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| Dr. Joel Aronowitz - The Truth About Sunscreens! |
Dr. Joel Aronowitz: Hi, everyone!
I hope
you're having a great day out there. Everything is wonderful here in Aronowitzland.
I just wanted to share with you a few thoughts about sunscreen, sun protection,
that sort of thing. It's the middle of the summer here and it's a good time to
do a little refresher.
So you may
have seen our Instagram post a man that was whose picture was published in the
New England Journal about 10, 12 years ago. It's really an old story, but he
has a lot of sun damage. On one side, marked wrinkles, roughness
hyperpigmentation of the skin, et cetera. And on the other side, where he
didn't get much sun exposure he has a lot softer skin, very few wrinkles and
very little sun damage. It's a good example of just what chronic sun exposure
can do.
But we
really don't need to read the New England Journal of Medicine to see what sun
damage what sun does to damage our skin. If you just hop in the shower, you'll
see this V here in your neck where it's usually exposed in men and women in the
course of the day. And if you compare that to a little further down on your
chest where you're really not getting much sun exposure typically because it's
covered by clothing 99% of the time you'll see that there's very little sun
damage. And although the skin still ages it ages in a much less accelerated way
than the parts that are exposed.
So sun
obviously has a lot of different forms of energy within it along what's called
the electromagnetic spectrum. So that goes from very intense cosmic rays, gamma
rays, X rays. These are rays that are mostly filtered out before they get down
to us but they still do get down to us and they can be very damaging all the
way down to visible light. But in between, there is a little narrow band called
ultraviolet light and those rays are damaging to the sun. We don't really see
them, but they can still damage our skin just like the more energetic cosmic
rays and gamma rays and all of those.
So those are
the rays that typically are what causes burning of the skin causes sun damage
which results in premature aging changes, and even skin cancers. And they're
divided up into ultraviolet A and ultraviolet B. UVA, UVB and sunscreens and
clothing that protect from the sun are called broad spectrum. Broad spectrum
sunscreens protect from both the UVA rays and UVB rays. So that's why they're
just in the broad spectrum.
Another
thing that's helpful to know about the rays of the sun are that it varies
depending on the time of day and the latitude we're at, obviously. So in the
winter above the Arctic Circle in Finland you're going to get a lot less
intensity of the sun than you will in the middle of the summer in Phoenix, for
example. And that's just common sense. We feel that on our skin, but also in
the course of the day, in the same location. At 08:00 in the morning, for
example, you're going to get maybe 20% of the energy of the sun that you would
get at, let's say, noon. So if you limit the time between ten and two that
you're exposed in the sun, then that's an easy way to limit your sun exposure
overall.
And one
final thought about sun exposure, and that is this concept that it's
cumulative. In other words, it accumulates over the course of our whole
lifetime, the same as x rays. If we get x rays once a week, all those x rays accumulate,
and they add up at the end of a lifetime. And there's a limit to how much your
body can tolerate. And it's the same with sun rays, they add up as well. So we
want to limit the overall exposure in the course of a lifetime.
Now, let's
talk about sunscreens. So with sunscreens, they're graded by the FDA if they
purport to have sun protective characteristics. And the FDA invented a term SPF
- Sun Protective Factor. And this is simply a number similar to what the EPA
gives to your car. If you buy a new car, the mileage that the EPA gives, it's
kind of an invented number. It's a good way to compare one to the other because
all of the sunscreens are tested in the same way under the same conditions, but
it doesn't relate to the real world actual efficacy of a particular product
very well.
For example,
if you have a sunscreen that's rated 15, that doesn't give you 15 hours of
protection. That just gives you, under ideal conditions, 1/15th of
the sun exposure for that limited amount of time that it's tested and under
those ideal conditions. So you shouldn't look at a sunscreen and say, oh, I've
got an SPF 18 and think I can be out in the sun for 18 hours. It's just not
true. And it also doesn't mean that a sunscreen that is 20 is twice as good as
a sunscreen that has an SPF of 10. That's really not how it works either. It's
just a general number, and you should use it only as a general guide not to
hang your hat on, so to speak.
Any
sunscreen needs to be reapplied every 2 hours, give or take, but certainly not
every 4 to 6 hours, close to every 2 hours for almost any sunscreen. Also, it's
good to know that there are basically two kinds of sunscreens, and that's not
the cheap and the expensive. The quality of the sunscreen, I don't think really
correlates very well with what you spend on them. What it really means is that
the two types in my mind are the kind that are mechanical, that are mineral
based. So something that has a fleck of metal in it, titanium, aluminum, zinc
in the ingredients, when you pick it up and you read the ingredients that has a
little fleck of that particular metal in it, and that's a mechanical block. And
that metal fleck can reflect light all day long. It's not going to age out or
time out by how long it's in the sun. As long as it's on there, it's working.
The other
type of sunscreen is a sunscreen that has a long chemical name that you can't
pronounce and you don't recognize, and those are chemical based sunscreens.
What happens with those is the ray of the sun hits that chemical and then that
chemical absorbs the light, absorbs that energy, and then it basically converts
it and it doesn't convert back automatically. So after that sunscreen has been
used, it really is used up. And although under ideal FDA laboratory conditions
it may have an SPF of 15, it really doesn't mean that it has that SPF of 15 in
terms of protecting you from the energy of the sun for very long.
So
sunscreens that are clear, that have a chemical name in them that you can't
pronounce and you don't recognize any mineral or metal name in them, I would
say are marginally effective, generally speaking. They have a good
characteristic in that they are clear and they can be prepared in a way that
isn't as pasty as the mineral based sunscreens. But you're also giving up a lot
in terms of the effectiveness of that sunscreen.
The other
issue is that we now have reports that some of those chemicals have been shown
to be absorbed through the skin with chronic use. And although there's not good
evidence they cause any harm, I don't think there's anybody out there really
looking at that question. So it is a question, and they certainly shouldn't be
used on small children. The mineral based sunscreens are very good with small
kids. You really shouldn't have a small child out in very intense sunlight for
very long anyway. But if you're going to trip to the beach or something like
that, the titanium or zinc or aluminum products are best for children because
they're not absorbed and there's very little likelihood that an allergic
reaction will occur from the metal and usually not the vehicle that the metal
is in either.
Okay, let's
talk about a couple of other ways we can protect our skin from the sun. So one
is stay out of the sun. Two are sunscreens. And three are mechanical devices.
And that's hats and clothes. So having a broad brimmed hat that gives your face
shade and the upper part of your body shade, the back of your neck, the tops of
your ears, your nose, the brow area, those areas that really get this direct
rays of the sun. If you think of it as a bird flying over what the bird's going
to see? Those areas are well protected by some type of hat with a broad brim
that extends over your ears as well as out in the front.
And the
other are sun protective clothing products and you can order these online all
day long. They're not very expensive and if you don't want to bother doing that
then basically just darker clothing will have a much higher sun protective
effect than lighter clothing. So those are good ways to protect yourself from
sun exposure. If you do have a burn and you do have changes due to chronic sun
exposure, then you may be interested in a few tips for things that we can do to
ameliorate, if not reverse some of those skin changes.
So what are
some of the changes associated with sun damage in our skin? Well, first thing
is pigment changes. Most of us can make melanin, not all of us, but most of us
can darken in other words, the melanocytes are stimulated to make increased
melanin that's picked up by the epithelial or the skin cells. And so our skin
darkens. But one of the problems is that sometimes the darkening is not even
and we can have sun spots, we can have little lentigos they're called, which
are little, they look like age spots or flat moles that are just slightly
darker than the surrounding skin.
We can have
also blotching that occurs because the skin gets burned and then it's not
burned quite evenly or the healing is complicated by blistering, maybe a little
irritation or superficial infection or scratching, that sort of thing. That can
cause pigment changes because as that skin repairs itself, what happens is that
the skin becomes inflamed and the inflammation stimulates production of melanin
because the melanin, if you think about it, the skin is producing melanin as a
type of armor, it's a type of protection. So anytime the skin thinks it's being
damaged or that it's vulnerable, it'll make that melanin as a form of self-protection.
And if that melanin is not, even if it doesn't happen to aesthetically look
particularly good, that can be kind of disfiguring.
So that's
one thing is the pigmentation, another is little hyperemic or blood vessel
induced changes. So if you get a burn, you know that your skin gets red, that's
called hyperemia and it's from the small capillaries in the dermal subdermal
plexus dilating up as a way to bring extra supplies and extra glucose, oxygen,
other cell messengers and even stem cells into the area to repair the area
because of the burn. And a sunburn is a burn like any other burn actually. And
it can be quite deep most of the time when we get a sunburn and we just get
blistering, it's what would be considered a superficial second degree or
partial thickness burn, maybe just a first degree burn, but it's a burn
nonetheless.
And that
hyperemia is something that occurs as a consequence of the burn. But we also
can get those little red spots or capillary angiomas. Those are seen very
commonly in very light skinned people, but we see them in everybody, every skin
type and they basically consist of a little nest of capillaries covered by a
thin layer of epithelium.
So that's
why if you scratch that capillary angioma, what happens is it bleeds like
nobody's business because all that's there are capillaries. So if you do that,
you're not going to bleed to death. You basically, like any other bleeding,
wipe away the blood clot, hold direct pressure with something cotton and just
light pressure with a finger and hold it for somewhere around 10 to 12 minutes
without interruption. Unless you have some kind of bleeding problem or you're
not holding directly on where it's bleeding, otherwise that's going to stop.
You don't want to keep looking at the area of bleeding. Obviously you want to
hold it so that it has a chance to clot.
So other
changes that happen with chronic sun exposure are loss of elasticity of the
skin. There's actually a protein in the skin called elastin and that material,
as it's degraded and it's not replaced, it will cause our skin to wrinkle. That
with the fact that our skin thins over time. The dermis, or the deeper layers
of the skin will actually thin over time as we lose that collagen from our
dermis. That's the layer under the epithelium.
So we have
more of that and then it thins out and stretches out. And now we don't have as
much elasticity. And so the muscles underneath, as they contract, the skin will
fold at a right angle to the muscle. So if the muscle is going this way, the
wrinkle is going to go this way. So I have muscles up here in my forehead. If I
raise my forehead, the muscle is going up and down, so the lines are going to
go this way.
So those
wrinkles occur with age normally, but they occur much more when you lose
elasticity and you have increased fitting of the skin due to the sun damage.
The other issue is dryness of the skin and that's from loss of some of the skin
adnexa. The skin adnexa are just little organelles or organs in the skin, like
hair follicles, the sweat glands, the oily sweat glands, the watery sweat
glands. When these glands stop working as well, skin gets drier that
contributes to those fine lines and wrinkles that we see and then just
naturally, over time, moles or little pigmented lesions, nevi is the medical
term. They will darken up more and they will even grow faster with the stimulus
of sun exposure.
So those are
just some of the changes and then more advanced changes. We'll see obviously
interference with the normal maturation of the skin cells and that's what leads
to what are called actinic or sun induced disorganization of the skin cells or
actinic keratosis is the medical term. And then eventually that leads in many
cases to little skin cancers, basal cell and squamous cell cancers. When that
sort of thing happens to the pigment inducing producing cells that's called a
melanoma, and those are the three major kinds of skin cancers. You have your
melanomas and then the basal cell and squamous cells. There are some others as
well, like merkel cell, different syringomas and different little lesions, but
you don't really need to worry about those 99% of the time.
So that's
just a little review of sun exposure, a few facts that I hope you find helpful,
a few facts and tips about sunscreens that I hope you find helpful, and a
little review of sun damage, what we can expect from the sun damage. And if you
hang around just a little bit longer, I'll go over some of the treatments for
sun damage.
Okay, what
are the treatments for sun damage? So it depends on what we're trying to
reverse. So if we're trying to reverse the hyperpigmentation, we can use laser,
which is coherent light, but most of the time we're using just intense pulse
light, which is more ordinary light from flash bulb, for example. So the flash
on your camera is going to be an intense pulsed light. And if we take a light
like that and make it more intense and send it through a filter, then we're
going to get that sort of intense light that is only a certain range of
wavelengths, a very more narrow range of wavelengths.
So we can
tune that to the color that we're trying to get rid of. So if we want to get
rid of something that's brown in the skin, then we'll use a filter that only
produces light, that is in that wavelength, that'll be absorbed by the brown
color, won't be absorbed by the surrounding whiter skin. And then, as a result,
that browner color will heat up. It'll burn it off, it turns a little darker
because it absorbs that light and then flakes off after a few days.
So that's
how IPL, or intense pulse light devices work. The one I own is made by a
company called Sciton, S-C-I-T-O-N which is a very good machine, I think. But
there are a lot of different brands of IPL around, a lot of different lasers
that can be used for this also. It's just they're generally a little more
intense and can produce damage when they're used at too high in intensity,
basically.
Chemical
peels can also be used as well as other both chemical and mechanical means to
abrade and damage the skin so that we flake off the area that's hyperpigmented
and produce a fresh healing layer. So as long as those things are done by
experienced hands for the right indication, they can be very safe and
effective. But most of the time for hyperpigmented areas, we're going to be
using some type of light device, typically in most medical practices.
Same thing
for vascular lesions, things that are red, those things that are caused by
inflammation that doesn't fade naturally in a relatively short time, or a
vascular lesion like capillary angioma or even small veins. Those will be
treated by some type of light producing device, either a laser or IPL machine.
There's no magic machine. It's really just a tool that's used by, hopefully
somebody who's experienced and knowledgeable about what that particular machine
can do in different clinical situations. I think it kind of fools Aaron to
search after the latest, greatest machine, when really, it's really not that
there's a special hammer, it's that the guy holding the hammer needs to know
how to use the hammer, if that makes sense.
Problems
that are a little more difficult, like wrinkles, these can sometimes be filled
with a filler. I think that fat and fat that's enhanced with your own
regenerative cells is very helpful. And it's probably the best thing, as long
as we don't overdo it on the replacement of volume. Fat in and of itself is a
very nurturing tissue, and most of our tissues improve when we add fat to them.
I agree with
everybody who's saying to themselves, yes, but I've seen these people puffed up
like a frog that look ridiculous because somebody injected too much fat, I
agree, but fat is better than artificial filler materials. Even the ha
products, we're seeing increasing reports of inflammatory reactions to these
products. I wouldn't dissuade you from having 1, 2, 3 CCS of these
intermittently two, three, four times a year, but people that are getting 10,
15, 20 CCS of these products, I think are putting themselves at risk for more
difficult complications. They're certainly not very, very common, at least as
far as we can tell, but there are increasing reports of these problems, and
once you inject these materials, it's hard to get them out. It's true you can
dissolve them with an enzyme, but that can be more difficult than it sounds, in
my experience. So, wrinkles, we can fill the tissue underneath to plump them
up.
Can you
actually make the thin aged skin thicker? You actually can with fat, and
especially stem cell enhanced fat, but that's going to be in an experimental
phase at this point, and there are applications for that. But it's not
something that you're going to find in every dermatology or plastic surgery
office. They're going to be specialized people who've been working in that area
for years. If you really are and will be discerning in who they select as
candidates for that kind of treatment.
The other
way to deal with these chronic wrinkles from age and excess sun damage is going
to be, of course, surgery that lifts the tissue, and that can be with internal
barbed sutures of different kinds, string lifts, that sort of thing, but more
likely either limited or more complete facelift and necklift. And that is a
subject for a whole other video, so I will leave it at that. I hope that this
little review of sunscreen, sun damage, the effects of the sun, and some of the
things we can do for the effects of sun damage was helpful. And I hope you
picked up some new information.
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