Before we buy makeup and skincare products, we’re asking different questions now. What’s actually IN this product? Is it good for my skin? Is it healthy? Are these products ethically and sustainably made? We’re becoming much more savvy consumers and more thoughtful advocates for our own health.

But, as a consumer, it’s challenging to separate substantiated health concerns from claims like “chemical free” which are basically meaningless, given that water itself is a chemical. That’s why I’m such a strong advocate of sharing studies and information to help educate consumers to make informed decisions about controversial ingredients.

This brings us to a new study on PFAS (per- and polyfluoroalkyl substances) just published this morning (link to full study below). PFAS are fluorinated pollutants – commonly found manmade chemicals used in a range of consumer products including water-resistant clothing, microwave popcorn bags, and stain-resistant furniture. They’ve been found in our water supply, in the soil, and now, in our beauty products. PFAS have been nicknamed “forever chemicals” for good reason: these chemicals persist in nature and in our tissues. These compounds are not only harmful to our planet, as they don’t break down in the environment, but they also accumulate in the human body and have been linked to a number of serious health concerns including: cancer, hormone disruption, obesity and liver toxicity. The CDC and EPA have recognized these compounds as toxic.

This new study showed high fluorine levels (which would suggest the probable presence of PFAS) in numerous waterproof mascaras, liquid lipsticks and foundations. Even more concerning was that these chemicals were not listed on the ingredient lists. You can read more about the study and its findings here. I am absolutely not advocating an alarmist approach here. I’m sharing information to help you stay informed so that you can make decisions based on your personal comfort level.

Skincare and Beauty Products:

PFAS are not necessary in makeup. I personally don’t choose to use skincare and beauty products with “perfluor” or “polyfluor” on the ingredient list because that’s my comfort level. Many people don’t realize that PFAs are used in cosmetic products because of their water-repellent or water-resistant properties. These perfluorinated compounds (PFASs or PFCs) are typically found in products meant to stay put for long periods of time. What makes them last longer on your eyelashes or lips are the same chemical properties that make them accumulate in our bodies and persist in our environment.
This new study concerns me because many of the contaminated products did not even list these compounds (PFAs or PFCs) on the ingredient list. Consequently, even a very savvy consumer would have no way of knowing if the product she is using contains PFASs or PFCs when buying and using the products tested.

Moreover, the types of products that tested positive for high levels of fluorine (and thus likely to contain PFAS) are often used close to and around the eyes and lips, such as mascaras and lipsticks. Ingredients are much more readily absorbed in those areas because of the thin, delicate mucous membranes and proximity to tear ducts. Furthermore, women often lick their lips and unknowingly ingest the ingredients in their lipstick, which is yet another route of exposure. Although it’s desirable to have mascara or lipstick or foundation that lasts a little longer, I believe consumers need to know which ingredients are contributing to that staying power. I personally love a good waterproof mascara, but not at the expense of my health.

Again, I’m not suggesting an alarmist approach here. I think this was eye opening and I’m so glad this information was brought to light. Are there PFAs in our environment? Yes. Are we exposed to them in water and food? Yes. Do we need to throw out all of our skincare and makeup? Of course not. This information helps guide us to press for transparency in ingredients and safety when it comes to the products we choose for our healthiest lifestyle. Some organizations are actively lobbying for more government oversight of cosmetics and consumer products, encouraging legislation that protects consumers and the environment.

So what can you do TODAY if you want to try to minimize your exposure?

I encourage my patients to shop brands that are transparent about their supply chain, and take efforts to ensure that ingredients and packaging are being sourced from safe, reliable sources in a sustainable and ethical way.

Some retailers also reassure their customers that any brands they carry do not contain PFAS, such as Credo.

Here are some other resources I offer my patients who are interested in learning more about PFAS:

Silent Spring Institute 

URI STEEP Superfund Research Program

PFAS EXchange, part of PFAS-REACH

STUDY: https://pubs.acs.org/doi/10.1021/acs.estlett.1c00240

Dr. Whitney

 

Dr. Whitney Bowe interviews Dr. Sandy Skotnicki

When I published The Beauty of Dirty Skin, not many people – including dermatologists – were focusing on our skin microbiome. So, when I met Dr. Sandy Skotnicki and she shared my passion, we had an immediate connection! Dr. Skotnicki’s area of expertise is contact dermatitis – which means, skin allergies and irritations. We took a deep dive together into this subject matter as specifically, how it impacts skincare product decisions. I’m excited to share this conversation with you!

Dr. Bowe: For my patients who don’t want to give up fragrances in skincare, and prefer clean products, what do you recommend as a compromise: a way to enjoy those products but minimize the risk of developing an allergy over time? 

Dr. Skotnicki: The first thing to get patients to understand is fragrance on a bottle is a placeholder term- fragrance or perfume on a label means another 20-30 individual ingredients. Most companies do not disclose what is in their fragrance due to trade secrets. What makes Pantene smell like Pantene? Well, it is not one chemical but all you will see on the bottle is the term fragrance.

So some individual fragrance molecules have very low allergy risk. Or the opposite -there are 26 individual fragrance molecules in particular that are identified and controlled in the European Union. Examples of these allergenic individual fragrance molecules would be cinnamon, geraniol, linalool, oak moss etc. Avoidance of those in formulas would be the first step. 

Next are plant extracts or essential oils. These ingredients are complex mixes of multiple chemicals- they are not one chemical. If you extract something from a plant or remove the “essence” of a plant – which is done in essential oils- you end up with something that contains a multitude of individual chemicals, sometimes numbering in the 20-30s.

 If an individual ingredient in a plant extract is identified as helpful – what should be done is to isolate that one chemical and use it or copy it in a synthetic variant. This way, you don’t get all the other parts of the extract. All the other chemicals are unknown and could be problematic i.e. allergic, irritant or hormone disruptive (like lavender and tea tree essential oil; Note: more on this below).

A good example of this technique is the famous medical plant, Centella Asiatica, also known as Gotu Kola. It has very well established wound healing and antioxidant properties. But the main active ingredient in this plant that affords these healing properties is Madecassoside. So, companies use this ingredient only and not the whole plant extract. This is how it should be done for better safety.  Naturally, this is a more difficult and expensive process than just using the plant extract. 

So what is the best way to have some fragrance in skincare and still have a natural and clean product? Choose one or two individual fragrance ingredients that have low allergy potential and/or use individual plant ingredients for fragrance and not essential oils or plant extracts. 

Dr. Bowe: During COVID, so many of my patients have gravitated more towards fragrances and aromatherapy.  Using a diffuser, or applying a skincare product that has a lovely, calming fragrance can really affect our moods, ease anxiety, and enrich an experience making it feel more like self care.  Many of my patients are surprised to learn that botanical, or “natural” fragrances, such as extracts and essential oils, are a very common cause of skin allergies.  What are the most common botanical ingredients that you’re seeing come up during your patch tests as the cause of skin allergies in adults?

Dr. Skotnicki: If I could show you some of my severe diffuser contact allergy cases, you would be floored! It’s a mini-epidemic. Severe facial swelling, sometimes so bad they can’t open their eyes.

Allergic contact dermatitis to essential oils has increased dramatically over the past years coinciding with their huge use and distribution in North America .The essential oil industry is set to continue to rise. The scary part is they market them for children. Undiluted essential oils should not be used on children and particularly not in a diffuser in their bedroom.

I get that fragrance is about self-care and not everyone has an issue.  But it is the assumption that ” it’s all natural so it can’t be bad for you” is what is troubling and causes many of my patients to suffer for many months until I patch test them and tell them they are allergic to their all natural essential oil.  

Some of the most common botanical allergens include ylang-ylang,( the base fragrance of Aveda) linalool ( which is a terpene in many essential oils), lavender, eucalyptus, tea tree oil, Jasmine, menthol and peppermint, lemon, lemongrass, rose, sandalwood, rosemary, feverfew, clove oil and many more.

It’s not just about skincare reactions from botanicals and essential oils. Several essential oils – tea tree and lavender – have been associated with hormone disruption and breast development in young boys.

Dr. Bowe: Tell me about your book, Beyond Soap, and why you decided to write it?  Having written a book myself, I know what a huge undertaking that can be!

Dr. Skotnicki: I decided to write my book to help explain why so many of my patients were reacting to their skincare and haircare.  Over the years I was being sent the same type of patient with the same problem and I got frustrated for them and for me!. I also live in Canada, where we have less than 600 Dermatologists in the country and only a handful that specialize in what I do- Contact Dermatitis.

So, I wanted to write a book on the topic to try and help inform patients who couldn’t get to a Dermatologist or had to wait and suffer for months before seeing one.  The main purpose of my book was to highlight what in skincare actually causes reactions?  It is not what the public thinks. 

What I found the most rewarding was the path my book took. I decided to do a broad research dive into the topic and I ended up reading outside of Dermatology- I read microbiology, immunology, general science, and what I learnt really shifted the way I view not only Dermatology but medicine.  It’s not just what is in skincare that is causing increased reactions, it’s the way we take care of our skin.  Washing and cleaning has increased over the past 150 years and along with it has come increased skin disease as well as other inflammatory conditions.  I think we realize in medicine that there is a connection but it is not clear- having said that the microbiome has something to do with it.

Thank you so much for sharing your insight and thoughts on these key topics with me and with my audience! I value your work so much and I can’t wait to share our live with my Instagram audience!

 

Dr. Whitney

 

I use many of the best cutting edge lasers and light devices in my office every day. However, I am the first person to talk my melasma patients out of using these devices, and opting for less expensive options instead. This blog focuses on why! 

If you have melasma, when you first get a laser or light based treatment, you might see the brown patches turn into a coffee ground material, and then slough off. At first, the results look great! However, the next time you go in the sun, you might notice your melasma comes back with a vengeance. I can’t tell you how many patients have come to me in tears after getting a series of laser or IPL (intense pulsed light) treatments at a spa, and realizing that they spent thousands of dollars only to find that their melasma is worse than it ever was.  

Here’s why that happens. We know that melanocytes, the pigment producing cells, are exquisitely sensitive to both heat and light. Consequently, it seems as though most laser and light devices, even used at very low/gentle settings, prime or sensitize the melanocytes. The next time these cells are exposed to sunlight or heat, they work overtime to pump out more pigment. As a dermatologist, on behalf of my patients, I’d rather be safe than sorry. Although every melasma patient would love a quick fix, and laser before and after photos can provide that WOW they are looking for, I strongly urge you to see a provider who takes a more conservative (and often less expensive) route.  

Now if you have sun damage, and your brown spots are lentigos, or sun spots, and NOT melasma, that’s a whole different story! Bring on the lasers and lights! In those cases, I absolutely love using lasers like the Fraxel laser to brighten dark spots from the sun. So, the very first and more important step is to make sure the person deciding on your treatment plan has a very good eye and knows how to diagnose disorders of pigmentation.

I’m sharing so much on melasma right here for you guys and I love the questions you have been asking. Check out my latest posts on my favorite skincare ingredients and products to address melasma and my thoughts on the safety of hydroquinone, a topical treatment often used to treat melasma.

Dr. Whitney

I’ve been getting so many questions about which skincare ingredients are most effective when dealing with melasma, or the type of hyperpigmentation known as the “pregnancy mask.” 

Overall, the strategic combination of complementary ingredients to target different aspects of melasma is, in my opinion, the best approach. Here’s why: some ingredients slow down pigment production, while others stop the transfer of pigment from the melanin producing cells to the other cells in the skin. Other ingredients help exfoliate away the uppermost layers of pigment-stained skin, and others act as antioxidants, neutralizing the free radicals and oxidative stress that makes melasma worse. So, combinations are going to be more effective than single modalities.

But, it’s a delicate balance because we don’t want to overdo it with potentially irritating ingredients. If you cause too much irritation in the skin, this can make melasma worse. 

In this post, I’ll cover both products you can get online or in stores, and ingredients that come in prescription strength, through your doctor. I’ve put together a list of the ingredients I find most effective in addressing melasma, and of course, I’ve added products in each category that I love to use:

Glycolic acid and/or lactic acid: 

While in office peels are going to get you more dramatic results more quickly, you can absolutely see improvements using at home peels if you use them right! 

First, look for ingredients like glycolic acid and lactic acid. If you have oily skin, you might enjoy a peel with salicylic acid, but that can be drying in more sensitive, dry skin types.

The peels you purchase online or over the counter, that are meant for at home use, tend to be much weaker than in office peels. However, you can still run into trouble. At home peels contain many of the same ingredients as in-office peels, so they do come with a risk of burn or skin irritation if used improperly.

Despite what the instructions say, the first time you use one of these at home peels, consider leaving it on for 5 minutes and then rinsing off, and immediately applying a moisturizer – this is the recommendation I make to my patients. This short exposure is a “test run” for your skin to see how you tolerate that peel. Another good rule of thumb is that tingling is ok, but stinging/burning is NOT ok.  If you feel anything more than a tingle, then wash it off immediately and apply a nourishing moisturizer. Burning does NOT mean it’s working- it means it’s triggering too much inflammation in your skin and that can make your melanocytes react by pumping out MORE pigment.  

If your skin feels healthy and you don’t experience any stinging/burning or red blotches in the days following the first peel trial, then you can consider leaving the product on the skin either for 10 minutes, or even overnight, depending on the strength of the product and how sensitive your skin tends to be. The goal is to try to work your way up to using one of these products twice a week at night, with each application spaced 3-4 nights apart.  

Some of my favorite at home peels are:

Moon Juice Acid Potion Resurfacing Exfoliator: (glycolic, lactic and salicylic acid)

Skin Fix Correct+ Dark Spot Corrector: (glycolic acid and lactic acid) 

Herbivore Botanicals Prism 12% Exfoliating Serum: (lactic, glycolic, and malic acids)

Vit C and other antioxidants (turmeric, Vitamin E, honey)

Cover FX Brightening Booster Drops (these drops have an oil soluble derivative of vitamin C called Ascorbyl Tetraisopalmitate.  It’s one of the most stable forms of vitamin C and stability is critical for vitamin C because it is prone to oxidation)  

Skinceuticals CE Ferulic with 15% L-ascorbic acid. (Strong science behind this one, but note that it is expensive)

Bakuchiol (a retinol alternative)

Check out my full blog post on this topic HERE.

Other topical ingredients to consider: azeleic acid, kojic acid, niacinamide, licorice root extract, mulberry extract and tranexamic acid, arbutin and soy. Licorice root seems to be more soothing, while niacinamide can cause irritation in some people. Topical tranexamic acid can sometimes help, but can also cause some irritation. Topical use is much less effective than when I prescribe tranexamic acid orally (more on this immediately below).

Turning to Prescription strength topical ingredients to address melasma:

In my office, I’ll often compound or blend my own prescription strength ingredients for my melasma patients.  Oftentimes, these products combine tretinoin or tazorac (forms of prescription strength vit A) with hydroquinone. Hydroquinone is a controversial ingredient with some very real side effects, so I strongly discourage anyone from using this ingredient if they are not under the direct supervision of a dermatologist. I have an entire post on the safety of hydroquinone here.  I talk about the risks and benefits of these treatments with my patients, and customize my approach for each patient based on their pigment pattern, medical history, budget and comfort level.

For info on how to address your melasma from the inside out through diet and supplements, check back soon!

Dr. Whitney

 

Melasma, and hyperpigmentation in general, is one of the most common reasons people schedule an appointment with a dermatologist. Below, I’ll talk all about one of the most powerful topical ingredients we use to treat melasma, hydroquinone, and the safety concerns surrounding its use. 

Okay, let’s dive into the topic at hand: just how SAFE is hydroquinone?

Hydroquinone is one of the most powerful topical ingredients when it comes to brightening dark spots, treating melasma, combatting hyperpigmentation and evening out skin tone. It’s available both as a prescription, often found in combination with other prescription medications like tretinoin, and is also available in OTC (over the counter) products. While it’s an incredibly powerful ingredient, and often considered first line by most dermatologists in the treatment of melasma, there are safety concerns surrounding its use. Does it get absorbed into the bloodstream? Can it cause cancer? Can it damage your liver? Should I be afraid to use it?  Having researched this ingredient extensively, and having used it in the office for over a decade, I will give you my honest opinion here.

First, should you be afraid of systemic absorption, and possible risks associated with systemic absorption? Many people aren’t aware that they are being exposed to considerable amounts of hydroquinone in their diet every single day. Hydroquinone is found in nature as either hydroquinone or arbutin, which is converted into hydroquinone in the body.  Hydroquinone and arbutin are found in tea, coffee, pears, wheat bread and red wine. Studies show that human exposure to hydroquinone from our diet is significant https://pubmed.ncbi.nlm.nih.gov/8568910/  I personally consume coffee and tea every day, and I love enjoying a juicy, ripe pear as a healthy snack.  

Does hydroquinone cause cancer or damage the liver? Most of these studies were done in rats, and many were done on populations of rats that already had predispositions for growing certain cancers and tumors. Although I certainly am not going to ignore these concerning studies, it is very hard to make a convincing case that what we see in rats will translate into humans. As far as liver studies go, hydroquinone seems to actually have a slight protective effect when you look at risk for liver cancers in rats. So clearly, we really are not certain of the true impact that hydroquinone has on our different organs. So far, studies done in humans who are exposed to higher concentrations of hydroquinone have been reassuring. I honestly don’t know any board certified dermatologists in the US who are afraid to use this ingredient because of concerns surrounding its “toxicity” to the body, after having reviewed the literature and science extensively.

What we do know is that high concentrations of topical hydroquinone, especially used for long periods of time without a doctor’s supervision, can lead to a skin condition called exogenous ochronosis, or pseudo ochronosis.  

This is when we see a darkening of the skin, even darker than the original melasma that these creams were meant to treat!  Furthermore, it is near impossible to get these stains to disappear!  

These cases, thankfully, are quite rare in the United States, and much more commonly found in parts of the world where people are also using antimalarial medications. Antimalarials also cause pseudo ochronosis, so the combination of hydroquinone plus antimalarials are probably a major risk factor for this condition.

The main risks seem to be: 

using concentrations higher than 4%

using hydroquinone for years at a time without breaks, and

combining hydroquinone with other ingredients such as oral antimalarial medications.  

We also know that many “bleaching” and “whitening” creams that you can find online or in other countries are contaminated with mercury and high potency steroids like clobetasol https://www.sciencedirect.com/science/article/abs/pii/S0013935116302651

Ok, so how do I approach hydroquinone in my office with my patients.  Here are my take homes:

  • Hydroquinone should only be used under the very strict supervision of a dermatologist
  • Each patient needs to weigh pros and cons, risks and benefits of using hydroquinone vs using other treatment modalities.  In cases where melasma is severe and affecting someone’s quality of life, the benefits may outweigh the risks. It’s a personal decision between that patient and the treating physician.
  • If you have been prescribed a hydroquinone containing prescription from your dermatologist, you MUST follow up carefully. Most derms will rotate you off of hydroquinone every few months, to make sure you get prolonged breaks between uses.
  • If you have used hydroquinone, or are using it, under the close supervision of a dermatologist, don’t lose sleep over it! Remember, everyone who is drinking coffee or tea, or eating pears or sipping on red wine, is also being exposed to hydroquinone.
  • Do NOT try to get hydroquinone containing products online or through online pharmacies.  If a friend brings you an extra “magic cream” across the border and swears by it, PASS!  Warn your friend about mercury and clobetasol and other risks she/he might not even know about.

For more recommendations and discussions surrounding melasma and hyperpigmentation, check out my IGTV and YouTube channels.

Dr. Whitney

 

 

Now that the warm summer months are becoming a distant memory for many of us, one major focus in my office is on hyperpigmentation that’s still lingering on my patients’ skin into the winter months. Specifically, melasma, also called the “pregnancy mask”, is common and can be incredibly frustrating. 

Melasma is a type of hyperpigmentation which is characterized by dark brown or gray-brown patches of skin on your cheeks, forehead, upper lip, or along the lower cheeks and jawline. My patients often describe it as having the appearance of “paint splatter” on their skin.  The excess pigment can be in the upper layers of your skin, or the deeper layers, or both. If you have excess pigment in the deeper layers, that can be much more challenging to treat.

A question I’ve been getting all the time on this subject is: Should I use retinol or bakuchiol if I have melasma?

Whereas retinol can be a bit of a diva in that it can be an irritant. Anyone who has tried a retinol has been there: you use it liberally for a few nights in a row and think: “No big deal! What’s all the fuss? My skin is doing fine.”  Then, about 4-5 days in, you find your regular moisturizer that you use all the time is making you red, blotchy and stings like crazy when you apply it. Then, you start to see the flakes, and you officially have a full blown case of “retinoid dermatitis!”

The new kid on the block, bakuchiol, is not irritating in the same way, and has been found to actually help soothe irritated skin!  When compared to retinol, bakuchiol is also very effective at reducing hyperpigmentation. This is so important because we know that irritation can actually exacerbate your melasma, making it worse. So although retinoids are so great at lightning the skin, it was always a delicate balance between getting the benefits without creating inflammation which we know could set melasma patients back.  

Now, we don’t have the same mountain of evidence for bakuchiol as we do for retinol because bakuchiol is so new on the scene, but the studies I’ve seen have been very, very promising and exciting on this front.

Also, bakuchiol is a great option for hyperpigmentation/melasma patients because it is not photosensitizing, meaning it won’t make your skin more susceptible to sun damage. Many retinol products, in contrast, are best used at night because they can make your skin more sensitive to the sun. 

Third, bakuchiol acts as an antioxidant, which is very beneficial for melasma patients given that oxidative stress and free radicals contribute to melasma. 

Finally, pregnancy and nursing often coincide with melasma (also known as the “pregnancy mask”), but we do not recommend use of retinol if you are pregnant or nursing. So, bakuchiol is a great option to help dial down melasma while you are pregnant or nursing. 

Here are some of my favorite bakuchiol products: 

Herbivore Botanicals Bakuchiol Retinol Alternative Serum-very lightweight, easily layers under your moisturizer.

Beauty Counter Countertime Tripeptide Radiance Serum 

You guys have asked so many great questions about melasma, so keep ‘em coming!

 

Dr. Whitney

As a dermatologist, a mom and a skincare lover, I am making a conscious effort to transition towards products that are not only safe for the skin, but also better for our bodies and to the environment.

I want to share my deep dive into clean beauty with you guys, as I educate myself on all things “clean.” One of the biggest issues I’ve been noticing in the clean space is that there is so much “greenwashing” and misinformation out there. I’m incredibly evidence-based and have always taken pride in making recommendations that are backed by sound science. My clean skincare journey is no exception, so I wanted to connect with the pioneers in this space and share their insight and knowledge with you!

My first Q & A on clean had to be with my friend and colleague, Mia Davis. Mia is not only one of the pioneers of “clean”, but her approach to her work is so innovative and thoughtful, it is just incredibly impressive. I know you guys will be as blown away by Mia as I am. I’m so thrilled to share this interview with you.

WB: Mia, your passion for clean began in 4th grade and you have been moving the needle ever since. You were the first hire at Beautycounter, you’ve consulted for goop, Honest Company, type A . . . and the list goes on. Now, at Credo Beauty, you’ve created the Credo Clean Standard and you lead the Credo “brand’s consortium,” which addresses key challenges in this industry, from fragrance disclosure to more sustainable packaging. I think it’s safe to say that you live and breathe all things clean beauty. How do you define the term clean?

Mia Davis: Clean is an evolution of natural, green, or eco—those are elements of clean, but it goes much further. To me, clean is nexus of these important elements: safety, sourcing, sustainability, ethics and transparency. A little more about these:

  • Safety is about the ingredient’s potential impact on health.
  • Sourcing is where it comes from—is it a synthetic chemical? A natural compound? Or naturally-derived?
  • Sustainability comes back to the ingredient’s impact on the environment.
  • For Ethics, questions include “were people paid a living wage to mine or harvest this ingredient?” or if the ingredient it comes from animals, “how were the animals treated?”
  • And transparency is really the web that holds these other terms together. If we don’t have transparency about the ingredients or the supply chain, how can we know it is “clean?” We cannot make an informed decision without information.

Check out this “Clean Beauty” infographic I made with Credo Beauty that illustrates all of this!

WB: I love the way that you share all of this information in a way that is accessible, clear, and beautifully stated. I absolutely agree that any brand that calls itself “clean” should consider those factors very carefully. When it comes to sourcing: can you elaborate on how you feel about ingredients that are natural vs naturally-derived vs synthetic?  I personally have seen numerous patients develop skin reactions when switching from synthetic to natural products.  Do you agree that when it comes to skin health, natural is not always better?

Mia Davis: Thanks—I know my definition of clean is complex—there is a lot to consider. But it is also the most honest approach! Your question about natural vs. synthetic really gets right to the point. If we only talk about an ingredient’s “natural-ness” but not about its safety or sustainability, then we’re missing the point of “clean.” Natural ingredients can be irritating, for sure. They can even be unsustainability, or unethical.  Some ingredients can be perfectly safe and natural for one person, and not for another person who might have sensitivities to it. So, I embrace the complexity—otherwise, it is just marketing.

WB: I have been searching and testing a variety of clean products over the last year, and trying to transition my own skincare to clean products.  Since “clean” is not an FDA regulated term (and in fact, the entire beauty industry is pretty under-regulated), different brands and different retailers are adopting different definitions.  For example, Sephora Clean is different from Target Clean is different from Credo Clean. I know you’ve been a trailblazer in this area, and many experts consider Credo’s standards to be among the most discerning — the “highest standards” of clean, if you will!  Can you elaborate a bit on the standards that Credo has adopted and how they differ from other brands and retailers that use the term clean?

Mia Davis: Credo, the largest clean beauty retailer, has a Clean Standard that operationalizes “clean,” so you know that the brands Credo carries have accountability. Outside of some system of accountabilty, “clean” can mean something or nothing. People have to look into the brand’s commitments. For example, are they formulating without ingredients of concern, like parabens, phthalates and more? Are they disclosing their “fragrance” ingredients? Do they talk about the source and safety of ingredients? Ask the brand what “clean” means to them. If the answer is wishy-washy, that is a red flag.

WB: Thank you so much for sharing your knowledge on this topic! I know we’ll go deeper into all of the clean elements—safety, sustainability and more—in the near future. I always value our discussions so much.

Mia Davis: Thank you so much for having me, and for sharing your clean skincare journey with your patients and community. What we put on our bodies and rinse down the drain matters, and how we make these ingredients in the first place really matters too.

 

 

 

 

Cellulite is one of those topics that dermatologists find frustrating.  We are very solution driven, and up until now, there haven’t been many effective long term solutions for cellulite.  All the creams and gadgets out there claiming to help with cellulite are more hype than reality, and the in-office procedures that actually work have been, for the most part, somewhat invasive to the point that most patients are turned off by the process.

So, you can imagine, I was pretty pumped to learn about a new FDA approved injectable treatment for cellulite… yes, an injection, similar to Botox and Dysport, injections I do all day long… that can be done in the office and dramatically improve the appearance of cellulite.

Caveat: Whenever things are new, they tend to be hyped up and marketing tends to focus on all the good without doing justice to the bad.  We also tend to learn about the downside of procedures long after they launch… sometimes it takes a full year or more to really assess the real life efficacy and safety of a new treatment.

That being said, this is pretty exciting! Let’s break it down together.

First, some groundwork. What is cellulite? 

There’s a major misconception out there that cellulite is caused by diet or lack of exercise.  That’s totally not the case- stop blaming yourself for your cellulite!

Cellulite is caused by the outpouching of fat lobules under the skin.  So we have a layer of fat under the skin, and there are bands of collagen called septae that attach the skin to the underlying layer of fascia.  So imagine a sort of sandwich—the skin on top, the fascia on the bottom.  These fibrous septae run up and down and tether the two together.  Where the septae tug on the skin, that’s where you see a dimple. In between the dimples are bulges of fat pooching up (protrusions of fat). So you’re left with an uneven surface.  There are some shadows and some bulges.  That’s cellulite. These fibrous septae are oriented differently in women as compared to men, so almost ALL women get cellulite whereas lass than 10% of men get it. About 9 out of 10 women have cellulite, and it affects women of all races and ethnicities and all shapes and sizes. Yes, you can be thin, muscular, in great shape and still have cellulite!

Why do we care?

Cellulite can have a major impact on self-esteem and confidence. And no surprise here: we blame ourselves!  Studies show that the majority of women are convinced it’s THEIR FAULT they have cellulite!

What can we do about it and what is Qwo? 

Yes, there are topical treatments and devices that can temporarily improve the treatment of cellulite.  Any time you boost circulation to the area, or any topical ingredients that stimulate blood flow or help to thicken the dermal layer of the skin can make the area look better.  The thing is that most creams and lotions on the market, and most at home devices, only give you a temporary improvement.  If they do create lasting changes, those results are very subtle.

So what’s Qwo?  It’s the first FDA approved injectable for cellulite. It just got FDA approval for moderate to severe cellulite in the buttocks of adult women. Will we end up using it off label for the thighs or the arms?  Maybe!  It’s still super early so that remains to be seen.

Qwo uses an enzyme called collagenase that targets types 1 and 3 collagen, so it basically eats away at or dissolves those fibrous collagen bands tethering the skin down.  I think it’s so interesting how we are trying to fight these types of collagen degrading enzymes in the skin, face and neck, but when it comes to cellulite, we want them to chew away at the collagen.  You can see the collagen band dissolving in the images below:

The trials to evaluate Qwo are the largest cellulite studies every conducted with 845 participants, and I REALLY love that about a third of the participants have skin of color.  So many procedures are only studies on white skin, and that’s not ok.  Darker skin types have different reactions- especially things like hyperpigmentation- that need to be carefully studied so we, dermatologists, can counsel those patients appropriately about the possible risks and side effects.

So what are the risks?

So far we’re seeing mainly tenderness, bruising, some discoloration which I’m SURE will be more common in skin of color, and of course swelling. This is probably a treatment you’re not going to want to do during the summer because a bruise in the buttock or thigh area can last up to 3 weeks and bruising seems to be pretty common. The protocol involved about 3 rounds of injections, spaced 3-4 weeks apart.

Cost?  Big question mark!  We shall see when it becomes commercially available—the thought is probably Spring 2021.

The studies are still ongoing to assess how long the results will last and to assess long term safety.

So what’s my take home?

I am very excited by the photos and clinical results I’ve seen thus far. It seems to be very effective even for severe cellulite. Here are some images the company shared with me:

I like that it’s an injectable.  I consider myself an expert injector, and I feel right at home with a syringe in my hand.  I can’t imagine incorporating this into my practice will be a challenge whatsoever from a skill and technique standpoint.

I like that it’s getting to the underlying root of the problem- the septae.  It has the potential to truly deliver long term results- we’re talking years if not permanent.

I’m worried about the cost—I suspect this will be pretty pricey, especially since there isn’t a competitor on the market yet in this space. Hopefully other companies will come out with competitive molecules, but until then, these guys are going to corner the market and that always leads to high prices.

Side effects: we need to really asses how severe the swelling, bruising and tenderness are, and how often it leads to hyperpigmentation – and how long it takes for those dark spots to lighten up.  My patients with skin of color who suffer from hyperpigmentation after a bug bite or scratch or pimple sometimes find the stain left over for months is worse than what caused it in the first place.

Stay tuned! I promise to update you guys on this as new info comes out.  For now, stick with self-tanners and cellulite creams and a cute skirt or flattering shorts!  And, please stop blaming yourself if you have cellulite.  WE ALL DO.  You’re in good company.

Check out my video with more info right here!

Dr. Whitney

During my Bowe Glow Boot Camp, my dear friend, David Kirsch, shared fitness and healthy cooking tips each week. David and I have known each other for years and every time I have the opportunity to see him or speak to him, I adore him even more. He’s not only an incredibly inspiring and talented trainer — to celebrities including J. Lo, Liv Tyler, and Heidi Klum – but he’s also a natural teacher. He has connected with so many people during quarantine through virtual platforms like HoneyComb.Fit and through his Instagram page – providing free workouts and tips to keep us all motivated, healthy, and moving. One of the most beautiful things about David is his role as a Mapa to his absolutely beautiful twins, Francesca and Emilia.

I am so honored to share this interview with you:

WB: In many homes, it’s a constant battle right now between screen time and staying physical.  How do you get your girls off their screens and convince them to be active? 

DK: So, full disclosure, there is still the occasional battle over screen time with Emilia and Francesca.  That said, my girls have grown up watching me exercise – both in the gym, at home and on vacation.  They have been organically exposed to the importance of moving your body a little every day.

WB: Do you think that people will return to gyms and working out with personal trainers in facilities in the same way they did pre-Covid?  What do you think people miss most about those in person workout experiences as compared with the remote training people have been doing from home? 

DK: I don’t think that things will completely go back to pre – Covid ways.  I think there is and will be genuine concern and monitoring of the number of bodies in the gym at any given time.  I think the thing that people miss the most about going to the gym is the social aspect and the overall general positive energy.  I have worked ‘overtime’ to try to create the energy, intimacy and vibe through my Zoom training sessions.

WB:  What’s your plan to return to training people in person?  Will you and your clients wear masks during the session?  Any tips for using a mask during times when people are really exerting themselves? 

DK: I think for the immediate future and for some time after, we will be masked and be socially distant and maintain a high level of personal hygiene.  I think masks are going to be extremely important, especially when people are exerting themselves – exhaling hard, and, at times, ‘spraying some saliva.’

WB: Do you have a go-to breakfast that Emilia and Francesca love and that you also feel good about giving them in the morning? We loved your frittata recipe and would love more of your insight! 

DK: Francesca and Emilia’s favorite go-to breakfast is avocado toast!!  My girls don’t like eggs, so my frittata doesn’t work for them.  I am a huge believer in healthy, substantial breakfasts.  Some of my favorites: frittata with whatever is in the fridge; avocado toast with hard boiled eggs, and Kite Hill unsweetened vanilla almond milk Greek yogurt with some seeds and fresh almond butter.  My girls are quite comfortable and competent in the kitchen, so I let them create at will.

WB: Do you have a mantra that keeps you motivated? Do you share a mantra with Emilia and Francesca?

DK: “It is better to conquer yourself than to win a thousand battles” — Buddha

WB:  What does your own personal workout schedule usually look like in a week? 

DK: My workouts have been shortened and are more frequent now.  I have turned my living room into a home gym with some hand weights, kettle bells, a strength band and a medicine ball.  All that said, my favorite purchase was a pull-up bar that I need to pass every time I leave my bedroom.  I workout via Zoom with a friend of mine no less than 5 days a week for at least 30 – 45 minutes.  Additionally, we ‘push’ each other to do at least 100, but most days, 200 pull-ups.  Last, in addition to my personal workouts, I often workout along with my clients.

WB: What type of activities do the girls like to do to stay active?

DK: Emilia loves to dance and she’s got those TikTok moves down (unofficially, as I won’t let her have an account).  Francesca loves doing Live workouts and has gotten quite good at it!  They both love to swim, play tennis and softball.

WB: What’s the one tip you would give families right now who are struggling to stay active? 

DK: It just takes a few minutes to get off of the sofa, put down the devices and MOVE your body!  It could be a walk, bike ride, or a swim in the pool.  Do it as a family, 5 – 10 minutes a day and build up from there.  You’ll have better energy, have a more positive outlook, be less stressed and look and feel healthier.

WB: Tell us more about Honeycomb and these amazing free workouts?

DK: HoneyComb.Fit was born out of the idea of creating a fully comprehensive health, wellness and lifestyle destination. We realized the best way to disseminate this philosophy was through social media. Mark Messier is one of the founding partners. Stacey Griffith, Tracy Carlinsky, and I have been offering exclusive, free workouts for almost four weeks now and the feedback has been good, as the buzz and our following is steadily growing.  After over thirty years in the fitness industry, I have truly enjoyed the opportunity to reach out to so many people around the world that wouldn’t otherwise have a chance to train with me.  I am so proud to be part of the HoneyComb family!!  In the next coming weeks, we will be inviting guest trainers with a variety of different exercise disciplines to join the team and share their expertise.

WB: What is one thing you’ve learned about yourself as a trainer during quarantine? 

DK: The most important thing I’ve learned about myself during quarantine is that I have discovered my love and passion for online training.  I was born to teach and I have conquered my initial trepidation of “talking” to my iPhone, and thoroughly enjoy the relatively new medium.

WB: What is one thing you’ve learned about yourself as a parent during quarantine?

DK: The one thing I have learned about myself as a parent during quarantine – in spite of the moments, and there are some, I love, appreciate and am grateful for the time I have gotten to spend with Emilia and Francesca.  Real quality time of laughing, loving, cooking together, exercising together, and just quality quiet time.  I have honed the art of patience, and realize that I am not always the perfect Mapa.  By the way, the art of good parenting is not about perfection, but striving to do your best, and remembering to say “I’m sorry, and daddy loves you always and forever” when I have those moments and ‘lose my xxxxx.’

And now you can see why I love David so much!! Be sure to check out his insta page because you will become as hooked on his workouts – and family workouts- as we are!

The subject of how our diet impacts the health of our skin has been incredibly important to me. I’ve been very vocal about this subject – even writing a book centered around the GUT-BRAIN-SKIN axis called The Beauty of Dirty Skin.

However, many dermatologists have remained skeptical about this connection because they felt that the data wasn’t strong enough to convince them to change their practice.  A new study, just out in JAMA, may finally change that.

This large, robust, epidemiological study AGAIN shows that adult acne is, indeed, associated with high glycemic index (e.g. sugary) foods and beverages as well as dairy milk.  Those findings appear consistent with prior studies as well, so this didn’t come as a surprise to me!

With the trending term “Maskne,” and all the stress we’ve been living with over the last few months, conversations about acne have hit a record high in my practice and in my direct message inbox on Instagram.  Adult acne, in particular, has been increasing in prevalence over the years, and it can really take a toll on quality of life, self-esteem and confidence.

Most observational studies to date looking at the link between diet on acne look back (retrospective design), this one looks forward.  It has what’s called a prospective design.  That prospective design, combined with the very large number of people involved (over 24,000 participants), and the wide number of dietary factors taking into account, makes these results hard to ignore.

As someone who sees the powerful effect of acne on lives every day, I firmly believe that educating patients on these associations between their diet and their skin are helping way more than hurting.  I personally don’t feel the need for a large scale clinical trial to further prove these associations. I believe if we keep waiting for “perfect” studies to be done, we will end up with many more emotional, and physical scars that could have been avoided through simple, accessible changes.

 

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