He's the founder and CEO of Patoskin MD Skincare Center in California, and he's the author of Botox and Beyond: Your Guide to Safe Nonsurgical Cosmetic Procedures. As an expert in cosmetic dermatology, board-certified dermatologist, and a fellowship-trained Mohs surgeon, he's been quoted in The New York Times, featured on ABC's 20/20 and NBC's Today Show. He's been named to San Francisco's Super Docs, and he received a prestigious Sulzberger Prize at the NYU Skin and Cancer Unit. He's published multiple medical journals and served two terms as the president of CALDERM, and he currently sits on the board of directors. He was section chair of dermatology at John Muir Medical Center and teaches future dermatologists at UCSF. In 2016, his facility was chosen as the first SkinCeuticals Advanced Clinical Spa in California. In 2005, he founded Vanity for Charity in response to Hurricane Katrina, and he has since raised tens of thousands of dollars for local and national charities. Dr. Protoskin is here today to talk to us about your skin on stress. Long time no see.

I know, how have you been? You look great.

Thank you, so do you.

Thank you, I'm trying not to fall apart.

Amazing.

Up until this year, I've never taken like a vacation that's been like 2 weeks because I figured I can't take more than 2 weeks off, and now it's like, yeah. So this is my COVID-19 experience. Okay. Ironically, it started the beginning of February. So I signed up for a course at Kellogg Northwestern's executive education called the Physician CEO. And I thought after, you know, being in practice for 21 years, running a small business and having no formal business education, it might make sense to take this class. So it's a, it's a 4-week class and they run it in Evanston, and it was amazing. There are 30 doctors from all over the world, and one of the lectures that we had was on crisis management. And in the crisis management course, they showed us a TED Talk. There's a TED Talk that Bill Gates did on global pandemics. Okay, so fit. So I'm flying home to Wednesday night, and I'm reading the Wall Street Journal And there was an article about this virus in China. And I handed the newspaper to the gentleman sitting next to me, asked, "Do you want to read?" He's like, "Sure." So he reads the paper and he turns to me, he's like, "Are you worried about this virus?" And I look at him like, "Not really." Right? So no one saw this coming. And then, you know, then like a week later, I was sitting in the office talking with my new associate and she has certain targets and goals. And she's doing great. And I looked at her and I said, the only thing that's going to stop you from hitting your goals is a global pandemic, right? And the reason you said that was because they showed you Bill Gates' TED Talk, and the— we started getting more information about the virus.

Why did they show that at the conference? Because it's something that they—

the lecture that we were in was about crisis management.

Obviously, that is And people did know that eventually we're going to have this again because we did have SARS and Ebola was just recently. That is true.

I mean, right now it's very— and the thing with the COVID the scary thing is the variation in severity of illness, right? So you have some people, they don't even know they're sick. You have other people who are intubated on ventilators and other people who unfortunately are going to die from this. And we have no idea what the numbers are because of the lack of testing. So it's, you know, I think you—

and even the testing is sometimes falsely negative.

I think that getting towards the whole stress and skin thing is we love to have some sense of control in our lives. And COVID, we have now no control, right? Because we are completely out of our element. We're completely out of our normal routines. I'm going stir crazy. I mean, I love what I do. I identify with what I do. You know, people who are physicians, we spend our whole lives, that's like our identity. Um, now it's like you're sitting there thinking, am I a ticking time bomb? Am I going to be one of the mild cases? Am I going to end up on a ventilator? Am I going to be one of the, we think, 2%, maybe less because we don't know what the numbers are, who, you know, succumb to the disease. I think physicians are at one end of the spectrum that we really like control. As a dermatologist, I also do a very specialized surgery for skin cancer called Mohs micrographic surgery. M-O-H-S, named after Fred Mohs, who invented—

Oh, that's his name.

And with Mohs micrographic surgery, we're using microscopic precision to remove skin cancer layer by layer, bit by bit. And that's like the ultimate micromanaging control type of of procedure. And people who go into that tend to be perfectionistic. They want to have some sense of control. And now it's like, there's no control.

We were going to talk a little bit about COVID-19 and handwashing and your face after mask wearing. Any tips on that? Sure.

Do you want to talk about some of the COVID-specific skin findings we're seeing, or do you want to not talk about that? Sure.

Is that something that, you know, when you have horrible disease, or can you find it in the beginning?

No, in the beginning. Yeah, yeah. So, so COVID's doing a lot of things. So first of all, obviously we're washing our hands a lot more, using hand sanitizer, so we're getting dried out. People are getting like breakouts from the masks on their face, pressure on their face. So I just think like with hands, it's important that obviously we do wash our hands to minimize exposure, but also keep some hand moisturizer in your in your pocket and get small little tubes of it.

Even have like the most spazzy times with moisturizer on my hands though.

Why is that?

I put moisturizer on my hand and, you know, it gets so slippery and then I can't do anything.

Oh, okay. You just need a little bit. Just apply sparingly.

Okay.

We'll have to do a whole video series for you. How to apply moisturizer. Use less and you should be fine.

Probably. I'm also putting it on when my hands are a little wet too.

And then some people getting perioral dermatitis, which is a kind of variant of rosacea on their face, that needs prescription medicine like topical metronidazole, and some people even need oral medicine to clear that up. But we're definitely seeing that from all the mask wearing that we're seeing.

My daughter had that.

Yeah, it's very common.

She stopped using anything. She didn't have to take any medication. She just stopped using any facial products.

So sometimes it can be related to facial products.

Okay, but is perioral dermatitis from COVID No, no, no, no, no, no. Oh, okay, just from just from wearing the mask, touching and the mask contact.

Yeah, and you can also get it from like using certain moisturizers on your face, and it's impossible to tell what is going to trigger one person versus the next person. I think that it's something that we can treat as it pops up, and for some people we recommend limiting their skincare products, limiting their moisturizer for a while.

People are wearing more masks now in general, and everybody's been advised to wear masks when you're in closed spaces. So is there something you can do to prevent?

Not really, because it's related to mechanical forces touching the skin.

Mm-hmm. Uh, you were saying that COVID-19 actually has some skin findings?

There's some COVID skin findings that we're finding. So one has been called COVID toes, but it can occur on the fingers and on the toes. And it's something that we've seen before COVID So there's a skin condition called chilblains or perniosis, P-E-R-N-I-O-S-I-S. And we oftentimes will see that in colder months. We'll see it in patients who have Raynaud's phenomenon or collagen vascular diseases. And what happens is when they're— when it's cooler out, they can get these purple nodules on their fingers and their toes. Sometimes it can form blisters. And historically, we would treat it with people keeping their hands, feet warm in winter months. Sometimes it's treated with a drug called nifedipine, but something that's been shown with asymptomatic COVID patients, they'll show up with just this finding and they have COVID.

So little purple nodules?

Correct.

Are they tiny, like millimeters? So purple nodules on the fingers or toes?

Correct.

Do they find it in younger kids also, or no?

They find it in everybody. Okay. Yeah.

Any other findings?

People are finding, um, hives. So anything that's gonna, you know, viruses alter our immune system. So hives, something that's something that has been associated with COVID-19. There's also a, like, a measles-like eruption that's been seen with COVID-19. Also red splotches, um, and bumps in the skin that's similar to what people have with dengue fever is something that's been shown with COVID-19. So, you know, it's doing stuff to our immune system for sure.

And these are people who are showing up with it that may not necessarily be hospitalized or have lung symptoms, right?

Correct. The challenge is these are common skin things. So hives are very common. So just because you have hives doesn't mean you have COVID-19.

Yeah. One, one semester my son came home and he broke out in this migrating hive thing after he had been sick with the virus. This was last year and it was frightening. His hands swelled up.

The angioedema. Yes.

I mean, it wasn't full-blown angioedema, but his hands were at least 40% bigger than—

that's crazy—

it normally was. And he didn't even notice it. He couldn't really bend it. And then he didn't notice it until after the swelling went down. He's like, Mom, you're right, my hands got bigger.

Yeah. So that happened to our best friend's daughter like 3 or 4 weeks ago at the beginning of this whole— she didn't have COVID, but it was at the beginning of this whole COVID thing. So it's like she had these horrible hives. It started getting swelling in her hands and her lips.

Okay, so it's doing everything that other viruses do to your skin as well.

It's doing everything that the viruses do, plus we're seeing this COVID toes, which we typically have not seen with other viruses.

Mm-hmm, interesting. Telemedicine— how are you finding dermatology and telemedicine? I love telemedicine, by the way. I don't ever want to go to a doctor's office, so I would love to do everything on telemedicine.

So, you know, when, when we shut the office down except for emergencies, we realized we still had to provide care and service our patients. We couldn't just, you know, say sorry. So we pivoted very quickly to launch telemedicine. And I don't think telemedicine is going to replace what we do because a lot of what we do is procedural. You can't do a skin biopsy via telemedicine. It's very— I mean, we can diagnose a lot of skin conditions, but for like evaluating like a pigmented spot, we use a special instrument called a dermatoscope that comes into contact with the skin and we— allows us to see the pigment pattern under the skin.

Mm-hmm.

As opposed to just like what we're seeing on the skin surface. And obviously the skin cancer surgery and all the cosmetic and laser stuff that we do, you can't do via telemedicine. But if someone's having a problem, you can offer them care. And, you know, we've been on an electronic medical record for years now, so it's really made sense for us to pivot to telemedicine. So we are doing telemedicine. So we're seeing patients in the comfort of their own home. And it's interesting seeing the range of home technological skills of our patients.

Oh yeah, my husband said that he had a patient who just was moving the iPad around so much that he couldn't see them. So obviously these are extremely stressful, unprecedented times. So what are you doing for yourself and what are you telling your patients to do? You've been posting some videos on how to stay well, right?

That's true. So, so what I've been doing is what I've been recommending for my patients and recommending for everyone.

Okay.

And that is we need to have some sense of control in the midst of chaos and lack of control of a global pandemic, right? So I think that the number one thing is you want to be safe and you want to be healthy. Right? So every quarter I historically have done goal setting for myself. And this quarter the goal setting was stay off a ventilator, stay healthy. That's like the top goal. But then, you know, once you're sheltered in place and you're at home, set up a routine for yourself so you have some type of a schedule. I'm a big, big believer in the mind-body connection. And I think that oftentimes our physical states can impact our mental states. So I like to get my body moving. I like to exercise and I exercise pretty much every day. And it, um, there's an app called Peloton, P-E-L-O-T-O-N. Mm-hmm. Um, I have no financial interest in any of these companies I'm gonna be mentioning, but Peloton has started out with a studio in New York and they basically would stream spinning classes and have a bike.

Do you have your, do you have their bike or you just use their app?

I have both.

Oh, you have both?

Yeah.

Okay, uh, that's pretty expensive.

Everything is relative, right?

However, and you can't take their classes unless you have the actual machine, right?

Untrue.

Okay, so, but it's no fun. It's no fun.

You're a killjoy, Juna.

Seriously, if you don't have that nice beautiful bike, then it's not fun.

I first started out with Peloton with the app on my iPad attached to a spin bike that I have, but not the Peloton bike. Okay.

Oh, okay. Um, all right, all right, fair enough. So any old bike with the app on the—

during the COVID the app used to be a 7-day free trial. Now they have 90-day free trial. Any old treadmill will do. They have great classes— run, walk, fun walks, everything you might want to do.

Do they see you live? And correct you.

No, however, they also have yoga, meditation, they have stretching, they have strength classes. I'm a fan.

I was totally into Orange Theory for the last 3 months until this happened. I signed my entire family up. We were all going, the 4 of us— my husband, my son, my daughter, and I. Wow. They'd be like, the Bobbies are here, and We were loving it. And sadly, um, it shut down.

There's an Orangetheory right near my office, and sometimes I'd go get coffee before work and I'd see these freaks there, 5 in the morning doing the Orangetheory. It's like, that's too early.

That's my husband. My husband was there.

That's way too early.

I used to try to go to the shorter ones. They had one for 45 minutes, and I was like, yes.

Those are killer workouts.

But actually, when I went with my daughter or my You know, she would really push me. So that was great. I loved it because I get really bored and you go from machine to machine, so you're not bored.

That's great.

But I also don't like waiting. Right. So you don't have to wait for anything and you're kind of like in your own zone.

Right.

So they leave you alone, but they're coaching you. So I like that. It's perfect for me.

So in 2010, my family was in New York City. I was invited to talk at a conference. And we almost got blown up by the Times Square terrorist. I don't know if you remember that. The guy with the van that tried to blow up Times Square.

I think you posted something on Facebook.

I did. When we got home, my mom had called the local news stations and told them, like, local family almost gets blown up. So the local news came to our house every night for 3 nights in a row. And I saw it on the news and I looked at it. I'm like, oh my God, who's Who's that fat guy on TV? I gotta do something about this. And our kids were young, I wasn't working out as much, and I was eating their leftovers. So chicken tenders and fries leftovers is not that good for like—

oh yeah.

So I discovered this workout called P90X that this guy named Tony Horton came up with.

Oh, this was your P90X phase?

My P90X phase?

Yes, I know Tony Horton. I had my whole family doing that one.

I met Tony Horton. I went skiing with him. Yeah.

How is he?

Like in his early 60s? Early 60s.

He looks amazing.

He and his friend Ted, they do an annual ski yoga fitness retreat at Jackson Hole. And my wife found out about this and got this for my birthday a couple of years ago. And I went, it was like, it was surreal because I'd done all the workouts. And then the first night I'm hanging out with him and 20 people. He's sitting next to me at dinner. The next day we're skiing. And by the end of the day, it's everyone else dropped off. It was me and him skiing, riding the lift. It's like he's my buddy. It was surreal.

Wow.

Beachbody. They have a million different workouts that you can actually stream. I used to do Shaun T. Shaun T. Yeah. But they have hundreds of workouts that you can stream for $99 a year. So I'm a big fan of getting that body, moving it, dancing. You know, you'll feel better.

What does exercise do for your skin?

Well, that is a great question. So, I mean, you definitely get a glow and you look better.

Like, most people look better after they exercise unless you have rosacea, right?

And then you get a glow. But, you know, I think it's all about stress management. Have you read the book, um, Why Zebras Don't Get Ulcers by Robert Sapolsky?

Dr. Robert Sapolsky, who studied, um, stress, stress, right? Stress in animals. Yeah.

So the difference between animals and humans is when animals have a stress reaction, you know, their hormones go crazy, but they're in a life or death situation. So they're either going to flight and run away from an attacking predator, or they're going to fight for their life. But humans, when we have stress, we don't have that outlet. It's all in our head. It's all bottled up in our body.

We think about it way into the future. We repeat that scenario over and over again.

Right.

Yeah. We worry about it for the next time.

Exactly. Yeah.

He's the guy who also studied the monkeys, right? With the social hierarchy where if a monkey was at the lower hierarchy, he would have more stress hormones. Wow.

That's interesting. I didn't know that. So all these stress hormones circulating your body are pro-inflammatory, right? And so many of what we see in skin disease is all about inflammation. You know, if you look at acne, psoriasis, atopic dermatitis, rosacea, um, All these things are inflammatory. And I think that, you know, there are various ways that we can mitigate inflammation in our bodies, right? So obviously in dermatology as physicians, there are medications we can prescribe for our patients. And I don't think that, you know, stress management is a substitute for that. But, you know, there have been studies like with psoriasis patients, they took one group of psoriasis patients and they were treating them with ultraviolet light. By itself. The other group, they were treated with ultraviolet light and meditation. The meditation group did better.

Right, that was the Jon Kabat-Zinn study.

I found that really interesting. You know, another thing is diet, what we eat. You know, there's, you know, we don't really have a lot of great studies in dermatology in terms of the impact of diet, but I think that shifting more towards plant-based diet, less processed foods, makes sense for most people.

So do you lead your patients through meditation while you're treating them for dermatological diseases?

I do not.

Would you be interested in that?

I think, I think that's something that I would delegate to someone else. I think that would be—

Or a recording.

That'd be a great idea.

Recording for your patients.

So I do mostly skin cancer surgery and reconstruction. I do a ton of cosmetics and I do some medical dermatology, but I also have other practitioners in my practice that do more medical dermatology than I do.

Mm-hmm. So being home in this time when we're all stressed out and, you know, I mean, obviously the skin is the biggest organ. It's an organ system.

It is, right? Yeah.

How do you think this stress and all the, all the stress hormones affect our skin with inflammation? So it's going to flare up whatever you happen to have. And then would you be at risk for breakouts or what? What do you think?

That's a great question. I think the there are several problems that are going to happen right now. Number one is that most parts of the country currently are shut down, right? We're sheltered in place. In California, Northern California, we've been sheltered in place since March 16th. Basically, we're only seeing urgent and emergency problems in the office. So people that have routine, you know, visits for skin problems are not able to come in. Okay. So people aren't getting the treatments that they need. So for instance, we have our psoriasis patients get ultraviolet light treatment. They're not getting their treatments right now, so they're probably going to flare. Also, people are stressed out. I know their skin disease is going to get worse. So in the meantime—

so you definitely see a correlation in your practice when people are stressed out?

Absolutely.

I remember being a medical student rotating through derm, and people would come in for psoriasis, and, and like, all the students who were— had finals coming up, they would come in with flare-ups.

Yeah, I know personally for me, when I did my internship year, where, you know, back in the day, they didn't have these regulations in terms of how many hours you could work, and it was insanity and stressful. I started getting seborrheic dermatitis. It would flare like crazy. Less sleep I got, the worse my skin got. The more stressed out I was, the worse I got.

So sleep— let's talk about sleep and skin. What's the correlation there? I mean, I have to ask you, um, I know this person who every time they don't get enough sleep, their skin color changes like into a totally different tone.

Yeah, exactly. I mean, Yeah.

What, what is that about?

We don't know the exact mechanism and no one's really that I know have studied it, but it's like, you know, people who have seborrhea or rosacea, if they're not sleeping, it's probably because there's oftentimes a stress component to that. So it's like, is their skin getting worse because they're stressed out? Is your skin getting worse because of lack of sleep or is it some kind of combination of the two? And, you know, in medicine we like to do controlled studies so we know what the deal is and none, no controlled studies have been done with respect to that. Mm-hmm.

But what would your recommendation generally be for your patients who have these types of flare-ups or, or even if they're getting, um, cosmetic procedures, would you recommend doing some type of wellness routine, like in general, sleep, hydrate?

So this COVID-19 experience, if you will, um, has had me thinking a lot about that because I'm just thinking, how am I managing my own daily stress?

So again, I think that And you're stressed because your office is shut down too and you can't see your patients, right?

So there's, you know, yeah, you know, we shut down on March 16th. I actually was thinking about what we should do before the San Francisco Bay Area shut down because I knew there was this virus that was here. There were asymptomatic people. It was lethal for some people. And I was weighing shutting— should I shut my office down? Because most of what we do in dermatology, it's not an emergency, right? Most of it—

Thank goodness.

Thank goodness.

That's why people go into dermatology.

Hey, that's what you said. I'm not saying that. So although the services that we offer are essential and necessary, there's very little that can't be delayed for 4 to 6 weeks.

Okay.

If someone has a high-risk melanoma, yes, we want to get that off. But most of what we can do, we can delegate or, or kind of postpone. So I was losing a lot. I was stressed out thinking like, should I close my office? Should I keep it open? I have 20+ employees. I'm shutting it down. The revenue drops off the cliff. And, you know, what do we do? And we had a team meeting and we discussed this, and it's an unprecedented time in our lives. And the team voted that they wanted to shut down. So We kind of moved into that arena. And so now it's like, what do I do with my employees? Do I keep them on payroll and burn through all the cash in the company and then have no company to come back to? Do we furlough? Do we lay off? And there were— it was rapidly changing, all these regulations. And, you know, we didn't know what was going to happen. Where was the virus going? Right now I'm pretty chill, but initially it was like stress off the charts. And then even applying for the Payroll Protection Program and then not getting that because these gigantic publicly traded companies were getting a disproportionate amount of the money for small businesses, which is completely insane. That's a— you could do a whole other podcast on that. So I came up with a routine for not just COVID, but also in general for people to take care of their overall wellness, including their skin. Okay. And that includes, as I mentioned, getting their bodies moving every day. Can be walking outside. It can be, you know, a more intense workout, but definitely get your body moving, get outside. And as part of that, daily use of sunscreen. So I recommend using sunscreen every day. I also recommend daily meditation. And historically, I've never been a big meditator. I've, you know, I'll sit there and I'm like, for after 2 minutes, I'm like getting antsy. But I think that there are some apps out there that are really helpful that will do guided meditations that I found very helpful. I remember one day I was really stressing out and I, I clicked on a panic and anxiety 15-minute guided meditation on Insight Timer. That's an app on my iPhone. And that really—

that's my favorite app—

that really helped me a lot. There are a lot of great meditations on there. Um, and I think that also You have to watch what you're eating too. I think that a lot of people are turning to like crap, basically, you know, chips and cookies and childhood crap, childhood crap. And that doesn't—

and hoarding, hoarding food that doesn't expire.

Exactly. Yeah. So I think it's, you know, you need to kind of take a step back, and mindfulness is critical at this point in time.

Okay, so you've got your sunscreen, your exercising, you're eating healthy, and you're meditating.

Correct. And then what about sleep? Sleep has been a bit of a challenge for a lot of people, and people are having all kinds of crazy dreams. And I think that we just have to do the best we can. I think that one of my bad habits is when I get in bed, taking my iPad with me and looking at like the news. That's not a— that's not a good thing to do right now, but you go to sleep. I think that maybe reading before you go to sleep, I think that maybe doing like a sleep meditation on some like Insight Timer is not a bad idea. And just make sure you're getting enough sleep. Also limiting alcohol ingestion. I think that people tend— alcohol sales have gone through the roof right now.

I'm sure. Yeah.

So I think you have to be—

I'm on day 330 of of not drinking any alcohol.

Wow, I'm on hour 13.

I mean, it wasn't anything, you know, severe. I would drink like 1 or 2 glasses. I don't have alcohol dehydrogenase, so— right, it was—

you turn red.

It was— I mean, I would just drink— yeah, I turn red. So I would just drink 1 or 2 glasses a night, but it was getting very, you know, it was like almost every night, right? Which is a lot. It adds up.

It does add up.

And as I got older, I just felt— I don't know, it just didn't feel right. So finally I just stopped, and I haven't thought about it since.

No, that's good. We, you know, we're here in Northern California near wine country, so yeah, um, we've actually been drinking less during this pandemic than before.

Really?

Yeah.

Interesting.

Yeah.

So why do you think?

Because—

because you're stressed out, you're home. Like, you would think that happy hour starts at 2 o'clock now.

Yeah, because we didn't want to develop any kind of dependence on it to manage stress.

Oh, so you did a conscious— you made a conscious decision?

Correct. Yeah.

Okay, that's nice. Yeah, it's good to think about that. Yeah, absolutely. So, um, when you talk about sunscreen, this is always something that baffles me. I know, because I, I get— I have low vitamin D, right, from, um, my darker skin tone and also I don't get out that much sometimes. When you're using sunscreen, how do you balance that out with the vitamin D? Or do you just recommend supplementation or?

Yes, I think it's almost a non-issue. I think that just pop a pill a day, vitamin D supplementation.

Okay. So forget, forget the natural D production.

I've been involved with the California Derm Society and we were lobbying we created a bill that limits tanning for tanning beds for kids, right? The tanning industry was going crazy, and their whole argument was the vitamin D issue. But you take vitamin D—

I didn't know you get vitamin D from tanning beds.

You do a little bit.

It doesn't have to be natural?

No. Oh, no.

But I didn't know that.

Yeah, I think that, you know, the risk of skin cancer is so high that to me I just take a vitamin, that's it.

Okay, so that works just as well?

Just fine.

Okay, which— what's your favorite kind of vitamin?

Yeah, I don't have a—

any particular? Okay. The sunscreen, which sunscreens do you like? I mean, there's so many different takes on it, whether you should have the ones with zinc or not, or if you should have the ones that get into your bloodstream, micronized.

So Before COVID sunscreen was really in the news a lot. Sunscreens can really be broken down into two subtypes. There are chemical sunscreens and chemical-free sunscreens.

Okay.

And that actually is in reference to just the active ingredient. So chemical sunscreens, the way they work is you put the sunscreen on your skin, it absorbs into the skin, and then when the ultraviolet light hits the skin, Within your skin, the chemical sunscreens will absorb the radiation so it doesn't get absorbed by the skin structures. Chemical-free sunscreens are sitting on your skin. So these are like titanium dioxide and zinc oxide. So when the sun hits the skin, it doesn't get into the skin. It gets reflected off. Both have been used for years. Chemicals, the safety of chemical sunscreens have come into question recently by, there was an FDA study that looked at absorption. And they found that there was measurable amounts of chemical sunscreens in the bloodstream when it was applied to the skin. Now, there are several questions about the study. So number one is, does that mean anything? So just because it's in the bloodstream, that doesn't mean it's a bad thing or it's harmful. And they had—

we have a lot of things in our bloodstream.

Yes, we do. They also had people applying the sunscreen to 75% of their body surface area multiple times a day. Which is not how people typically use sunscreen.

Okay.

It's challenging enough to get people to apply sunscreen once a day, and most people don't reapply, but to limited parts of their body. But having them 75% of their body surface area 4 times a day is highly unlikely for people to use it that way.

Okay, so, and that was the study? That was the study.

So I have patients coming to me and they ask me, well, what should I do? And I tell them, well, if you're worried about this, just use the chemical-free sunscreens. Use the zinc oxide and titanium dioxide sunscreens. Personally, I use zinc oxide, titanium dioxide sunscreens on my face, and I just use the spray-on sunscreens for the rest of my body.

The spray-on thing, I have a question about that. I can't imagine that it's not getting into our lungs, and especially when I see moms or dads spraying their little children with it. I really worry that these kids are inhaling microscopic aerosolized sunscreen into their lungs.

Well, I think that you have to be careful how you're applying it, right? So I think don't spray it on someone's face, right? I mean, that's like common sense, right?

I mean, when you see people on the beach, they just go, shh, and it's like, like a big cloud over their child.

Yeah, I think that for, for little kids, you're probably better off using a non-aerosolized product. You know, there's plenty of everything. So for little kids, use the creams or lotions, non-aerosolized.

Okay, okay. So you don't have a problem with using the chemical ones on kids?

You know, I, I don't think we have enough information about it. We don't have any information that says it's harmful at this point, and it's been used for years. And I think that the risk of melanoma is probably higher than the risk of having a problem with using sunscreen.

Mm-hmm. Okay, so the aerosolized, as long as you keep it away from your face and you're not inhaling the stuff, and do it outdoors.

Don't do it like in— don't put it on your bathroom.

Uh-huh. Okay, good. So eating, I definitely know the difference between my two children, my son who is home from college right now and my daughter who's in high school. She eats crazy clean, right? Fruits, vegetables, whole food. She cooks her own stuff. There was a very small window of time when we moved, when she was going into her freshman year of high school, where she started eating a little bit more processed food and she started breaking out a little bit. And then she switched completely to whole foods. Her skin is like so beautiful. My son had some of the worst breakouts. They had an open campus, so he would walk across the street to the pizzeria to Garden catering with the chicken nuggets and, you know, he was soda.

All that good stuff. All that good stuff, right?

Yeah. Yeah. So he had big breakouts through his teen years. This is just anecdotal and me observing, and I have looked up studies. I can't find definitive studies on diet and skin, but what is your experience?

So this is an area of great interest of mine.

Oh good, I did literature search.

Not much there.

I couldn't find anything because I guess it's so hard to study. And also, you know, medical journals, they really don't talk about anything unless, you know, it's diagnosable and it's something to give medications to or surgery. So I found a lot of articles on how to use Accutane. It's a retinoid and it's, it can affect your liver.

Really rare. So I think that Accutane is a miracle drug. It's just for people with acne, it is just— it's better than anything out there. And if one of my kids had severe acne, I would prescribe it in a heartbeat.

I've seen it. I've seen the results. Yeah, it's like for cystic acne.

It's for all— I mean, it's FDA approved for severe cystic and nodular acne, but it works for a variety of different acne-type eruptions.

Uh-huh. But what about the diet?

So, so, so, you know, there's not a lot of studies, right? It's, you know, probably hard to get funding for a study. Um, there's some limited studies that dairy might make acne worse, but there's not a ton out there. I think that part of it is because of money. You know, it's like in our country, the food food lobbyists, they are deep pockets, right?

Unless maybe you go for the strawberry people or the Fruit and Vegetable Growers of America.

Yeah, I mean, just look at, um, you know, the cattle ranchers. When these plant-based meat substitutes have come out, they're like, they're lobbying that they can't use the word meat or what have you, plant-based meat, and it's just crazy. I can tell you, in like, in our household, it's either 2 or 3 years ago, my wife forced me to watch that movie What the Health. Have you seen that?

Oh yeah. Oh yeah. I showed that to some of my students. Some of them got really angry with me for showing it.

Why?

They were a particularly precocious group of teenagers, right? And they, they're very analytical, and, um, they thought that the documentary was biased.

It was biased. And I mean, there are a lot of movies— Forks Over Knives, there's Force Over Knives is more like scientific, I think. I agree.

But what the hell, I loved it, but it was shock factor and it was kind of biased. And yeah, so that's why they were pissed.

It was highly biased. Like, for instance, when they call the American Diabetes Association and he's trying to get all this information out of the poor receptionist, it's like if you called my office and asked my receptionist for detailed information about some skin problem So that, that was ridiculous. Uh-huh. But I think that the overall messaging made sense to me, and I completely changed my diet after that. I think with that movie, you have to get past the bias. I remember in, in 2000— was it 2009 when Obamacare was first coming out? And they're always talking about the healthcare system in our country, and I always start thinking if they looked at the American diet and really worked on reforming that, that would help, you know, minimize the risk of heart disease, diabetes, you know, cancers, and so forth. That would probably decrease the burden on our health system dramatically. Not— I mean, beyond dermatology. And I mean, in dermatology, we just don't have the studies that look at the influence of diet on skin disease. All of our studies are, you know, therapeutic intervention. Oftentimes there's the study sponsored by the drug company, and so on and so forth. So it's really hard to find unbiased information.

But have you noticed a difference in your personal life or in your practice when you—

Absolutely. So I feel great.

Your skin looks good, or are you like doing all your derm stuff on yourself now?

I'm very simplistic in my routine. I, I, I am very simple for my routine. It's mild cleanser in the morning, sunscreen, topical antioxidant, topical retinoid at bedtime, and that's it.

So what's your favorite mild cleanser?

This is my bare bones skincare routine.

Okay.

I'm a SkinCeuticals fan. I think that their products are based on science, but I think a lot of it is personal preference. So I like their Simp, their soothing foaming cleanser. I'm not a fan of harsh cleansers. That's what I use in the morning. Then I use their Matte 50 sunscreen. It's a 50 SPF, has a slight tint to it so it looks natural. You don't if you've got white stuff caked up on your skin.

Mm-hmm.

And then at bedtime, I'll either use topical vitamin C or topical resveratrol. Those are antioxidants. So when we're outside, the sun, ultraviolet light creates free radicals in our skin. Those free radicals grab onto the skin structures, elastin and collagen, and break them down. So those antioxidants are free radical scavengers.

Topical vitamin C, right?

Or topical resveratrol. So resveratrol— resveratrol—

red wine, right?

It's antioxidant found in red wine. But I'm not putting red wine on my skin. I'm putting resveratrol gel from SkinCeuticals on my face.

Because I have very sensitive skin, so I rarely put anything on. But what is the bare minimum dose for those things? Vitamin C, like if somebody goes to the store, they're going to pick out a product. Product, what would you look for?

So it's not like a dosing in terms of like milligrams and so forth. So for instance, again, SkinCeuticals C+E Ferulic is a serum that they make. 2 drops in the medicine dropper is enough to cover your whole face. Resveratrol gel, 1 little pump out of the bottle, enough to cover your whole face. They just need a little bit. And with—

and then no moisturizer?

I'll get to that. Yeah, I'm saying bare minimum, bare minimum. Okay. And then moisturizer, it's preference. I like a moisturizer called Triple Lipid by SkinCeuticals.

Mm-hmm. Is it important to use one brand? I don't know why I would. I buy stuff and then I run out of one part and then I'm mixing all these different brands together.

You can mix brands. There's no problem with that.

It's fine. Okay.

Yeah, absolutely. And then lastly, a topical retinoid. So retinoids are vitamin A derivatives. So there are prescription ones such as tretinoin, which is the active ingredient in the drug called Retin-A or Renova, and then there's over-the-counter retinol. So the prescription ones are much stronger than the over-the-counter, but they both have benefits to help stimulate collagen and elastin in the skin.

Do you recommend one or the other, prescription or over-the-counter?

So I usually recommend people starting off with retinol, particularly if they're over over the age of 30, because over the age of 30, there's less oil production. We're more sensitive, more likely to have skin irritation. So the retinol non-prescription tend to be less irritating than the prescription drugs. And then tretinoin is the generic name for Retin-A, Renova, and that's a prescription.

And do you wash your face at night before?

Yes.

Okay, so you wash your face twice?

Correct.

With the same gentle cleanser.

Correct. So this is my order. Wake up in the morning, brush teeth.

Good.

Wash face with the soothing foaming cleanser. Then I put 2 drops of topical vitamin C on. Then I put sunscreen on. Off to work I go. Then in the evening, I wash my face, usually wait a minute, I'll put topical Renova on, which is prescription drug. It's tretinoin 0.02%. Then I'll usually wait a minute or 2 and put a moisturizer on. And oftentimes I'll alternate at bedtime using retinoid like the Renova with resveratrol. So one night I'll use resveratrol, the other night I'll use Renova.

And why is that?

The Renova can be a little bit irritating. The resveratrol is anti-inflammatory, it's not irritating. So some people, they can't tolerate using a retinoid every single night because it just gets too irritating.

Yeah, that would be me. Yeah. And then the moisturizer is at night only?

I only need it at night. There you have it, simplicity.

Would you recommend anything different for women?

You know, I would just say that women in general are more interested in more complexity and more steps and more specific things. So for instance, women will often ask for an eye cream, and there are a number of different ones they can use. They're more interested in some more specialty products. So I think that women are more interested in maxing out their skincare routine, or more willing to Whereas men just want like the bare bones, if anything. Like my male patients, I feel if I can just get them to use sunscreen every day, that's a win.

Well, I'm one of those people because I can't follow any regimen, so I just like everything in one pot.

So it's funny that you say that. SkinCeuticals last year launched something called Custom Dose, and basically we have this device in our office that has multiple different ingredients in it and you enter in information about your patient, and it'll customize a specific serum for that person.

Yeah. So one thing?

Yeah, one thing.

That's what I need. So what do you suggest for teens or young adults in their 20s?

For teens and young adults, I recommend a very basic skincare regimen. I recommend basically washing twice a day, and you need to be Careful, you don't want to overwash your skin. A foaming or gel cleanser would be great to use. If you have acne-prone skin or blackheads, you might want to choose a cleanser that has salicylic acid in it. I would definitely recommend washing off makeup before bed. Um, in terms of acne products, benzoyl peroxide is one that you might want to try, also adapalene. However, if these are not are not doing the trick for you, I recommend seeing a board-certified dermatologist, and I definitely recommend sunscreen every single day, and above all, avoid tanning beds. That's really a great, um, simple game plan for teenagers and young adults. Um, really the two key things would be to protect your skin from the sun, don't overwash your and there are certainly over-the-counter acne treatments you can try. If those don't do the trick, go see a board-certified dermatologist. They'd be happy to help you.

So I have a question to you from a young listener. What do you think about spot treating acne or breakouts?

As far as spot treatments go for acne, that's really a myth. Spot treatments really do not work very well. You need to treat the entire area that tends to break out. Another thing does not work really well are those blackhead strips. I don't really recommend them. You will get much better results using a prescription medication such as a topical retinoid. Any board-certified dermatologist would be happy to prescribe that for you. Um, with respect to removing makeup, those makeup wipes are perfectly fine. I do recommend using oil-free products for breakout-prone skin, whether it's moisturizer or sunscreen. I'm a big fan of the SkinCeuticals line, but there are many great lines out there, and for many people it can be just trial and error, see what your personal preference is.

What do you suggest for that dreaded post-workout breakout?

As far as taking care of your skin after a sweaty workout, it is important that you shower up pretty quickly after a sweaty workout, otherwise you can get buildup of bacteria that can lead to a skin problem called bacterial folliculitis, where the bacteria gets into the hair follicle and causes a skin rash that can be very itchy and sometimes challenging to treat.

Any other tips, Dr. Patoskin, on how to stay well and glowing through this, this home confinement?

I think the most important thing in the home confinement is to stay present in the moment, which is very hard for people to do.

That's good for your skin.

It's very good for your skin and your overall health. It's very important to limit your exposure to the constant news cycle. So listening to CNN or MSNBC or Fox or whatever your preference for news is, um, it's very important to limit that.

And I think you have no doubt that it's going straight to your skin, all this?

Oh yeah.

Oh yeah, unending news cycle.

Yes. Another thing I would throw out there is that, so let's say someone's out there and they're really stressing out.

Uh-huh.

I would say, you know, limit your news exposure, make sure you're exercising. Even if you're not a meditator, get that Insight Timer app, listen to them, um, and then just take a step back, take a deep breath, and realize that you know, as long as you're healthy, things are going to be okay. And then another thing I do like to watch on Discovery Channel, there's a TV show called Naked and Afraid. You seen that show?

No. Okay, I'm afraid not.

If you're stressed out about the things that's happening in your environment, watch a few episodes of Naked and Afraid, and then you'll be less stressed out.

Is this where they take people off and they have no clothes and they leave you on an island?

They leave you in the middle of nowhere. Two people have never met, usually one guy, one gal. They can each bring one item. They have no clothing, no shoes, no food. Usually one of them brings a machete, one brings a fire starter, and then they have to survive for 21 days. And, you know, this scarce food a lot of the time. It's like, yeah, it's COVID, but I got a pantry full of food.

Yeah. And Naked and Afraid is your stress management tool.

That's my go-to.

So by the way, I have meditations on my podcast and they're totally free.

Nice.

I go through cycles to make sure that the scientific aspects are covered, okay, in order to elicit the relaxation response.

So, you know, I'm a meditation novice. I'm like a meditation dummy. So I find— are your meditations, are they guided meditations? Were you talking through them, or are they I'm on my own meditating?

Mine are guided.

Good.

Because otherwise I would be uploading a silent 10 minutes of silence. I guess I could do that.

You could do that.

But I do love Insight Timer, and I am uploading some of my meditations into Insight Timer at some point.

Wow. High five.

Hey, that was fun. All right, thank you so much for taking your time.

That was fun.

This is Dr. Bobby. Thank you so much for listening. Please subscribe, leave a review, and share this with anyone who could use more resilience and less stress. Visit the website mindbodyspace.com for free meditations and more awesome interviews and expert tips that you can download from this episode and others. Email me at info@mindbodyspace.com to ask questions of my guests or me about stress and resilience. You can also suggest topics and guests. Until next time, wishing you and yours happiness, wellness, and hope.