The Skin Clinic Fremantle | Dr Sarah Boxley


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Skin Picking: A guide to dermatotillomania

beautiful woman picking skin

“Skin-picking can be a sensitive subject. In the aesthetic dermatology industry, we see it frequently amongst our patients, many of whom are surprised to hear it is an actual thing and that they are not alone.” – Dr. Sarah Boxley, Medical Director, The Skin Clinic Fremantle

 

We have collated the information below with an aim of educating sufferers and their family members, and to offer guidance towards strategies that can help. So please read on if you are affected, fascinated or otherwise interested in learning more about this ……

Also known as excoriation disorder, or compulsive skin picking, dermatillomania is a psychological condition that is expressed in the form of repetitive touching, scratching, picking, and digging at one’s own skin. It is an impulse-control disorder and one of several body-focused repetitive behaviors (BFRB) currently classified in the DSM-5 as Obsessive Compulsive and Related Disorders.

Dermatillomania affects up to 5% of the population and approximately 75% of those affected are female. However, not all people who pick their skin have dermatillomania. The difference between dermatillomania and normal picking at skin imperfections and irregularities, is that the behaviour is chronic, results in tissue damage, and causes the person distress, dysfunction, and often feelings of embarrassment and even shame.

How do I know if I have dermatotillomania?

Most people pick at their skin from time to time, but you may have skin picking disorder if you:

  • can’t stop picking your skin
  • cause cuts, bleeding or bruising by picking your skin
  • pick moles, freckles, spots or scars or try to “smooth” or “perfect” them
  • don’t always realise you are picking your skin, or do it when you are asleep
  • loose track of time when you are picking your skin
  • pick your skin when you are feel anxious or stressed

You may pick your skin with your fingers, fingernails, teeth or with tools like tweezers, pins or scissors.

 

Symptoms

Repetitive skin picking can also extend to pulling, scraping, and even biting both healthy and damaged skin from various parts of the body, though most often on the face, hands, fingers, arms, and legs. Skin picking commonly begins in adolescence (but can occur at any age) and can result in visible skin damage such as lesions, discolouration, open wounds, scars, and infections. Dermatillomania is generally a chronic condition, though symptoms may arise and disappear from time to time. Those with dermatillomania exhibit a wide range of picking behaviours. Some pick as little as a few times per day, briefly without even knowing it. Others can spend hours picking at individual areas. Skin picking is almost always done with the fingernails. In some cases, tweezers or other tools are used. 

Skin picking can cause a number of complications. Infection at the picking site is perhaps the most prevalent. Tissue damage is a close second. Some cases can be severe enough to warrant skin grafting. Permanent scarring and physical disfigurement are common effects of skin picking. Dermatillomania can cause mental effects as well as physical effects. Anxiety, depression, shame, fear of exposure, and embarrassment over the condition usually leads to attempts at covering up the skin with makeup, clothing or by other means, and can also interfere with normal social interactions resulting in uncomfortable relationships with family and friends. At the same time, these feelings loop around on themselves and increase the likelihood of self-harm including continued picking. 

Dermatillomania is not diagnosed when the symptoms are caused by another medical or psychiatric condition. For instance, skin picking can also occur with with dermatological conditions, autoimmune disorders, opiate withdrawal, and developmental disorders such as autism.

 

Causes of Dermatillomania

It appears there may be a genetic link to dermatillomania, since some people appear to have an inherited tendency to BFRBs such as skin picking and hair pulling, as well as higher-than-average rates of mood and anxiety disorders in first-degree relatives. Other factors, such as individual temperament, stress and age appear to play roles in the development of the condition. Chronic skin picking behaviour often coincides with the onset of puberty Dermatillomania may also be associated with perfectionism that leads to over-grooming, or used as a means of avoiding stressful events or releasing tension that builds up as a result of negative emotions such as impatience, frustration, dissatisfaction and even boredom.

 

Things you can try to stop picking your skin

DO

  • keep your hands busy – try squeezing a soft ball or putting on gloves
  • identify when and where you most commonly pick your skin and try to avoid these triggers
  • try to resist for longer and longer each time you feel the urge to pick
  • remove or cover mirrors in your house
  • care for your skin when you get the urge to pick it – for example, by applying moisturiser
  • tell other people – they can help you recognise when you are picking
  • keep you skin clean to avoid infection

DON’T

  • do not let your nails grow long – keep them trimmed

 

Treatments for Dermatotillomania

For those who have made repeated attempts to stop picking on their own and have been unsuccessful, it may be time to seek professional treatment. 

Pharmacological Treatment

There are several different types of pharmacological treatment for skin picking disorder, although none of these are approved as first-line treatment for skin-picking. The most common type of treatment is Selective Serotonin Reuptake Inhibitors (SSRI). These have been shown to be highly effective in treatments for OCD. Because of this, they have also been used for treating dermatillomania although to date there are no specific clinical studies supporting the use of SSRIs for this condition. Doxepin, clomipramine, naltrexone, andolanzapine, and pimozide all may be effective in the reduction of skin picking behaviours. Nutraceuticals, such as n-acetyl cysteine (NAC), may also be of help.

Behavioural Treatments

Behavioural treatments for dermatillomania are far more common than pharmacological treatments. These treatments include cognitive-behavioural therapy (CBT), acceptance-enhanced behavioural therapy, acceptance and commitment therapy, and habit reversal training. Habit reversal, in particular, has been shown to be effective.

 

More information & help:

https://www.letserasethestigma.com/dermatillomania/

https://pickingme.org

https://www.skinpick.com/dermatillomania

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CoVid-19: Additional measures we are taking in the clinic

In light of the current global coronavirus pandemic and its continued potential impact on our local healthcare system, it is critical that we do our part in reducing the possibility of community transmission, as well as proactively reducing exposure to our valued team members.

At the current time, our clinic is fully operational, although some treatments are restricted. This may change at short notice should there be a spike in community transmission of CoVid-19. As a medical clinic, the safety of our patients is always paramount, and our infection control measures are already exceptional. In addition to our standard practises, we have instigated risk-minimisation strategies as described below regarding social distancing within the clinic. These may make your visit slightly longer than usual and we are grateful for your understanding and cooperation in this respect.

We can also provide telehealth consultations for some of our services, either via phone or through a secure video link that opens in a browser (no software or app downloads are necessary).

We can still provide your favourite skincare products via post or by home delivery. Please contact the clinic by email or phone to order skincare.

 

For the safety of our patients and team members we have instituted the following infection control measures in the clinic:

1. Regular cleaning has been increased so that all door handles, surfaces and key contact areas are disinfected with antiviral cleaner between each patient.

3. You will be requested to wash or disinfect your hands with sanitiser on arrival at the clinic. Chlorhexidine mouthwash will be provided for examination or procedures around the lower face if appropriate.

4. Your temperature will be checked on entry to the clinic.

5. You will notice that your Nurse/Doctor will be wearing a face mask and gloves to minimise the risk of asymptomatic viral spread.

6. We are spacing our appointments further apart to minimise contact between patients and to allow for additional cleaning measures.

7. There are changes in the waiting room, including further spacing between chairs, removal of all magazines, and social distancing markers on the floor.

8. Please do not bring children or additional adults with you to your appointment unless they are required as a carer or translator.

9. We ask that any patients who are unwell in any way, have been in contact with a known or suspected case of CoVid-19, or who have returned from overseas/interstate within the past 14 days do not visit the clinic. Please contact our reception to rearrange your appointment.

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Do you clean your make-up brushes?

So seriously, when was the last time you washed your make-up brushes? Last month? Before Christmas? Never?? 

If you are anything like most of us, it’s one of those things you occasionally think about (usually when you are in a rush in the morning and notice that your brushes are actually a bit gross) but never quite get around to doing.

But we would actually recommend that you wash those brushes at least once a week. Make-up brushes harbour all sorts of bacteria, so keeping them clean not only prolongs their life but is also much better for your skin.

Here at the clinic we use a Brush Cleanser from Synergie for our tester brushes after each use. It’s really simple to use – just spray it onto a tissue or cotton wool pad, then pat the brush gently to remove makeup. Let the brush dry for 5-10 minutes and it is good to go. Once or twice a week we also do a deeper clean for all our brushes using shampoo.

 

How do I wash my makeup brushes?

Its pretty much exactly the same as washing your hair 🙂

Step 1: Run the brushes under warm water and add a little bit of conditioning shampoo. Our personal favourite is the classic MooGoo Milk Shampoo.  If you have a few smaller brushes to clean, you can do them all at the same time. 

Step 2: Massage the brush gently to loosen any makeup and then rinse to remove all soap and debris, repeating this motion until the water runs clear and there is not sight of any colour. It’s just like cleaning paintbrushes at school.

Step 3: Once you have washed your brushes, simply squeeze the remaining water out with a tissue or clean towel, working from the tip of the brush hair to the base. Then, gently tease the brush hair into its natural shape whilst it is still damp. 

Step 4: Lay the brushes flat on a piece of paper or a towel to dry. Don’t leave them standing upright in a container – water can run from the brush head down into the base of the brush, which can result in the paint peeling away from the handle over time, or even loosen the handle away from the brush head.

How long do makeup brushes take to dry?  

Its usually best to leave them overnight to dry. If you can line them up with the handles on a bench and the heads sticking out the air can circulate and they will dry quicker.

Is the cleaning process different for synthetic brushes vs natural hair makeup brushes? 

No the technique is exactly the same. Synthetic brushes tend to be a lot stronger and easier to clean so you can be slightly rougher when you are handling them. If you are using oil-based products such as a lipstick on natural brushes and you find that you’re having difficulty removing it, try using washing-up liquid instead of shampoo.

Can I use an automatic brush cleaner?

Yes you can. There are a number of cheap and effective machines on the market that will quickly clean and dry your brushes. These machines are little so they don’t take up much space, and are usually battery-powered. They can clean and dry brushes in as little as 30 seconds (meaning you can do it more often!) Just remember to reshape the bristles straight away. 

Our favourite automatic cleaners:

Thin Lizzy

StylPro Original

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Does chocolate cause acne?

As a primary care skin clinic we see a lot of acne patients and this question gets asked frequently. Since it’s Easter we thought we’d bring it up again and have a look at the latest evidence.

So, does chocolate cause acne? Despite lots of studies, the scientific and medical communities are still not sure. The answer at the moment is “well, it’s complicated”. Let’s delve deeper…

There are plenty of good, robust studies that suggest that high glycemic index (GI) foods – ie those rich in refined carbohydrates and sugar, including sugary drinks, processed breads, snacks and “junk food” – are bad for acne-prone skin[1-3]. High GI foods cause a quick spike in blood sugar, which makes the body produce more insulin, as well as an insulin-like growth factor and hormones known as androgens. All these things lead to more sebum (oil) production in the skin, and to increased growth of the skin around the hair follicles which serves to trap the sebum. This then leads to blackheads, whiteheads and pimples.

So we know foods with a high sugar load are bad, but where does chocolate fit in? Previous research has dodged a link between chocolate and acne, including one study back in 1969[4] that was actually supported by the Chocolate Manufacturers Association of the USA. However, more recent studies indicate that it may indeed be a contributing factor. 

In 2016, separate groups of university students in the US were randomly assigned to eat a chocolate bar or 25 jelly beans, both of which provided the same glycemic load[5]. Interestingly, the jelly beans didn’t have an effect on acne. But when people ate chocolate, their pimples increased.

“We found that, on average, people had about five more pimples with the ingestion of chocolate,” said study author Dr. Gregory R. Delost of the Department of Dermatology at University Hospitals, Cleveland Medical Center. “Some people might say, five pimples, no big deal, but if someone is getting ready for their high school dance … then five pimples is definitely clinically relevant in that situation.”

One confounding factor in the “jelly bean v chocolate” study is that they used milk chocolate, which has a higher sugar content than dark chocolate and obviously some dairy in there too.

So let’s look at another study from back in 2011, where the participants were given 100% pure chocolate in the form of capsules, with no added milk or sugar. The study was small but was double-blinded and placebo-controlled. It showed that ingestion of pure chocolate in capsule form caused a greater increase than placebo in the number of inflammatory and non-inflammatory acne lesions in young men who had a history of acne but who had no acne lesions at baseline[6].

Moving on to yet another study, again from 2016 but this time using 99% dark chocolate…. A group of 25 acne-prone men were asked to consume 25g daily for 4 weeks. Statistically significant changes of acne scores and numbers of comedones (whiteheads) and inflammatory papules were detected as early as 2 weeks into the study. At 4 weeks, the changes remained statistically significant compared to baseline[7]. This study was also a small one and did not include a control group or female participants, who are more difficult to study because of their cyclical hormonal changes which we know can impact on their acne scores. It does not address whether chocolate can cause acne in those who are not acne-prone, but it does suggest that dark chocolate can exacerbate acne that those what are already prone to it.

So, in milk chocolate, the dairy and/or sugar might be involved in aggravating acne, but in the case of dark chocolate, it could be the various fatty ingredients rather than the chocolate itself. The cocoa butter in dark chocolate contains fats known as stearic acid and oleic acid, which have been shown to be involved in the pathogenesis of inflammatory acne [8].

In addition to the fat component of chocolate, which has been linked to blackheads, some research suggests that chocolate may have pro-inflammatory influences in the skin, which could contribute to inflammatory acne, characterized by red papules and pustules, especially in the presence of known acne-causing bacteria.

Other researchers have looked at whether chocolate affects skin differently at different ages, by dividing men into “young” and “middle-aged” groups who were all given 10g per day of dark chocolate for 4 weeks[9]. They reported that chocolate consumption caused a significant increase in shedding of the top layer of skin but only in the group of young men. They also found that the presence of acne-causing bacteria on the skin significantly increased in both the young and middle-aged men, though this effect was noticeably stronger in the young men. 

But isn’t chocolate meant to be good for you? Cocoa contains molecules called “flavonoids”, which are known to be anti-inflammatory and could theoretically be beneficial to the skin. Cocoa beans fresh from the tree are exceptionally rich in flavanols. Unfortunately, during conventional chocolate making, this high antioxidant capacity is greatly reduced due to manufacturing processes [10]. Studies are currently ongoing in to whether these antioxidant properties can be preserved and utilised for both improvement in skin function and for sun protection.

Further investigation is needed if we are going to work out the exact link between chocolate and acne, but for each individual patient, knowing how your own skin reacts to chocolate will give you all the information you need. Keeping a food journal can help you work out whether your acne worsens when you eat chocolate. Unfortunately, that may mean giving up the indulgence, at least some of the time, or limiting the amount you eat. Every skin reacts to dietary influences slightly differently and every body has its own triggers. The bottom line is, if chocolate breaks you out, you should consider not eating it 🙁

Dr. Sarah Boxley MBBS BSc MRCGP FRACGP FSCCA FACAM

Bibliography

1. Melnik, B.C. and G. Schmitz, Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris. Exp Dermatol, 2009. 18(10): p. 833-41.

2. Melnik, B.C., Linking diet to acne metabolomics, inflammation, and comedogenesis: an update. Clin Cosmet Investig Dermatol, 2015. 8: p. 371-88.

3. Melnik, B.C., Acne vulgaris: The metabolic syndrome of the pilosebaceous follicle. Clin Dermatol, 2018. 36(1): p. 29-40.

4. Fulton, J.E., Jr., G. Plewig, and A.M. Kligman, Effect of Chocolate on Acne Vulgaris. JAMA, 1969. 210(11): p. 2071-2074.

5. Delost, G.R., M.E. Delost, and J. Lloyd, The impact of chocolate consumption on acne vulgaris in college students: A randomized crossover study. J Am Acad Dermatol, 2016. 75(1): p. 220-2.

6. Block, S.G., et al., Exacerbation of facial acne vulgaris after consuming pure chocolate. J Am Acad Dermatol, 2011. 65(4): p. e114-e115.

7. Vongraviopap, S. and P. Asawanonda, Dark chocolate exacerbates acne. Int J Dermatol, 2016. 55(5): p. 587-91.

8. Li, W.H., et al., In vitro modeling of unsaturated free fatty acid-mediated tissue impairments seen in acne lesions. Arch Dermatol Res, 2017. 309(7): p. 529-540.

9. Chalyk, N., et al., Continuous Dark Chocolate Consumption Affects Human Facial Skin Surface by Stimulating Corneocyte Desquamation and Promoting Bacterial Colonization. J Clin Aesthet Dermatol, 2018. 11(9): p. 37-41.

10. Andres-Lacueva, C., et al., Flavanol and flavonol contents of cocoa powder products: influence of the manufacturing process. J Agric Food Chem, 2008. 14: p. 56.

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Photo of moisturiser bottles and plant leaf

Understanding different moisturisers

There is a lot of confusion out there in what to look for in a moisturiser. Not all moisturisers work in the same way or are ideal for all different environmental conditions. This is a very basic summary to try and explain the two main types of moisturiser: Emollients and Humectants…

Emollients:

Many people use the terms “moisturiser” and “emollient” interchangeably, though typically an emollient describes a particular ingredient inside a finished moisturiser.

Emollients are used to soften and smooth the scales of the outer layer of skin (stratum corneum). They can be useful in helping reduce rough, flaky skin.  They are also occlusive agents: substances that provide a layer of protection to help prevent moisture evaporation from the skin, aka transepidermal water loss (TEWL).

A few examples of emollients are vegetable oils (grape seed, sesame seed, jojoba, etc.), butters (cocoa butter, shea butter), alcohols (stearyl alcohol, cetyl alcohol), silicones (dimethicone, cyclomethicone), and petrolatum derivatives (petroleum jelly, mineral oil).

Use an emollient directly onto damp skin after a shower to lock moisture in.

Humectants:

A humectant is a substance that actually bonds with water molecules to increase the water content in the skin itself. Humectants typically draw water into the skin from a humid environment, and they enhance water absorption from the outer layer of skin. However, a pure humectant moisturiser applied to the outside of the skin in a very dry environment will not be able to draw water from the atmosphere (as there is none) and so will suck water from the deeper layers of the skin instead. Whilst this may make the top layers of skin seem temporarily more hydrated, ultimately the deeper layers will be deprived of moisture and so the skin overall can become dryer.

Glycerin is one of the more typical and effective water binding agents found in skin care products.  Other humectants include sugars (glucose, fructose, sucrose, honey), hyaluronic acid, proteins, amino acids, elastin, and collagen. Lactic acid, which is one of the alpha-hydroxyacids (AHAs), is known for its moisturising properties as well as its ability to exfoliate. Whilst most AHAs can increase the skin’s ability to trap water due to an increased production of natural hyaluronic acid, good old lactic acid’s additional humectant properties make it ideal for treating dry skin. 

A bit more info on hyaluronic acid, which is being used more and more in skincare over the last few years for increasing hydration and reversing cell damage: Hyaluronic acid (HA) is a natural moisturising factor (NMF) found in the deeper skin layers. Referred to nature’s ‘super moisturiser’, this substance is able to hold 1000 times its weight in water and when applied topically it will attract moisture to the outermost layers of skin. This plumps those layers and temporarily reduces the appearance of wrinkles and fine lines. However, remember to be wary of using HA topically in very arid or air conditioned environments for the reasons stated above. In these situations you could consider injectable moisturiser directly to the dermis, with an emollient topically to prevent TEWL. 

Many humectant’s also have emollient properties, while not all emollients are humectants. The best moisturisers have a combination of emollients and humectants. 

Who needs moisturiser?

The requirements of our skin for moisture changes as we age. The skin naturally alters as we get older – the dermis, where collagen and elastin are predominant, gets thinner, whilst the stratum corneum, the thick horny outer layer of the epidermis, gets thicker. As a generalisation, by the time we are 70 years old, our skin only holds 20% of the moisture that it did when we were 20. Using regular and effective topical moisturisers from our early adulthood can reduce this moisture loss and slow down the natural ageing processes of the skin, as well as protecting the skin from additional environmental stresses. 

Moisturisers and acne:

Patients with acne are often hesitant to use a moisturiser as they believe this will clog their pores, increase their oil production and make their acne worse. However, even acneic skins need moisture and will in fact function better and be less inflamed if they are well hydrated. A light, non greasy, non-comedogenic moisturiser is suitable in this situation – we usually recommend either Hydrogel or BrightEnlite from Synergie, or NMF by The Ordinary.  Hydrogel is a lightweight noncomedogenic moisturising gel fortified with cosmeceutical botanicals and hyaluronic acid, great for those with oily skin and enlarged pores and for skin exposed to high levels of humidity.

Can my moisturiser do more?

Many modern moisturisers come mixed with other active ingredients to target different skin concerns. This is where it can get complicated. We would always recommend discussing your own skin’s requirements with a professional prior to spending money on skincare. If you are someone who has a bathroom cabinet crammed with costly products that promised miracles but don’t seem to deliver, then it may be worth a few minutes with a Dermal Therapist to design a tailored skincare regime.

My personal choices? As a middle-aged woman with naturally dry skin who spends most of my life either in air conditioning or outdoors in the harsh Perth climate, my personal choice for moisturiser is the lightweight but super hydrating and soothing MSM cream (MooGoo) twice a day. In the mornings, I follow this with UberZinc (Synergie Skin) – an antiageing moisturiser with 21% pure zinc oxide to give me effective UVA/B protection. As a body moisturiser I love Solarcare (Bernier pharmaceuticals) – a light but effective mixture of emollients and humectants with the addition of 5% niacinamide (vitamin B3) to fight environmental damage and reverse signs of ageing. 

*we do stock all the above products in the clinic but they are also easily available either online or at local pharmacies in Australia*

Would you like personalised skincare advice? Make an appointment with one of our Dermal Therapists here

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Photo of ripe tomatoes in someons hand

Ingredient focus: Lycopene

What is lycopene and why should we be using it on our skin?

Lycopene is the bright red carotene pigment and phytochemical found in red fruits and vegetables, such as tomatoes & red carrots, watermelons and papayas.

It is a powerful antioxidant and anti-inflammatory – helping protect skin from environmental agents that can contribute to clogged pores and breakouts. Most importantly for long-term skin health, it can help protect against sun damage. Studies have indicated that lycopene helps protect fibroblasts (skin cells that make collagen) & eliminate skin-ageing free radicals caused by ultraviolet rays, both UVA and UVB.

Lycopene accounts for a whopping 90% of the colour of tomatoes. As an antioxidant it is twice as effective as beta-carotene and 10 times more than alpha-tocopherol (vitamin E). Our favourite anti-ageing cosmeceutical skin product – Superserum+ by Synergie, contains lycopene sourced from hydrolysed tomato skins.

Lycopene is a relatively new product from a commercial point of view and recently it has been added to fortified foods such as yoghurt and drinks.

Can the lycopene in your diet actually help your skin?

Although the absorption via diet is still being researched, the current evidence indicates that lycopene is absorbed in the intestine and then distributed to the liver and kidneys. It appears to be excreted into the skin via sweat glands, therefore the lycopene from your diet tends to accumulate on specific regions such as forehead, nose, chin, palms etc. A small study on healthy volunteers showed that a 10-week lycopene-rich diet improved the minimal erythemal dose by 40% compared with the control group. (Minimal erythemal dose is essentially the amount of UV radiation needed to turn the skin pink) NB: Watermelons are NOT a substitute for sunscreen!

Could your skincare be delivering more than your diet?

Back to cosmeceutical skincare: Hydrolysation of tomato skins stabilises the lycopene. Once it is stabilised, it can be distributed evenly and homogeneously across the skin. It’s a clever little ingredient, naturally sourced, that boosts our skin’s ability to protect itself. “Clean science” in action. Find it in these Synergie products: SuperSerum+, Practitioner A+, BB-Flawless makeup.

 

Interesting fact: although lycopene is chemically a carotene, it has no vitamin A activity. 

 

References:
Synergie Skin Hydrolysed tomato skin (lycopene) clinical data
Furr HC, Clark RM Intestinal absorption and tissue distribution of carotenoids Nut Biochem 1997 8:364-377
Fazekas Z et al. protective effect of lycopene against ultraviolet B-induced photo damage. Nut and Cancer 2003 47(2) 181-7
Stahl W et al. Dietary Tomato Paste Protects against Ultraviolet Light-induced Erythema in Humans J Nutrition 2001
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image of a young woman applying sunscreen to her face in the morning

Sunscreen: When should you use it?

 

Research from The Cancer Council’s recent National Sun Protection Survey show that nearly one in two Australians mistakenly believe that sunscreen can’t be used safely on a daily basis. 

For some years now, we have been advising our patients about the daily use of sunscreen here in Perth. We have been very pleased to see that in the last few weeks, the peak bodies responsible for sun safety advice in Australia and New Zealand have published an updated policy on sunscreen use, which makes our advice not only evidence-based but now also the accepted recommendation in this country.

The advice is now simple: make sunscreen part of your morning routine, just like brushing your teeth.

The national policy change has come about following a national Sunscreen Summit in Brisbane last year, that examined the current evidence on sunscreen use, and was published at the end of January in the Australian and New Zealand Journal of Public Health. The publication, led by Professor David Whitman and Associate Professor Rachel Neale from QIMR Berhofer Medical Research Institute, shows that there is now clear evidence on the benefits of daily sunscreen use.

As Associate Professor Neale explains “up until now, most public health organisations have recommended applying sunscreen ahead of planned outdoor activities but haven’t specifically recommended applying it every day as part of a morning routine,”

“In Australia, we get a lot of incidental sun exposure from everyday activities such as walking to the bus stop or train station, or hanging out washing.

“In recent years, it has become clear that the DNA damage that causes skin cancer and melanoma accumulates with repeated small doses of sunlight.

“At last year’s Sunscreen Summit, we examined all of the evidence around sunscreen use and we have come to a consensus that Australians should apply sunscreen every day when the maximum UV level is forecast to be three or higher.”

“For much of Australia, that means people should apply sunscreen all year round, but in areas like Tasmania and Victoria there are a few months over winter when sunscreen is not required.”

Facts you need to know:

  • Australia has one of the highest skin cancer rates in the world.
  • Research shows undoubtedly that sunscreen helps prevent skin cancer, including the deadliest form, melanoma.
  • There is consistent and compelling evidence that sunscreens are safe for human use
  • Adverse reactions such as allergies occur in a very low proportion of the population
  • Clinical trials have found that people who use sunscreen daily have the same levels of vitamin D as those who don’t.
  • The recommendation to apply sunscreen every day is to protect against the little bits of incidental UV exposure that most of us get each day, that cause damage over time.
  • Sunscreen is not a suit of armour – if you are planning outdoor activities you should also seek shade, wear a hat, protective clothing and sunglasses, and reapply your sunscreen every 2 hours.
  • Regular skin checks can save lives  – get your skin checked annually by your GP, a Skin Cancer Clinic (a list of accredited doctors can be found here) or a Dermatologist.

So what is the NEW RECOMMENDATION?

Sunscreen* should be applied and used regularly:

  • During everyday activities which add up over time (e.g. travelling to and from work; doing household chores; shopping etc)
  • During any planned or prolonged outdoor activities (e.g. doing outdoor work; gardening; playing or watching sport; going to the pool or beach; exercising outdoors etc)
Sunscreen for everyday activities

When the UV index is forecast to reach 3 or above, it is recommended that sunscreen is applied every day to the face, ears, scalp if uncovered, neck and all parts of the body not covered by clothing. Ideally, this would form part of the morning routine. This protects the skin from the harmful effects of everyday sun exposure.

Sunscreen for planned or prolonged outdoor activities

During planned or prolonged outdoor activities, for the best protection it is recommended that sunscreen is used along with other sun protection measures (i.e. clothing to cover as much of the skin as possible; hats; sunglasses; shade and scheduling outdoor activities to avoid the middle part of the day).

When the UV index is forecast to reach 3 or above, sunscreen should be applied to the face, ears, scalp if uncovered, neck and all parts of the body not covered by clothing.

Sunscreen should be re‐applied every 2 hours or more frequently if swimming, sweating or towel drying.

Sunscreens should not be used to promote tanning, but rather as one of five strategies (along with shade, hats, clothing, sunglasses) to reduce exposure to harmful UV radiation.

So, based on the average daily maximum UV index, residents in Australia’s capital cities should apply sunscreen daily in the following months:

Brisbane, Perth & Darwin

All year round

Sydney

Every month except June

Canberra & Adelaide

Every month except June & July

Melbourne

Every month except May, June & July

Hobart

Every month except May-August

 

*“sunscreen” means sunscreen with an SPF of 30 or more and compliant with Australian/New Zealand Sunscreen Standard AS/NZS 2604:2012.

To read the full recommendation “When to apply sunscreen: a consensus statement for Australia and New Zealand” click here

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make up brush on pink background at the skin clinic fremantle

Make-up and dermal filler procedures – what is the problem?

Do you ever wonder why we ask you to remove your make-up when you come in for a dermal filler procedure with us?

Quite simply, both your makeup and indeed your own skin are an infection risk. There is increasing evidence that the complications of dermal fillers that were once thought to be caused by our own immune system are in fact due to infection. The most likely time for introduction of infection is at the time of injection1,2.

 

Bacteria on Skin

It has been estimated that 30–50 million bacteria can be found on each square inch of human skin. The majority of these are normal, friendly microbes, and if they remain on the outside we have no problems. The skin and mucous membranes are the body’s protective barriers. Breaching these barriers (eg with a needle or a scalpel) can introduce those bacterial into the subcutaneous tissue, muscle, bone and body cavities.

We know that most surgical site infections originate from the patient’s own bacteria entering the wound at the time of surgery3. Dermal filler procedures involve multiple passes of a needle or cannula from skin to bone, so disinfection of the skin before the injection of a filler is absolutely crucial in reducing the risk of microbial contamination. If bacteria is introduced into the body with the dermal filler at the time of injection, it can use the filler substance as a food source and slowly multiply, potentially leading to the onset of lumps and hardening of the filler, and even to abscesses. Reducing the number of bacteria on the entire face, not just the site of injection, will reduce the risk of a patient developing an infection-related complication4,5,6,7.

We therefore need to thoroughly clean and disinfect your skin before and during your filler procedure. Logically, in order to do that we need to remove your makeup.

Bacteria in Makeup

Also, in addition to simply getting in the way, the makeup itself is potentially an infection hazard8. In a small study in 2015, items of out-of-date make-up were tested under strict laboratory conditions. All tested positive for enterococcus faecalis, a deadly strain of bacteria that can cause meningitis and septicaemia9. Other bacteria that were found growing in the make-up and their potential health risks include9:  

  • Ubacterium: causes bacterial vaginosis
  • Aeromonas: one of the causes of gastroenteritis and wound infections
  • Staphylococcus epidermidis: a bacterium which is resistant to antibiotics and can be deadly to people in hospital or who have catheters or surgical implants
  • Propionibacterium: one of the main causes of acne and other skin conditions
  • Enterobacter: causes urinary and respiratory tract infections

 

Make-up and photography

Makeup also interferes with our photography system – we can’t get reliable before and after photos when patients are wearing full contouring foundation, and the filters we use to highlight UV damage, vessels and wrinkles can’t see through the makeup.

 

At The Skin Clinic Fremantle

As dermal filler procedures become more and more popular, and access to them easier and easier, we find ourselves increasingly reminding patients that these are not beautician treatments. The injection of a foreign substance (that is going to last for months/years) into your face is a medical procedure and it should be treated as such.

Patient safety and outcomes are our paramount concern and so yes, despite our patients finding it inconvenient at times, we will insist on total make-up removal and thorough skin disinfection prior to dermal filler procedures.

Thank you for your understanding, Dr. Sarah 🙂

 

References

1. De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment, and treatment. Clin Cosmet Investig Dermatol. 2015;8(8):205–214.

2. King M, Bassett S, Davies E, King S. Management of Delayed Onset Nodules. J Clin Aesthet Dermatol. 2016;9(11):1–5.

3. Ayliffe GA. Role of the environment of the operating suite in surgical wound infections. Rev Infect Dis. 1991;13(Suppl 10):S800–804 

4. Heydenrych I, Kapoor KM, De Boulle K. et al. A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management. Clin Cosmet Investig Dermatol.  2018 Nov 23;11:603-611

5. Signorini M, Liew S, Sundaram H. et al. Global Aesthetics Consensus: avoidance and management of complications from hyaluronic acid fillers—evidence and opinion-based review and consensus recommendations. Plast Reconstr Surg. 2016;137(6):961e–971e.

6. Wagner RD, Fakhro A, Cox JA, Izaddoost SA. Etiology, prevention, and management of infectious complications of dermal fillers. Semin Plast Surg. 2016;30(2):83–86.

7. Ferneini EM, Beauvais D, Aronin SI. An overview of infections associated with soft tissue facial fillers: identification, prevention, and treatment. J Oral Maxillofac Surg. 2017;75(1):160–166.

8. Collier H. Infection control in aesthetic medicine and the consequences of inaction. J Aesth Nursing 2018; 7(7): 352-361

9. Matewele P. Out of date make up can contain lethal bacteria, London Met scientist finds. 2015. https://tinyurl.com/ybuat6o5

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Photo of a white shire on a white background

Sun Protection: How to get the most from your clothing

A patient recently asked whether it is really worth covering up; how much sun protection would he actually be getting from wearing a long sleeved shirt?

As a general rule, light-coloured, lightweight and loosely woven fabrics do not offer much protection from the sun. That white shirt you slip on at the beach when you feel your skin burning provides only moderate protection from sunburn, with an average ultraviolet protection factor (UPF) of 7. The sun protection lowers to an approximate UPF of only 3 when that shirt gets wet. (UPF stands for ultraviolet protection factor and is the rating system used for clothing and fabrics. It is different to the SPF system used for skin products. The UPF indicates how much of the sun’s UVA and UVB rays are absorbed. A fabric with the rating of 50 will only allow 1/50th of the sun’s UV rays to pass through)

So, what should you be looking for when choosing sun protective clothing? Not all clothing fabric is equal. You need to consider:

Fabric structure:

If you can easily see through the fabric, chances are UV can easily pass through it. The tighter the fabric structure, the better the sun protection. Tightly woven, lightweight natural fabrics such as linen, cotton or hemp will also help keep you cooler than synthetic fibre equivalents.

Tension:

If a fabric is stretched, it will be less protective. This is common in knitted or elasticised fabrics.

Layering:

Layering of fabrics and garments is an effective way of increasing protection from UV.

Colour:

Darker colours absorb UV rays better than white or pastel colours of the same fabric.

Moisture content:

Fabrics offer less protection from UV radiation when wet. How much less protection will depend on the type of fabric and the amount of moisture it absorbs. To reduce the effect of the moisture, take dry clothes to change into or if dipping in and out of the water, choose a fabric that provides effective protection from UV and that will dry quickly.

Caring for your clothes:

Washing new clothes can improve their sun protectiveness by shrinking gaps in the structure. However, old, threadbare or faded clothes may offer decreased protection over time.

UV absorbers:

Some clothing is treated so it can absorb more UV radiation. Check the clothing label to see if your clothes have been treated and follow the care instructions.

Source: Cancer Council Australia, Coolibar


Related: What you need to know about Skin Cancer >

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Photo of a mother about to breastfeed her baby

Cosmetic Procedures when Breastfeeding – are they safe?

So, you’ve made it through 9 months of pregnancy and now that the dust has settled and you are getting down to the joys of motherhood, you are perhaps realising that you might have lost that pregnancy-glow and perhaps haven’t had your anti-wrinkle injections for over a year? Frown lines are creeping back and your skin is looking dull and tired? This is a familiar story we hear from our patients on a fairly regular basis, and the question for many at this point is what cosmetic treatments are possible when you are breastfeeding? This is a time when it is especially important to know who’s hands are treating you and which cosmetic procedures are safe to have so that you can perk up your skin with no risk of harm to your baby.

Dr. Sarah Boxley, our Medical Director, is on the faculty of the Allergan Medical Institute, sits on Medical Advisory Boards for dermal filler products and is a principal investigator in clinical trials. Here she gives us the low-down on the skin treatments that are safe to have when breastfeeding…

What are the facts about cosmetic procedures when breastfeeding?

Very few actual scientific studies have been conducted looking particularly at the safety of cosmetic procedures during lactation (breastfeeding). Clearly, the main concern in this situation is the possibility of chemicals or medications being absorbed into the mother’s system and from there excreted into her breast milk, which could potentially affect neonatal growth and development. Review articles in Dermatological Surgery in 20131 and in the International Journal of Women’s Dermatology 20172 both summarised that most cosmetic procedures are safe to use during lactation since there is low concern for significant systemic absorption of any of the agents used in these procedures. In more detail….

Chemical Peels when breastfeeding

Superficial and medium depth chemical peels do not lead to absorption into the body, as long as care is taken around mucosal surfaces such as the mouth and eyelids. Therefore, we can be confident that routine cosmetic peels are safe during breastfeeding. Peels containing high concentrations of salicylic acid (including Jessner’s peels) and TCA are not recommended for use in pregnancy but can be used safely when breastfeeding. Because we have such high UV levels in Australia, these are peels that are most appropriate in winter.

More about chemical peels >

Anti-Wrinkle Injections & Dermal Fillers when breastfeeding

Scientifically speaking, the doses of neuromodulators/anti-wrinkle injections (sorry – I am writing this in Australia where the law prevents me from mentioning the names or ingredients of these) that are used cosmetically are very small compared to the doses used for medical reasons and carry only a very low risk of systemic absorption into the mother. On top of this, the molecular size of neuromodulators, and incidentally of dermal filler materials, make them incredibly unlikely to be excreted into breast milk, with their use in lactation being deemed by experts to be safe1,2. However, despite this consensus opinion, the use of these products in lactating mothers remains off-label. No large scale studies have been (or will be) performed, and so as prescription medications they are not technically licensed for use during breastfeeding. For patients who remain concerned, we recommend the “pump & dump” technique – continued breastfeeding with pumping and discarding the breast milk in the first 24 hours after treatment.

Dermal filler procedures are safe to have when you are breastfeeding, as long as you are physically well with no symptoms of mastitis or any other infection/illness. As at any other time, it is important that your filler procedure is performed in a clinic with rapid access to fully trained medical personnel with emergency protocols in place, as very rarely complications can occur.

More about Anti-wrinkle injections >

Hydrafacial® when breastfeeding

This popular medical-grade facial treatment uses a low concentration of salicylic acid, but at a level that would be considered safe to use both during pregnancy and breastfeeding. Your skin may be more sensitive post-pregnancy and so it is important that you let your therapist know you are breastfeeding so that he/she can adjust their technique and the level of suction if necessary.

More about Hydrafacial® >

Fat transfer when breastfeeding

Procedures which necessitate the redistribution or removal of fat such as fat transfer or tumescent liposuction are not recommended in the immediate postpartum period, although not specifically because of breastfeeding. These procedures have an invasive nature and there is a lack of safety studies particularly in the postpartum period. Increased fat stores are expected because of pregnancy, and women should allow for stabilization of their postpregnancy weight before pursuing cosmetic procedures.

More about Fat Transfers >

Body-sculpting procedures when breastfeeding

Non-invasive fat removal methods such as cryolipolysis (fat-freezing), ONDA® (cool wave energy) and injectable fat-dissolving medications have also not been studied during breastfeeding and therefore safety data is not available. However, it would seem reasonable that these body-sculpting procedures could be used (on body parts other than the breasts) during breastfeeding. Again, we would recommend to wait until your post pregnancy weight has stabilised before investing in these treatments. Energy-based devices that result in skin tightening, such as ONDA® radiofrequency and HIFU can be really helpful post-pregnancy for women who feel they need to regain their body confidence.

More about ONDA® >

Sclerotherapy when breastfeeding

Sclerotherapy should be avoided during lactation1. Generally, hypertonic saline solutions that were traditionally used in sclerotherapy are safe but there are no data on whether other sclerosing solutions are excreted in breast milk, which has led to the recommendation to avoid this therapy while breastfeeding. However, anecdotally, some women have pursued this therapy and continued breastfeeding with pumping and discarding the breast milk in the first 48 hours after treatment. Nevertheless, there are no reports on the outcomes and/or complications of doing this and therefore experts can not make a recommendation on its safety.

More about Sclerotherapy >

Laser & Lights

With regard to laser procedures, the wavelength of light used for skin treatments is not deep enough to affect function of the milk ducts. Low-level light therapy can be used to treat postpartum mastitis as well as sore nipples and to enhance wound healing after episiotomy, and has been shown to have no serious effects on lactation3,4,5. Laser therapy should not produce adverse effects on lactation, breast milk production, or quality of breast milk1, and so can safely be used for cosmetic facial indications during breastfeeding. This applies to LED light therapy and biophotonic treatments (Kleresca®) such as are used for acne, as well as pigment, vascular and fractional ablative lasers. Indeed, a recent systematic review of all the available scientific literature concluded that the use of lasers and light therapy, (including IPL, BBL, tattoo removal, vascular, pigment and ablative lasers) are safe to use on the skin even during pregnancy6. However, you need to be aware that treatment of hormonal pigmentary changes (such as melasma) and increased facial hair growth caused by pregnancy should not necessarily be treated until the hormones have stabilised as results may be suboptimal in these situations.

More about Kleresca® >

Come in for a Consultation

If you are currently pregnant or breastfeeding and would like to explore your options for cosmetic skin treatments please hit the link below to arrange an appointment with a member of our team. And we wish you many congratulations on the addition to your family 🙂

Dr. Sarah x

or Contact Us to Arrange Your Appointment.


1. Lee K.C., Korgavkar K., Dufresne R.G., Higgins H.W. Safety of cosmetic dermatologic procedures during pregnancy. Dermatologic Surg. 2013;39:1573–1586.
2. Trivedi M.K., Kroumpouzos G., MuraseJ.E. A review of the safety of cosmetic procedures during pregnancy and lactation. Int J Women’s Dermatol. 2017; 3(1):6-10.
3. Kymplova J, Navratil L, Knizek J. Contribution of phototherapy to the treatment of episiotomies. J Clin Laser Med Surg, 2003; 21:35–9.
4. Pietschnig B, Pani M, Kafer A, Bauer Wais E, et al. Use of soft laser in the therapy of sore nipples in breastfeeding women. Adv Exp Med Biol, 2000; 478:437–8.
5. Kovalev MI. Prevention of lactation mastitis by the use of low-intensity laser irradiation. Akush Ginekol (Mosk), 1990; 2:57–61.
6. Wilkerson EC, Van Acker MM, Bloom BS, Goldberg DJ. Utilization of Laser Therapy During Pregnancy: A Systematic Review of the Maternal and Fetal Effects Reported From 1960 to 2017. Dermatol Surg. 2019 Jun;45(6):818-828.

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