Latest / Clearly Hormonal / Ep 33: Midlife Skincare with Dr. Sarah Stierman

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Ep 33: Midlife Skincare with Dr. Sarah Stierman · Clearly Hormonal

• 0:02
  Dr. Komal Patil-Sisodia: Welcome to Reset Recharge, the podcast where women's health takes center stage.
• 0:07
  Dr. Komal Patil-Sisodia: I'm your host, Dr.
• 0:08
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, a triple board certified endocrinologist and women's health expert.
• 0:13
  Dr. Komal Patil-Sisodia: This show is all about empowering you with the knowledge to understand your metabolic health, navigate hormonal changes, and feel confident in the conversations you're having with your healthcare provider.
• 0:24
  Dr. Komal Patil-Sisodia: Whether you're managing symptoms, exploring treatment options, or just want to feel more in tune with your body, you're in the right place.
• 0:31
  Dr. Komal Patil-Sisodia: As a physician, my goal is to educate on this podcast.
• 0:34
  Dr. Komal Patil-Sisodia: The content shared here is for informational purposes only and should not replace personalized medical advice.
• 0:41
  Dr. Komal Patil-Sisodia: If something we discuss resonates with you, please talk to your healthcare provider at your next visit.
• 0:46
  Dr. Komal Patil-Sisodia: Now let's dive in and help you reset, recharge, and take control of your health.
• 0:55
  Dr. Komal Patil-Sisodia: Hi everyone.
• 0:55
  Dr. Komal Patil-Sisodia: Welcome back to Reset Recharge.
• 0:58
  Dr. Komal Patil-Sisodia: I am excited to introduce our guest for today's episode to Sarah Stierman.
• 1:03
  Dr. Komal Patil-Sisodia: She is a board certified dermatologist, dermatopathologist, and president of her busy northwest Ohio independent private practice.
• 1:12
  Dr. Komal Patil-Sisodia: She's originally from Ohio, and attended University of Toledo College of Medicine.
• 1:19
  Dr. Komal Patil-Sisodia: And graduated from there with her doctorate in medicine, did her residency at Riverside Methodist, and then did her dermatology training at Wayne State University in Detroit.
• 1:30
  Dr. Komal Patil-Sisodia: She then did a fellowship in Dermatopathology and she's board certified in both dermatology and dermatopathology.
• 1:36
  Dr. Komal Patil-Sisodia: We met in a physician moms group Style MD where it was focused on fashion and fun things.
• 1:43
  Dr. Komal Patil-Sisodia: And, Sarah made this amazing post about, skincare and how we should layer it.
• 1:49
  Dr. Komal Patil-Sisodia: And I think everybody was just like, oh my gosh, who is this woman?
• 1:53
  Dr. Komal Patil-Sisodia: It kind of shot you to a little bit of notoriety in our group, which was great.
• 1:56
  Dr. Komal Patil-Sisodia: She has a special interest in clinical pathologic correlation of disease, the microbiome and medical grade skincare.
• 2:04
  Dr. Komal Patil-Sisodia: So I invited her on the podcast to talk about all the skincare things that we want to know as we're navigating perimenopause and menopause, because we do actually go through quite a bit of change in terms of our skin texture and things like that.
• 2:20
  Dr. Komal Patil-Sisodia: Welcome Dr.
• 2:20
  Dr. Komal Patil-Sisodia: Stierman, and, thank you for being here today.
• 2:23
  Dr. Komal Patil-Sisodia: I'm so excited.
• 2:23
  Dr. Sarah Stierman: Thanks.
• 2:26
  Dr. Komal Patil-Sisodia: Did I miss anything in your background that you wanna talk about?
• 2:30
  Dr. Sarah Stierman: The past is always the past it's so interesting to be practicing medicine in this timeline and especially practicing dermatology.
• 2:39
  Dr. Sarah Stierman: It's phenomenal and I am so incredibly fortunate and grateful to have the job that I do.
• 2:46
  Dr. Komal Patil-Sisodia: There's so much technology and innovation that's happened, over the last several years, and I love hearing from you what we need to be doing and how the recommendations have changed over time.
• 2:57
  Dr. Komal Patil-Sisodia: So let's dive right in.
• 2:59
  Dr. Komal Patil-Sisodia: For skincare as we mature, one of the big issues I, hear from my.
• 3:03
  Dr. Komal Patil-Sisodia: Patients is the elasticity and my skin doesn't look the same, I'm not glowing the same or it's drier.
• 3:09
  Dr. Komal Patil-Sisodia: What are the changes happening during this timeline in our life?
• 3:13
  Dr. Komal Patil-Sisodia: Let's talk a little bit through that so we understand, the hormonal connection between skin.
• 3:17
  Dr. Sarah Stierman: So estrogen is, incredibly important for skin health elasticity, barrier, function.
• 3:25
  Dr. Sarah Stierman: As women transition through perimenopause menopause and post menopause, the falling estrogen levels directly affect the skin.
• 3:33
  Dr. Sarah Stierman: You develop more dryness, you're more likely to develop, barrier dysfunction, which means that you're more likely to have sensitive skin even if you've never had sensitive skin before the skin will thin over time as well, as we start losing collagen and elastin.
• 3:48
  Dr. Sarah Stierman: Your fibroblasts, which are your collagen factory cells, start getting lazy around age 26.
• 3:55
  Dr. Sarah Stierman: I know.
• 3:55
  Dr. Sarah Stierman: It's so not fair.
• 3:58
  Dr. Sarah Stierman: Even a decade before many women start to experience other symptoms of perimenopause, your collagen factory is already slowing down combine hormonal changes with UV radiation.
• 4:11
  Dr. Sarah Stierman: And a lot of the aging changes, like hyperpigmentation and elastic damage to the face, we see compounded by decades of cumulative UV exposure.
• 4:23
  Dr. Sarah Stierman: By the time, you hit your forties, you're looking at decades of direct sun exposure that have snuck up on you,
• 4:30
  Dr. Komal Patil-Sisodia: Yeah.
• 4:31
  Dr. Komal Patil-Sisodia: And we kind of grew up at a time where tanning beds were definitely a thing.
• 4:35
  Dr. Sarah Stierman: for prom, for spring break for the beginning of the summer where I'm just gonna get that quote unquote base tan so that I don't burn on vacation or if I'm gonna be outside.
• 4:45
  Dr. Sarah Stierman: Well, I am here to confirm that there is no such thing as a healthy tan.
• 4:51
  Dr. Sarah Stierman: A tan actually denotes DNA damage externally.
• 4:55
  Dr. Sarah Stierman: People are like, well, I just get a little bit of color.
• 4:57
  Dr. Sarah Stierman: And I'm like, well, that's DNA damage.
• 5:01
  Dr. Sarah Stierman: And can, can your immune system and your body and your repairative cells do a reasonable job of repairing DNA damage?
• 5:08
  Dr. Sarah Stierman: But if you continue to allow it to be inundated by DNA damage through direct sun or UV exposure daily, then you're really doing yourself an incredible disservice.
• 5:19
  Dr. Sarah Stierman: I have a lot of women who do come to see me who have concerns about facial, especially facial aging, but then face, neck, chest, hands, often areas that are constantly sun exposed.
• 5:30
  Dr. Sarah Stierman: They're like, what can I do?
• 5:31
  Dr. Sarah Stierman: And in my head I'm like, short of a time machine.
• 5:35
  Dr. Sarah Stierman: Well, I think we would all love a time machine, but short of that, where you could go back in time and tell teenage you to start wearing sunscreen every single day, it's the best thing we can do for our skin.
• 5:49
  Dr. Komal Patil-Sisodia: Absolutely.
• 5:49
  Dr. Komal Patil-Sisodia: I remember when I first saw your posts about the skincare regimens you thought were optimal, and I realized that I had no SPF in any of my skincare regimen.
• 6:00
  Dr. Komal Patil-Sisodia: I'll tell you I have been so dialed in on my sunscreen I live in Seattle, so if I'm doing it, everybody should be doing it I can tell you that.
• 6:07
  Dr. Komal Patil-Sisodia: Same, same, oh, that's right.
• 6:08
  Dr. Komal Patil-Sisodia: 'cause you guys don't get a whole lot of, sunny days either, comparatively.
• 6:12
  Dr. Komal Patil-Sisodia: so now that you've nicely explained what those skin changes are, let's talk about what you think are good things that we can start doing for our skin as it starts aging, right?
• 6:22
  Dr. Komal Patil-Sisodia: Because we know that the collagen factories have long shutdown, sadly, I think it's been like 20 years for mine.
• 6:30
  Dr. Komal Patil-Sisodia: So, collagen factories are shutting down.
• 6:32
  Dr. Komal Patil-Sisodia: We have all this photo damage, we're seeing the changes as our hormones change, what are the things that we need to, let's talk about what a good baseline skincare regimen is.
• 6:41
  Dr. Komal Patil-Sisodia: Just for any woman, we can even go back to twenties or thirties, what you would recommend there.
• 6:45
  Dr. Komal Patil-Sisodia: And then let's talk about how we need to shift that as we hit our forties, fifties.
• 6:50
  Dr. Komal Patil-Sisodia: Absolutely.
• 6:50
  Dr. Sarah Stierman: I think the key components of any healthy skin regimen.
• 6:55
  Dr. Sarah Stierman: Includes spf and so SPFI, I know I'm gonna harp on s SPF so much during this episode, but it's really that critical.
• 7:03
  Dr. Sarah Stierman: Yes.
• 7:03
  Dr. Sarah Stierman: Sunscreen, SPF 30 or higher is the bare minimum recommended by the American Academy of Dermatology for daily UV radiation protection.
• 7:12
  Dr. Sarah Stierman: It used to be 15, but now we know there is a clinically appreciable difference in the level of protection you get between SPF 15 and SPF 30.
• 7:21
  Dr. Sarah Stierman: There also is a statistically significant difference between SPF 30 and SPF 50, but when you get above 50, there doesn't really have as much of a statistical difference the FDA has changed the labeling of sunscreens or has approved it differently.
• 7:35
  Dr. Sarah Stierman: Where now you'll often see s pf 50 plus.
• 7:38
  Dr. Sarah Stierman: Because the difference, right?
• 7:40
  Dr. Sarah Stierman: So the difference between an SPF of a hundred and an SPF of 80 is not incredibly high.
• 7:46
  Dr. Sarah Stierman: So it you could, SPF 50 plus is fantastic.
• 7:49
  Dr. Sarah Stierman: So 30 or higher we recommend every single day with reapplication, which is the key component most people are missing.
• 7:57
  Dr. Sarah Stierman: If you are going to be outside during peak sun hours in Seattle and Ohio, yeah, that's probably about 10 to two during the winter and 10 to four during the summer.
• 8:09
  Dr. Sarah Stierman: Maybe even nine to four during the summer.
• 8:11
  Dr. Sarah Stierman: If your shadow is shorter than you are, you really should be seeking shade.
• 8:16
  Dr. Komal Patil-Sisodia: Ooh, I never heard the shadow rule, yeah, tell me more about that.
• 8:19
  Dr. Sarah Stierman: It's the way that the direct rays of the sun hit the surface of the earth, and so if your shadow is shorter than you are, you can pretty much guarantee you're outside during peak sun.
• 8:27
  Dr. Sarah Stierman: So, SPF is clearly the cornerstone of any sort of healthy skin regimen as we start to get into those.
• 8:35
  Dr. Sarah Stierman: Eras of our life where our collagen factory has started to slow down.
• 8:40
  Dr. Sarah Stierman: After the age of 26, when we're talking about thirties, forties, fifties and beyond, the next most important component of a healthy skin anti-aging regimen is a topical retinoid.
• 8:52
  Dr. Sarah Stierman: Topical retinoids go by many different names.
• 8:55
  Dr. Sarah Stierman: Tretinoin is the gold standard retinoid for improvement of facial skin and reduction arid disease, which is the fancy medical word for wrinkles.
• 9:06
  Dr. Sarah Stierman: So Tretinoin was actually FDA approved for wrinkles, cosmetically in 1969, I believe, was the sentinel paper.
• 9:15
  Dr. Sarah Stierman: And so it has decades of data behind it being the most critical and important prescription grade, ingredient for skin health.
• 9:25
  Dr. Sarah Stierman: Retinoids help with skin turnover.
• 9:28
  Dr. Sarah Stierman: They change the way that your skin matures, and they also stimulate collagen.
• 9:33
  Dr. Sarah Stierman: You can wake some of those lazy fibroblasts back up by using a retinoid.
• 9:37
  Dr. Sarah Stierman: Retinoids are to be used at bedtime only.
• 9:40
  Dr. Sarah Stierman: They are not a daytime sort of treatment, for two reasons.
• 9:44
  Dr. Sarah Stierman: Number one, they can make you more photos sensitive.
• 9:47
  Dr. Sarah Stierman: And number two, the vast majority of topical retinoids actually are not photos stable.
• 9:52
  Dr. Sarah Stierman: And so if you go outside in the sun, it'll break down and you'll get side effects, but you won't get results.
• 10:00
  Dr. Komal Patil-Sisodia: That's unfortunate.
• 10:01
  Dr. Komal Patil-Sisodia: I did not know that actually.
• 10:02
  Dr. Komal Patil-Sisodia: It's like completely useless then and maybe a little harmful.
• 10:04
  Dr. Sarah Stierman: Yeah.
• 10:04
  Dr. Sarah Stierman: Now for people who do not tolerate, retinoids because they help with skin turnover very frequently.
• 10:10
  Dr. Sarah Stierman: They can cause initial irritation until you get used to the product.
• 10:15
  Dr. Sarah Stierman: They can also cause peeling redness and irritation, and so there are definitely different ways that we can help people begin to tolerate a topical retinoid, or there are also now some new retinoid alternatives that are non retinoid, but similar mechanism of action that are available on the market which are incredible.
• 10:36
  Dr. Komal Patil-Sisodia: Okay.
• 10:36
  Dr. Komal Patil-Sisodia: That's fantastic.
• 10:37
  Dr. Komal Patil-Sisodia: And with the retinol, so they're stimulating the collagen and then creating that turnover.
• 10:42
  Dr. Komal Patil-Sisodia: I was one of those people when I first started.
• 10:44
  Dr. Komal Patil-Sisodia: I had a little bit of irritation.
• 10:46
  Dr. Komal Patil-Sisodia: What do you recommend for people who are getting irritated from the retinoid, like doing it once or twice a week?
• 10:52
  Dr. Komal Patil-Sisodia: I've also heard you can mix it in with your moisturizer or you can layer it in a different way so it's not.
• 10:57
  Dr. Komal Patil-Sisodia: Irritating your skin as much, what are your recommendations?
• 10:59
  Dr. Sarah Stierman: Lot of recommendations that are out there floating out there, and some of them I find to be very utilitarian, and some of them I find to either not help or be untrue.
• 11:09
  Dr. Sarah Stierman: So let us dispel some of this.
• 11:11
  Dr. Sarah Stierman: When we're talking about active ingredients in skincare, whether they are prescription or over the counter, it doesn't matter.
• 11:17
  Dr. Sarah Stierman: When we talk about an active, we really don't like to mix things.
• 11:21
  Dr. Sarah Stierman: We like to layer.
• 11:22
  Dr. Sarah Stierman: The reason that we like to layer rather than mix is mixing, dilutes the active, right?
• 11:27
  Dr. Sarah Stierman: If you're mixing your tretinoin, cream with a moisturizer to make it more tolerable, you could be cutting its strength by who knows how much.
• 11:36
  Dr. Sarah Stierman: Because it's not regulated.
• 11:38
  Dr. Sarah Stierman: It's not like a dosed compound when you do that.
• 11:41
  Dr. Sarah Stierman: So I like to layer, the first thing I tell patients, whether they're teenagers, because of the cell turnover thing, we prescribe topical retinoids for acne as well.
• 11:51
  Dr. Sarah Stierman: This is the same advice I give to a lot of my teenage patients, let alone my mature female patients.
• 11:56
  Dr. Sarah Stierman: So I definitely would be gentle with your choice of cleanser prior to a retinoid.
• 12:03
  Dr. Sarah Stierman: We're talking about an evening routine at this point, because we know topical retinoids are applied at bedtime only.
• 12:08
  Dr. Sarah Stierman: So gentle cleanser, rinse really well, but then wait until your skin is dry before you apply any of your products in the evening.
• 12:18
  Dr. Sarah Stierman: You don't wanna apply active products to a wet face simply because your barrier isn't completely pH balanced yet if you've just washed your face.
• 12:27
  Dr. Sarah Stierman: And so you do need to allow it to settle a little bit so that it's not irritating.
• 12:31
  Dr. Sarah Stierman: Putting actives on a wet face tends to be very irritating.
• 12:34
  Dr. Sarah Stierman: So waiting until your skin is dry and then.
• 12:38
  Dr. Sarah Stierman: Yeah, moisturizer is a retinoids friend.
• 12:41
  Dr. Sarah Stierman: When we talk about moisturizers, there are many different ingredients.
• 12:45
  Dr. Sarah Stierman: From glycerin and cholesterol to ceramides because if you think of your skin as a brick wall and your skin cells are the bricks and there's mortar between those bricks, the mortar that holds your skin barrier together is actually vastly composed of lipid or fat.
• 13:02
  Dr. Sarah Stierman: The most frequent concentration of fat in the skin lipid barrier is ceramide.
• 13:07
  Dr. Sarah Stierman: That's why ceramide is such a powerful ingredient in moisturizers because not only does it hydrate, it helps with barrier dysfunction, which happens to all of us as we age, especially those of us who are estrogen deficient.
• 13:22
  Dr. Komal Patil-Sisodia: Yeah.
• 13:22
  Dr. Komal Patil-Sisodia: And with barrier dysfunction, can you break that down a little bit?
• 13:26
  Dr. Komal Patil-Sisodia: Or like what does that exactly mean for, the average person that comes into your office?
• 13:31
  Dr. Komal Patil-Sisodia: How do you describe what barrier dysfunction is?
• 13:32
  Dr. Sarah Stierman: Can be genetic as in the case of atopic dermatitis or eczema.
• 13:36
  Dr. Sarah Stierman: Those people have a genetic deficiency in a molecule called rin.
• 13:40
  Dr. Sarah Stierman: That's another component of the skin barrier.
• 13:42
  Dr. Sarah Stierman: But those of us who start having barrier dysfunction with age, it is that lipid loss due to falling estrogen levels in the skin.
• 13:50
  Dr. Sarah Stierman: And when your barrier is not completely intact, you can think of it like cracks in your wall, right?
• 13:55
  Dr. Sarah Stierman: Cracks in your brick wall.
• 13:57
  Dr. Sarah Stierman: Right.
• 13:57
  Dr. Sarah Stierman: And then moisture gets in and out we call that TEWL or trans epidermal Water loss.
• 14:04
  Dr. Sarah Stierman: And that is a key component of barrier dysfunction because the human body is made up of so much water and the skin is a big part of that too.
• 14:12
  Dr. Sarah Stierman: Yeah.
• 14:12
  Dr. Sarah Stierman: So moisturizer is a retinoids French for sure.
• 14:15
  Dr. Sarah Stierman: I definitely encourage people to moisturize, but layer not mix when they're trying to get used to a retinoid.
• 14:22
  Dr. Sarah Stierman: Pea-sized amount of a topical retinoid.
• 14:24
  Dr. Sarah Stierman: Only more is not more with these get a pea-sized amount on your finger and make little polka dots on your face with just that pea-sized amount, avoiding really close to the eye.
• 14:36
  Dr. Sarah Stierman: And mouth.
• 14:37
  Dr. Sarah Stierman: Some people do get a little irritated in their nasal labial folds as well.
• 14:41
  Dr. Sarah Stierman: So those are areas where we tend to not slather on a topical retinoid.
• 14:45
  Dr. Sarah Stierman: Another popular buzz term over the last, five to 10 years is slugging.
• 14:50
  Dr. Sarah Stierman: I'm sure you've heard this.
• 14:52
  Dr. Komal Patil-Sisodia: About that.
• 14:53
  Dr. Komal Patil-Sisodia: Yes.
• 14:53
  Dr. Komal Patil-Sisodia: Because I was like, that just looks like a ton of Vaseline on your face.
• 14:56
  Dr. Sarah Stierman: when it comes to tolerating retinoids very frequently we'll put a thick moisturizer, if not Vaseline or Aquaphor around the canthi of the eyes.
• 15:05
  Dr. Sarah Stierman: So around the lateral aspects of the eye, where the skin is really thin and delicate, and then your lips as well.
• 15:11
  Dr. Sarah Stierman: You can even put it right here in the corners of your nose to create a barrier between you and a retinoid.
• 15:18
  Dr. Sarah Stierman: That is my slugging advice.
• 15:19
  Dr. Sarah Stierman: I don't like to slather the entire face in occlusive Vaseline unless we're talking post procedure.
• 15:24
  Dr. Sarah Stierman: That's a different conversation.
• 15:26
  Dr. Sarah Stierman: But yeah.
• 15:28
  Dr. Sarah Stierman: Protecting those little areas before you put a topical retinoid on can make it a lot more tolerable.
• 15:33
  Dr. Sarah Stierman: Moisturizer after, protect the delicate areas and then if you're still not tolerating it.
• 15:39
  Dr. Sarah Stierman: So just making sure that you can moisturize and then protect the areas that are likely to get irritated, and not applying too much because you wouldn't believe how many people come in having used, like I know that I've given them a month's supply and it's two weeks later, their face is on fire and more than half of the tube is gone.
• 15:56
  Dr. Sarah Stierman: And I'm like, how much are you putting on your face?
• 15:59
  Dr. Sarah Stierman: Beyond that, after those basic steps, if you still can't tolerate a topical retinoid, we can do my favorite trick, which is called a retinoid sandwich.
• 16:09
  Dr. Sarah Stierman: You can apply a layer of moisturizer, wait a minute, and then apply your retinoid polka dots, wait a little bit, and then another layer of moisturizer.
• 16:18
  Dr. Sarah Stierman: So you are bolstering your barrier, and occluding the retinoid as well, so it works better,
• 16:24
  Dr. Komal Patil-Sisodia: yes, it works
• 16:25
  Dr. Sarah Stierman: a little bit better when we seal it in like that, but it also, creates less irritation when we can use something emollient like a moisturizer.
• 16:33
  Dr. Sarah Stierman: So the retinoid sandwich is my favorite trick.
• 16:37
  Dr. Sarah Stierman: My second favorite trick is actually backing off on the frequency of use.
• 16:44
  Dr. Sarah Stierman: So I let people start nightly Now, I used to, when I was in training, we would train people to start maybe a couple nights a week and work up to nightly.
• 16:54
  Dr. Sarah Stierman: I like to hit it hard to start.
• 16:55
  Dr. Sarah Stierman: If you can push through the worst of it, then you'll be able to tolerate the medication long term usually.
• 17:01
  Dr. Sarah Stierman: So I recommend, nightly to start and if you don't tolerate it, backing it off to three times a week, and then slowly working back up to nightly as tolerated.
• 17:11
  Dr. Sarah Stierman: Now that can get tricky I am a creature of habit and routine, and if I don't do the same thing every single night, I'm not necessarily gonna remember to do it.
• 17:23
  Dr. Sarah Stierman: So I'm gonna be like, wait, did I put that on Monday or Tuesday?
• 17:26
  Dr. Sarah Stierman: And what day is today?
• 17:27
  Dr. Sarah Stierman: Who am I?
• 17:27
  Dr. Sarah Stierman: Where am I, you know.
• 17:29
  Dr. Sarah Stierman: Which gets worse than perimenopause, right?
• 17:31
  Dr. Sarah Stierman: For those who do better with the same routine every night, instead of backing off the frequency, we can back off the amount of contact you give.
• 17:40
  Dr. Sarah Stierman: Rather than wearing it overnight as a topical, what we can do instead is I kind of do the after dinner party.
• 17:49
  Dr. Sarah Stierman: So after dinner, but before bed, you can apply, you can wash your face and apply your retinoid, but then before you go to bed, wash it off and repair your barrier.
• 18:00
  Dr. Sarah Stierman: Oh, and so that's the other thing you can do.
• 18:02
  Dr. Sarah Stierman: We call that short contact therapy.
• 18:04
  Dr. Sarah Stierman: And for stronger retinoids, sometimes short contact therapy is the way to go.
• 18:08
  Dr. Sarah Stierman: With frequency of retinoid, the one to two nights a week that you talked about is not sufficient, unfortunately.
• 18:15
  Dr. Sarah Stierman: Three is the magic number.
• 18:17
  Dr. Sarah Stierman: If you are not able to tolerate a topical retinoid at least three nights a week, you are getting all of the side effects and none of the benefit.
• 18:27
  Dr. Komal Patil-Sisodia: Okay.
• 18:28
  Dr. Komal Patil-Sisodia: That's really good to know.
• 18:29
  Dr. Komal Patil-Sisodia: And does that hold true for, I know there are people who use over the counter retinols, which I know are not as strong as the retinoids.
• 18:36
  Dr. Komal Patil-Sisodia: Is it the same rule of three applies there?
• 18:37
  Dr. Komal Patil-Sisodia: Yes.
• 18:37
  Dr. Komal Patil-Sisodia: Absolutely.
• 18:38
  Dr. Sarah Stierman: Frequency is the same.
• 18:39
  Dr. Sarah Stierman: So over the counter drug store, topical retinoids, the vast majority of those are retinal alcohol.
• 18:46
  Dr. Sarah Stierman: Retinal alcohol has a concentration roughly a hundred times less than rettino and 0.05% cream.
• 18:53
  Dr. Sarah Stierman: And then the next strongest version of over the counter non prescription retinoids is retinol.
• 19:00
  Dr. Sarah Stierman: Retin aldehyde is just one decimal point.
• 19:03
  Dr. Sarah Stierman: So a 10% change from rettino into that, usually physician dispensed, but sometimes pharmacy dispensed, grade of retinoid.
• 19:11
  Dr. Sarah Stierman: I find that Retin Aldehydes, if you do not tolerate Tretinoin, which is prescription strength retinoid, then a Retin Aldehyde is usually my next go-to.
• 19:21
  Dr. Komal Patil-Sisodia: That's good.
• 19:22
  Dr. Komal Patil-Sisodia: Thank you so much for clarifying that.
• 19:24
  Dr. Komal Patil-Sisodia: There's so many labels on bottles and when we don't know what is the gold standard versus everything else, I feel like, I can walk into a Sephora or an Ulta and be duped and buy all sorts of stuff that's not doing a darn thing for my
• 19:38
  Dr. Sarah Stierman: Absolutely.
• 19:39
  Dr. Sarah Stierman: It's so overwhelming.
• 19:40
  Dr. Sarah Stierman: Like you don't even get me started about the skin.
• 19:42
  Dr. Sarah Stierman: I love skincare.
• 19:44
  Dr. Sarah Stierman: Yeah.
• 19:44
  Dr. Sarah Stierman: And I love medical skincare and I love science and I am a physician scientist at heart, but the cosmeceutical industry, very much like the nutrition and fitness industries, in my opinion, really prey on our insecurities, especially as women walking into a Sephora or an Alta or into a department store, and having somebody accost you with like 18 different serums and creams and things you need to try.
• 20:09
  Dr. Sarah Stierman: I'm a keep it simple sort of girl and it better have amazing data behind it.
• 20:13
  Dr. Komal Patil-Sisodia: Yeah, I love that.
• 20:17
  Dr. Komal Patil-Sisodia: And it is so hard to do that right.
• 20:19
  Dr. Komal Patil-Sisodia: I'm wondering, have you noticed that since the pandemic women are so much more nitpicky with their faces because I feel like I am, you know, like you sit there and you stare at yourself on a screen all day.
• 20:29
  Dr. Komal Patil-Sisodia: You're like, oh wait.
• 20:30
  Dr. Komal Patil-Sisodia: What's happening here?
• 20:32
  Dr. Sarah Stierman: Advent of the stay at home work from home and then zoom meetings, so many people have come in and are like, oh my God.
• 20:40
  Dr. Sarah Stierman: And honestly, what's hilarious is that some of it is the face, but so much of it is neck, because of, I don't believe that actually of tech neck because we don't pay attention.
• 20:48
  Dr. Sarah Stierman: Well, and because of, I mean like literally forward head position in front of a camera all day long, it's tech neck as we call it, which causes some skin changes.
• 20:59
  Dr. Komal Patil-Sisodia: You know, that's so interesting because I always thought tech neck was like on the back, like mm-hmm.
• 21:03
  Dr. Komal Patil-Sisodia: You know, kind of hunched over posture.
• 21:05
  Dr. Komal Patil-Sisodia: I never really thought about it.
• 21:07
  Dr. Komal Patil-Sisodia: 'cause if you're hunched over, yeah, that makes sense.
• 21:08
  Dr. Komal Patil-Sisodia: That things are in the front.
• 21:09
  Dr. Komal Patil-Sisodia: Right.
• 21:10
  Dr. Komal Patil-Sisodia: Well, all right, so retinoids, that's like the next, so what, what comes after?
• 21:17
  Dr. Komal Patil-Sisodia: So sunscreen and a retinoid
• 21:18
  Dr. Sarah Stierman: Those are the cornerstones, those are the non-negotiables of any sort of healthy skin, anti-aging regimen, sunscreen and retinoid.
• 21:25
  Dr. Sarah Stierman: If you're not doing those two things, you're doing yourself an incredible disservice.
• 21:29
  Dr. Sarah Stierman: People who come into me for Botox and fillers and laser and neuromodulators and all of these things, if they are not doing sunscreen and a retinoid every single day, I'm like, wait, that's like audible flushing of money down the toilet.
• 21:44
  Dr. Sarah Stierman: Let's just bring it back.
• 21:46
  Dr. Sarah Stierman: So sunscreen and a retinoid.
• 21:47
  Dr. Sarah Stierman: I'm off of my soapbox.
• 21:48
  Dr. Sarah Stierman: Now, the next thing that I would consider adding, would be, and I'm biased, so the vast majority of my dermatology colleagues would probably say the next thing to add would be an antioxidant.
• 21:59
  Dr. Sarah Stierman: So like a vitamin C, product to help with oxidative stress.
• 22:03
  Dr. Sarah Stierman: Yes.
• 22:04
  Dr. Sarah Stierman: I am a growth factor girl.
• 22:05
  Dr. Sarah Stierman: I have been for a very long time.
• 22:07
  Dr. Sarah Stierman: And so my next one, if you wanna best bang for your buck, for just really kind of aggressive collagen production, is either a growth factor a peptide or an exosome.
• 22:18
  Dr. Sarah Stierman: Those are all in the same family of products.
• 22:20
  Dr. Sarah Stierman: The first time I did the skincare post in the group that you and I met in growth factors were at their advent, they were new, the original TNS, tissue Nutrient Solution was patented by Skin Medica back in the very late nineties.
• 22:36
  Dr. Sarah Stierman: But that was still, it didn't have broad distribution really until the 2000 tens probably.
• 22:43
  Dr. Sarah Stierman: And so growth factors were just beginning to take off when I became very interested in medical grade skincare.
• 22:50
  Dr. Sarah Stierman: Growth factors, like TNS or other alternatives now.
• 22:54
  Dr. Sarah Stierman: Growth factors, what they do is they sit on the surface of the skin, and then they actually sell cell signal.
• 23:01
  Dr. Sarah Stierman: And so they send a message to your fiberglass and your dermis from the cells in the epidermis.
• 23:08
  Dr. Sarah Stierman: They signal down to the dermis and try to wake them back up and start collagen production again.
• 23:13
  Dr. Sarah Stierman: There are a lot of growth factors derived from mesenchymal growth factors or, platelet derived growth factors.
• 23:21
  Dr. Sarah Stierman: Those are the two main groups.
• 23:23
  Dr. Sarah Stierman: Peptides are like tiny little emails from your system down to the cells.
• 23:28
  Dr. Sarah Stierman: Just tiny little nudges like, Hey, hey, wake up.
• 23:30
  Dr. Sarah Stierman: Hey, hey.
• 23:31
  Dr. Sarah Stierman: You know?
• 23:31
  Dr. Sarah Stierman: So peptides have very similar function to growth factors, but maybe just slightly less potent.
• 23:36
  Dr. Sarah Stierman: Exosomes are kind of the new.
• 23:39
  Dr. Sarah Stierman: Rage, if you will.
• 23:40
  Dr. Sarah Stierman: So exosomes are usually derived from blood product.
• 23:45
  Dr. Sarah Stierman: And there are a variety of sources.
• 23:47
  Dr. Sarah Stierman: Yeah.
• 23:47
  Dr. Sarah Stierman: And there are a variety of sources, they're like a little bubble or a little FedEx truck that holds all of the growth factors and peptides and signaling messages.
• 23:57
  Dr. Sarah Stierman: And so it can be a more comprehensive message, but the one word to the wise about exosomes is because many of them are blood derived, the sources are sometimes questionable, depending on how much data there is behind a particular brand.
• 24:13
  Dr. Sarah Stierman: Exosomes are not regulated by the FDA as of now.
• 24:18
  Dr. Sarah Stierman: So be careful when we start talking about unregulated things.
• 24:21
  Dr. Sarah Stierman: The jury is still out about whether or not they will be able to be regulated.
• 24:25
  Dr. Komal Patil-Sisodia: But the growth factors you were talking about that have been in development for a long time are not necessarily falling into that
• 24:32
  Dr. Sarah Stierman: No.
• 24:32
  Dr. Sarah Stierman: The questions that I get from patients about safety and efficacy with growth factors usually are like, well, so you're stimulating cells.
• 24:42
  Dr. Sarah Stierman: What if I have a history of skin cancer?
• 24:44
  Dr. Sarah Stierman: Can I put that on my face?
• 24:46
  Dr. Sarah Stierman: And what I will say is that it has never been shown to proliferate a cancer line.
• 24:51
  Dr. Sarah Stierman: You're not gonna get a double-blinded controlled study on growth factors in skin cancer.
• 24:56
  Dr. Sarah Stierman: But we have as close to really good data as we can get to know that it is safe.
• 25:02
  Dr. Komal Patil-Sisodia: That's excellent.
• 25:03
  Dr. Komal Patil-Sisodia: And then what about inflammatory skin conditions like psoriasis and eczema?
• 25:07
  Dr. Komal Patil-Sisodia: Do you feel like those, are okay to use growth factors with will, growth factors, exacerbate skin conditions like that?
• 25:14
  Dr. Sarah Stierman: I have not seen a topical growth factor cause a flare of psoriasis, a flare of eczema, or stimulate the hair on my face to grow okay.
• 25:23
  Dr. Sarah Stierman: I didn't think about that one.
• 25:24
  Dr. Sarah Stierman: The answer is no.
• 25:25
  Dr. Sarah Stierman: Thank goodness.
• 25:26
  Dr. Sarah Stierman: I don't need any more of that either.
• 25:28
  Dr. Sarah Stierman: Growth factors are my next favorite, ingredient in a healthy skin anti-aging regimen.
• 25:34
  Dr. Sarah Stierman: So we've talked about SPF and retinoid again, cornerstones sunscreen, and a retinoid cornerstones of a healthy anti-aging regimen.
• 25:42
  Dr. Sarah Stierman: Vitamin C for a lot of my colleagues would recommend.
• 25:46
  Dr. Sarah Stierman: I will digress briefly about vitamin C'cause there are a lot of different vitamin C products out there as well.
• 25:51
  Dr. Sarah Stierman: My favorite form of vitamin C, the easiest form of vitamin C topically to get your hands on is L ascorbic acid or L ascorbate while it is relatively effective, it is a very volatile compound.
• 26:06
  Dr. Sarah Stierman: That's why you'll see like the SkinCeutical ce ferulic, which is the gold standard of a topical vitamin C.
• 26:13
  Dr. Sarah Stierman: They kind of had the corner on that a long time ago.
• 26:17
  Dr. Sarah Stierman: You'll notice it's in a brown bottle.
• 26:18
  Dr. Sarah Stierman: The reason it's in a brown bottle is because it isn't photo stable.
• 26:22
  Dr. Sarah Stierman: It needs to be in an opaque container in order to be stable.
• 26:25
  Dr. Sarah Stierman: It also tends to be very irritating and kind of barrier disrupting as well.
• 26:29
  Dr. Sarah Stierman: I find when patients are on a regimen and then add a really potent vitamin C, it can cause purging and breakouts like acne breakouts.
• 26:38
  Dr. Sarah Stierman: But my favorite form of vitamin C by far, and I'm gonna take a second to say it'cause you can stumble over this very long word, but it is tetra heyl Desal asco bait.
• 26:50
  Dr. Komal Patil-Sisodia: Okay.
• 26:51
  Dr. Komal Patil-Sisodia: I'm not even gonna try and repeat that.
• 26:53
  Dr. Komal Patil-Sisodia: That's okay.
• 26:53
  Dr. Sarah Stierman: It's my favorite.
• 26:54
  Dr. Sarah Stierman: And the reason that it's my favorite is that it is very well tolerated and it's photos stable.
• 27:00
  Dr. Sarah Stierman: And it's photos stable.
• 27:01
  Dr. Sarah Stierman: Yeah.
• 27:01
  Dr. Sarah Stierman: So you can use it anytime of day.
• 27:03
  Dr. Sarah Stierman: No big deal.
• 27:06
  Dr. Komal Patil-Sisodia: Is there a particular, I know like there's so many brands that, put that out there and if you don't wanna give a specific brand, I'm fine with that.
• 27:12
  Dr. Komal Patil-Sisodia: But is there, because I will remember a brand more than the very long multi-syllabic word that you just said.
• 27:19
  Dr. Sarah Stierman: So you're right.
• 27:20
  Dr. Sarah Stierman: In general, I will preface any sort of brand related discussion saying I have absolutely zero partnership with any brand out there.
• 27:27
  Dr. Sarah Stierman: I am not brand loyal at all.
• 27:29
  Dr. Sarah Stierman: Yeah.
• 27:30
  Dr. Sarah Stierman: But.
• 27:31
  Dr. Sarah Stierman: I do have two vitamin Cs where the active ingredient is tetra yl des ascorbate, which is my favorite.
• 27:39
  Dr. Sarah Stierman: Number one is the revision c plus 30%.
• 27:43
  Dr. Sarah Stierman: Mm-hmm.
• 27:44
  Dr. Sarah Stierman: That it's so, it's so beautiful.
• 27:46
  Dr. Sarah Stierman: It's such an elegant cream.
• 27:47
  Dr. Sarah Stierman: It's very well tolerated.
• 27:48
  Dr. Sarah Stierman: I've never had anyone come back to me saying, oh, it gave me breakouts.
• 27:51
  Dr. Sarah Stierman: Oh, it made me dry or red.
• 27:53
  Dr. Sarah Stierman: And if you're looking for something that is not usually revision is physician dispensed or dispensed out of like a MediSpa where they have a supervising physician.
• 28:03
  Dr. Sarah Stierman: So sometimes it's a little bit harder to get revision, but I do like revision of the, more accessible brands, like you can get it all to.
• 28:12
  Dr. Sarah Stierman: And Sephora, my favorite version of that vitamin C is from Sunday.
• 28:16
  Dr. Sarah Stierman: Riley.
• 28:17
  Dr. Sarah Stierman: It's in an orange container.
• 28:18
  Dr. Komal Patil-Sisodia: I know.
• 28:19
  Dr. Komal Patil-Sisodia: Well I've used that one before.
• 28:22
  Dr. Komal Patil-Sisodia: See, learning some new tips here.
• 28:24
  Dr. Komal Patil-Sisodia: Thank you for that, Sarah.
• 28:25
  Dr. Komal Patil-Sisodia: That was a fully selfish question.
• 28:27
  Dr. Komal Patil-Sisodia: Here we are, but here we here.
• 28:27
  Dr. Komal Patil-Sisodia: That's real.
• 28:28
  Dr. Sarah Stierman: And I'm here for it.
• 28:29
  Dr. Komal Patil-Sisodia: So we've gone through SPF, retinoids, the growth factors and now an antioxidant.
• 28:36
  Dr. Komal Patil-Sisodia: Are there other antioxidants outside of vitamin C that people use or recommend there are numerous,
• 28:42
  Dr. Sarah Stierman: Antioxidants outside of vitamin C.
• 28:43
  Dr. Sarah Stierman: Vitamin C is probably just the most prolific and concentrated of them.
• 28:48
  Dr. Sarah Stierman: But, honestly, green tea is probably another one of my favorite ingredients.
• 28:52
  Dr. Sarah Stierman: It has high antioxidant power, which is fantastic.
• 28:55
  Dr. Sarah Stierman: It's also really well tolerated.
• 28:57
  Dr. Sarah Stierman: You see green tea in a lot of products that are meant to be calming to the skin, which is great.
• 29:03
  Dr. Komal Patil-Sisodia: Okay.
• 29:04
  Dr. Komal Patil-Sisodia: That's fantastic.
• 29:06
  Dr. Komal Patil-Sisodia: All right, so we do that for, retinoids for evenings.
• 29:10
  Dr. Komal Patil-Sisodia: I'm assuming the antioxidants during the day.
• 29:13
  Dr. Komal Patil-Sisodia: And then the growth factor would be the growth factor.
• 29:17
  Dr. Sarah Stierman: On the indication on the packaging and depends on the dosing that's recommended, but the vast majority of growth factors are twice a day.
• 29:25
  Dr. Komal Patil-Sisodia: That's good to know because, I would be like the person trying to budget and get away with them once a day.
• 29:31
  Dr. Sarah Stierman: Well, when we start
• 29:32
  Dr. Komal Patil-Sisodia: Ease of use and lazy when we start talking about
• 29:34
  Dr. Sarah Stierman: compliance of actually applying topical medications.
• 29:37
  Dr. Sarah Stierman: This is, um, this has to do with psoriasis.
• 29:39
  Dr. Sarah Stierman: There's a very famous dermatology study where they put a microchip in the top of a jar of topical steroid.
• 29:47
  Dr. Sarah Stierman: For their eczema and psoriasis patients.
• 29:48
  Dr. Sarah Stierman: And then monitored'em Yeah.
• 29:51
  Dr. Sarah Stierman: Over a period of time and had them bring their jar back with them into the clinic and they scanned it.
• 29:56
  Dr. Sarah Stierman: And on average, literally when something is prescribed to put on your skin twice a day on average, people were applying it like twice a week.
• 30:06
  Dr. Komal Patil-Sisodia: Yeah.
• 30:07
  Dr. Sarah Stierman: Mm-hmm.
• 30:08
  Dr. Komal Patil-Sisodia: Wow.
• 30:08
  Dr. Komal Patil-Sisodia: Okay.
• 30:09
  Dr. Komal Patil-Sisodia: So even daily is a stretch sometimes.
• 30:11
  Dr. Sarah Stierman: Sometimes.
• 30:11
  Dr. Sarah Stierman: There are days that I get home and I'm exhausted and I'm lucky that I get my contacts out of my eyes before my head hits the pillow, let alone doing an 18 step regimen.
• 30:21
  Dr. Sarah Stierman: Not that my regimen is even close to 18 steps.
• 30:24
  Dr. Komal Patil-Sisodia: No, yeah, I know.
• 30:26
  Dr. Komal Patil-Sisodia: We see all these things that, you know, like 10 step regimen.
• 30:29
  Dr. Komal Patil-Sisodia: Seven step regimen, and I'm like, I just wanna wash my face, put some stuff on and then like you, I need my head to hit the pillow.
• 30:37
  Dr. Komal Patil-Sisodia: Especially.
• 30:38
  Dr. Komal Patil-Sisodia: Yeah, keep, keep it simple.
• 30:40
  Dr. Sarah Stierman: Because there are more steps does not mean it is better.
• 30:42
  Dr. Sarah Stierman: TikTok, we're talking to you.
• 30:44
  Dr. Sarah Stierman: Yes, we're talking to the ticking to, and it has nothing to do with a 13 step skin regimen.
• 30:50
  Dr. Komal Patil-Sisodia: So let's talk a little bit about cleansing the skin, right?
• 30:53
  Dr. Komal Patil-Sisodia: Because a lot of times people will be like, oh my gosh, I need something to get everything off.
• 30:58
  Dr. Komal Patil-Sisodia: We are of the era of the, Saint Ives apricot scrub and all of the stuff that was like, you know, basically taking like a group cheese grater to your face, right?
• 31:09
  Dr. Komal Patil-Sisodia: Yeah.
• 31:09
  Dr. Komal Patil-Sisodia: For how rough it was on our skin.
• 31:11
  Dr. Komal Patil-Sisodia: What is the best way to wash your face and still protect that skin barrier?
• 31:15
  Dr. Komal Patil-Sisodia: Because it sounds like as we age, it's all about the barrier and making sure that we're keeping it protected and then also doing these other things to stimulate collagen.
• 31:22
  Dr. Komal Patil-Sisodia: Correct.
• 31:23
  Dr. Komal Patil-Sisodia: So,
• 31:23
  Dr. Sarah Stierman: Do not over exfoliate.
• 31:25
  Dr. Sarah Stierman: I'm saying it again, do not over exfoliate.
• 31:27
  Dr. Sarah Stierman: If you're on a retinoid, you're already getting a chemical exfoliant because it's helping with cell turnover.
• 31:33
  Dr. Sarah Stierman: You shouldn't need to scrub your face with walnut shells, which is what stine's is.
• 31:38
  Dr. Sarah Stierman: It's ground up walnut shells.
• 31:40
  Dr. Sarah Stierman: Who knows what it is now, but that's what it used to be.
• 31:42
  Dr. Sarah Stierman: You don't need little tiny pieces of fiberglass on your face'cause that's what it feels like.
• 31:48
  Dr. Sarah Stierman: But yes, we all grew up doing that.
• 31:50
  Dr. Sarah Stierman: I would've taken a Brillo pad to my face if it meant that I wouldn't have had acne when I was 16.
• 31:54
  Dr. Sarah Stierman: But here I am and I survived.
• 31:56
  Dr. Sarah Stierman: Yes.
• 31:56
  Dr. Komal Patil-Sisodia: Right?
• 31:57
  Dr. Sarah Stierman: Yes.
• 31:58
  Dr. Komal Patil-Sisodia: Yes.
• 31:58
  Dr. Komal Patil-Sisodia: We made it to midlife.
• 32:00
  Dr. Sarah Stierman: Yes.
• 32:00
  Dr. Sarah Stierman: So a gentle soap pre cleanser is my preference I don't think.
• 32:05
  Dr. Sarah Stierman: You should spend insane amounts of money on a cleanser.
• 32:08
  Dr. Sarah Stierman: There are a lot of fancy cleansers that are very pricey.
• 32:12
  Dr. Sarah Stierman: I find that your money is best spent on Levon products, not something that you're going to wash off of your face.
• 32:19
  Dr. Sarah Stierman: There are a lot of lovely, elegant, drugstore based cleansers by, you know, CeraVe and Cetaphil and Laroche Poe and Neutrogena that I absolutely love.
• 32:31
  Dr. Sarah Stierman: And you don't need to spend, la mere prices to get your face dewy and cleansed.
• 32:36
  Dr. Sarah Stierman: A soap free cleanser, the reason I say soap free is not, necessarily because there's something wrong with soap, but the pH of traditional soap tends to be very alkaline your skin is ever so slightly acidic.
• 32:48
  Dr. Sarah Stierman: You're going to unbalance the pH of your skin if you are using soap, like the soap that you might use on your body.
• 32:55
  Dr. Sarah Stierman: Mind you, I use soap free cleanser everywhere.
• 32:58
  Dr. Sarah Stierman: If you're used to using Irish Spring in the shower and then you're just like, I'm just gonna wash my face real quick, and you use that on your face, you'll pay for it later, I promise.
• 33:07
  Dr. Sarah Stierman: So a gentle soap free cleanser that we're careful about the pH.
• 33:11
  Dr. Sarah Stierman: Nothing scrubby or abrasive.
• 33:13
  Dr. Sarah Stierman: If you're a washcloth girl, fine.
• 33:16
  Dr. Sarah Stierman: I'm a fingers girl just because I can control the amount of pressure and I know that my fingers are clean when I'm washing my face.
• 33:24
  Dr. Sarah Stierman: And so I'm not inoculating my face with bacteria like from a loofah that's been sitting in your bathtub or shower for a week, you know?
• 33:32
  Dr. Sarah Stierman: Beyond cleansing.
• 33:34
  Dr. Sarah Stierman: Let's, dispel some myths.
• 33:36
  Dr. Sarah Stierman: Let's talk about the step between cleansing and starting to apply product.
• 33:42
  Dr. Sarah Stierman: You know what I'm gonna talk about?
• 33:43
  Dr. Sarah Stierman: The toner, toner, toner.
• 33:45
  Dr. Sarah Stierman: Oh yes.
• 33:46
  Dr. Sarah Stierman: Oh my God.
• 33:47
  Dr. Sarah Stierman: Okay.
• 33:47
  Dr. Sarah Stierman: So you do not need a toner at all.
• 33:51
  Dr. Sarah Stierman: Why does toner exist?
• 33:53
  Dr. Sarah Stierman: Because a very long time ago when we all had hard water and didn't have any sort of water softening or treatment.
• 34:00
  Dr. Sarah Stierman: And we used lie based soap to wash everything, including our faces and hair and body and whatever.
• 34:07
  Dr. Sarah Stierman: Hard water plus lie would create a precipitant on the surface of the skin.
• 34:13
  Dr. Sarah Stierman: This waxy film on the surface of the skin that then an alcohol based toner was used to break down and strip off the face before you could do anything else.
• 34:24
  Dr. Sarah Stierman: The myth of the toner has been perpetuated beyond its utility.
• 34:32
  Dr. Komal Patil-Sisodia: I didn't even know that it actually had a purpose.
• 34:35
  Dr. Komal Patil-Sisodia: I just thought it was a product made up to make money.
• 34:38
  Dr. Komal Patil-Sisodia: But it sounds like it was actually useful, but we don't need it anymore.
• 34:41
  Dr. Sarah Stierman: you're right.
• 34:42
  Dr. Sarah Stierman: You're actually right on both counts.
• 34:44
  Dr. Komal Patil-Sisodia: Fair.
• 34:46
  Dr. Komal Patil-Sisodia: It's oh gosh, I didn't realize that.
• 34:48
  Dr. Komal Patil-Sisodia: 'Cause you see all these different things that are out there, like a exfoliating toner, a moisturizing toner, whatever.
• 34:54
  Dr. Komal Patil-Sisodia: But it sounds like you can just get that with the baseline skincare if you're using appropriate products for your skin.
• 35:00
  Dr. Komal Patil-Sisodia: Correct.
• 35:01
  Dr. Sarah Stierman: And if you are so into wanting to use a toner simply for a sensory experience.
• 35:06
  Dr. Sarah Stierman: Some people just enjoy a sensory experience between cleansing and putting product on.
• 35:12
  Dr. Sarah Stierman: I would just, if you're going to use a toner at all on your face for any reason whatsoever, make sure that it's alcohol free.
• 35:20
  Dr. Komal Patil-Sisodia: That's fair.
• 35:20
  Dr. Komal Patil-Sisodia: There's some really lovely ones that are like rose water that for the sensory experience, I never really thought they were doing much for my skin, but now that's confirmed, so I appreciate that.
• 35:30
  Dr. Komal Patil-Sisodia: I might save my money now instead of buying all this stuff.
• 35:35
  Dr. Komal Patil-Sisodia: Okay, so that's really helpful and interesting.
• 35:37
  Dr. Komal Patil-Sisodia: I did have one more question.
• 35:38
  Dr. Komal Patil-Sisodia: This part comes up to me from my patients actually.
• 35:41
  Dr. Komal Patil-Sisodia: 'cause I deal with a lot of PCOS and acne.
• 35:43
  Dr. Komal Patil-Sisodia: What are your thoughts on oil-based cleansers and what do you use to remove makeup?
• 35:47
  Dr. Komal Patil-Sisodia: Right.
• 35:48
  Dr. Komal Patil-Sisodia: Because a lot of times my patients with acne will try covering it with makeup and then getting it off without irritating.
• 35:53
  Dr. Komal Patil-Sisodia: The skin is a big thing what is the best way to do it?
• 35:56
  Dr. Sarah Stierman: A fan of an oil-based cleanser.
• 35:57
  Dr. Sarah Stierman: If you tolerate it, it can be relatively occlusive, so around the eyes, sometimes people can get a little bit more breakouts or, I mean, god forbid a ty or something like that along the lash line if you're not careful about rinsing it.
• 36:09
  Dr. Sarah Stierman: But I am a fan of the double cleanse to remove makeup and then to cleanse the skin thereafter.
• 36:14
  Dr. Sarah Stierman: When you double cleanse, you use something either like an oil-based, cleanser to start, or a micella water is another wonderful way to gently kind of double cleanse.
• 36:24
  Dr. Sarah Stierman: That's the first step.
• 36:25
  Dr. Sarah Stierman: And then once that gets rinsed, you move on to a soap free cleanser.
• 36:31
  Dr. Komal Patil-Sisodia: Okay, great.
• 36:32
  Dr. Komal Patil-Sisodia: Thank you for that.
• 36:33
  Dr. Komal Patil-Sisodia: That's, so helpful to a lot of my patients, so I appreciate that.
• 36:37
  Dr. Komal Patil-Sisodia: Now let's, switch gears and talk a little bit about supplements.
• 36:40
  Dr. Komal Patil-Sisodia: You talked about how our collagen factories are shutting down collagen supplements, vitamins for hair, skin, and nails.
• 36:46
  Dr. Komal Patil-Sisodia: There's a whole bunch of stuff that I think we just need to know, like, is this a skip or a buy?
• 36:52
  Dr. Sarah Stierman: So if you have specific ingredient questions, let me know, but I'm just gonna hit the top five.
• 36:57
  Dr. Sarah Stierman: People ask me about collagen powders all the time.
• 37:00
  Dr. Sarah Stierman: Micronized collagen, is available in capsule form too, but I tend to prefer powder because I generally think it does mix well into beverages like coffee.
• 37:10
  Dr. Sarah Stierman: But capsules, if you take collagen capsules, it's all of that powder stuffed into little capsules.
• 37:16
  Dr. Sarah Stierman: And it ends up being something like six to eight capsules a day, which is a lot of pills.
• 37:20
  Dr. Sarah Stierman: Oh.
• 37:20
  Dr. Sarah Stierman: So I'm a powder girl.
• 37:22
  Dr. Sarah Stierman: Yeah.
• 37:23
  Dr. Sarah Stierman: So hydrolyzed collagen, releases in your digestive tract releases small collagen peptides, and we know that peptides are messengers.
• 37:30
  Dr. Sarah Stierman: If the message is received, it'll stimulate fibroblasts and collagen in the skin.
• 37:35
  Dr. Sarah Stierman: There are almost 30 different types of collagen.
• 37:37
  Dr. Sarah Stierman: Not all collagens are the same.
• 37:39
  Dr. Sarah Stierman: Collagen.
• 37:40
  Dr. Sarah Stierman: One is the most prolific collagen in your entire body.
• 37:43
  Dr. Sarah Stierman: It's about 80% of the collagen in your body, and that's what makes your teeth, firm and makes your, hair, skin, and nails.
• 37:51
  Dr. Sarah Stierman: And then your bones.
• 37:51
  Dr. Sarah Stierman: It plays a really big part in your bone structure as well, but collagen, type one.
• 37:57
  Dr. Sarah Stierman: And collagen type three are the two that we most want to use to, help with skin, hair, and nail health.
• 38:05
  Dr. Sarah Stierman: Other types of collagen.
• 38:06
  Dr. Sarah Stierman: Can have a little bit of a cosmetic benefit.
• 38:09
  Dr. Sarah Stierman: When we talk about multi collagen powders, you're wanting to focus on not just hair and skin, nail health, but also joint health.
• 38:17
  Dr. Sarah Stierman: And so if you're wanting to use something with multiple types of collagen in it, it will help with both skin and joints, which is great.
• 38:26
  Dr. Sarah Stierman: Yeah, that's good to know.
• 38:27
  Dr. Sarah Stierman: The reason I talk about that is that the, I would say the most, the easiest collagen powder to commercially get, I think, is Vital Proteins.
• 38:36
  Dr. Sarah Stierman: I think people will recognize that brand name.
• 38:39
  Dr. Sarah Stierman: And it comes both as a bovine source and as a marine source.
• 38:45
  Dr. Sarah Stierman: Anecdotally, marine based collagen does tend to be a little bit better for skin health.
• 38:51
  Dr. Sarah Stierman: But Vital Proteins doesn't have as many types of collagen in it as some of the other more comprehensive brands.
• 38:58
  Dr. Sarah Stierman: There have been some really large studies that have had very positive results, in favor of collagen use for skin health.
• 39:07
  Dr. Sarah Stierman: The, problems with some of these studies is that they were self-reported.
• 39:11
  Dr. Sarah Stierman: So it's the patient just saying, I think it's better.
• 39:13
  Dr. Sarah Stierman: And so you can't really.
• 39:15
  Dr. Sarah Stierman: Judge whether or not some of that is placebo effect.
• 39:18
  Dr. Sarah Stierman: But I have seen enough people benefit from collagen powder when they start it in my practice.
• 39:25
  Dr. Sarah Stierman: And I personally have had enough benefit that I don't think it's all in my head.
• 39:30
  Dr. Sarah Stierman: The largest study in 2019 on hydrolyzed oral collagen supplementation was a 96% positive predictive rate for increase in the, youthfulness and, just the health overall of your skin.
• 39:46
  Dr. Sarah Stierman: So, so collagen is a definite.
• 39:49
  Dr. Sarah Stierman: Okay, that's great.
• 39:50
  Dr. Sarah Stierman: Let's, I so wanna pick your brain about biotin because you're an endocrinologist.
• 39:54
  Dr. Sarah Stierman: Oh yes.
• 39:55
  Dr. Sarah Stierman: Let's do this.
• 39:56
  Dr. Sarah Stierman: How about we have the endocrinologist talk about biotin first?
• 39:59
  Dr. Sarah Stierman: She's gonna be smarter about it.
• 40:00
  Dr. Sarah Stierman: I'll tell you what I tell all my patients about biotin.
• 40:05
  Dr. Komal Patil-Sisodia: Okay, so I will tell patients that, it may or may not help your hair, skin, or nails, but it's gonna mess up your thyroid blood test by messing with the lab essay.
• 40:16
  Dr. Komal Patil-Sisodia: For some people they take it and they're like, oh, I feel like my hair is growing back thicker, or my hairdresser commented on it I'm not sitting there counting the number of follicles per whatever it is, like square centimeter, square inch on the scalp.
• 40:27
  Dr. Komal Patil-Sisodia: So I don't actually know.
• 40:29
  Dr. Komal Patil-Sisodia: My biggest pet peeve is how it throws off thyroid tests.
• 40:32
  Dr. Komal Patil-Sisodia: I tell people you have to be off of it for three days minimum.
• 40:35
  Dr. Komal Patil-Sisodia: That creates a lot of anxiety for people because they're like, but it's helping my hair and if I miss it for three days to a week, what's gonna happen?
• 40:42
  Dr. Komal Patil-Sisodia: I don't actually know the answer to that.
• 40:43
  Dr. Komal Patil-Sisodia: I just know it messes up the thyroid function test.
• 40:45
  Dr. Komal Patil-Sisodia: It doesn't actually mess up your thyroid function.
• 40:48
  Dr. Komal Patil-Sisodia: It just makes the lab test look a little wonky.
• 40:50
  Dr. Komal Patil-Sisodia: So that's why I prefer people to be off of it when they get that trial.
• 40:54
  Dr. Sarah Stierman: Thyroid panel is a biotin lab.
• 40:56
  Dr. Sarah Stierman: Newsflash not just the thyroid panel, but cardiac assays are biotin native as well.
• 41:02
  Dr. Sarah Stierman: If you were having a heart attack and we ran your cardiac enzymes, they would not be normal if you were on high dose biotin.
• 41:10
  Dr. Komal Patil-Sisodia: Holy moly.
• 41:11
  Dr. Komal Patil-Sisodia: Yeah, I did not know that.
• 41:12
  Dr. Sarah Stierman: Was a really tragic story where there was a lady who was just postmenopausal, started having some atypical chest pain, like just a little tightness.
• 41:21
  Dr. Sarah Stierman: Didn't really radiate, had unusual symptoms she came into the emergency room and it either wasn't disclosed that she was on high dose biotin or they didn't think it was a big deal.
• 41:32
  Dr. Sarah Stierman: But they ran her troponins, so her cardiac essays to see whether or not there was any heart damage.
• 41:37
  Dr. Sarah Stierman: They were normal.
• 41:38
  Dr. Sarah Stierman: They sent her home.
• 41:39
  Dr. Sarah Stierman: She died.
• 41:40
  Dr. Sarah Stierman: She had a heart attack
• 41:42
  Dr. Komal Patil-Sisodia: home.
• 41:42
  Dr. Sarah Stierman: Yeah.
• 41:45
  Dr. Komal Patil-Sisodia: Oh my gosh.
• 41:46
  Dr. Komal Patil-Sisodia: I had not heard that case.
• 41:48
  Dr. Komal Patil-Sisodia: I'm gonna have to look that up.
• 41:49
  Dr. Sarah Stierman: So here's the thing, when the standard of care, has been the same.
• 41:54
  Dr. Sarah Stierman: For decades those of us who are currently practicing, forget the sentinel evidence.
• 42:00
  Dr. Sarah Stierman: That made us make that recommendation or standard of care to begin with.
• 42:04
  Dr. Sarah Stierman: The evidence for biotin is actually from the veterinary literature.
• 42:09
  Dr. Sarah Stierman: It's from the veterinary literature and the sentinel paper was in the 1970s and it was subjective thickening of horse hoves because they added biotin to horse speed.
• 42:22
  Dr. Sarah Stierman: So,
• 42:24
  Dr. Komal Patil-Sisodia: There's never been any human data to show that it improved care,
• 42:27
  Dr. Sarah Stierman: data at best and new slash
• 42:29
  Dr. Komal Patil-Sisodia: wow.
• 42:30
  Dr. Komal Patil-Sisodia: No, no, no, we're not.
• 42:32
  Dr. Komal Patil-Sisodia: Oh my gosh.
• 42:33
  Dr. Komal Patil-Sisodia: Okay.
• 42:33
  Dr. Komal Patil-Sisodia: Well, I'm gonna have to tell that story to all my patients I think what's really throwing me, especially since, I've been doing so much more work in the midlife women's space, given, my mom's history of heart disease and all of those things, that story is terrifying to me.
• 42:49
  Dr. Komal Patil-Sisodia: Right.
• 42:49
  Dr. Komal Patil-Sisodia: It's terrifying to me.
• 42:50
  Dr. Komal Patil-Sisodia: Right.
• 42:50
  Dr. Komal Patil-Sisodia: Thank you for sharing that.
• 42:51
  Dr. Komal Patil-Sisodia: So it's
• 42:51
  Dr. Sarah Stierman: It's just that we don't recommend taking higher doses than what the USDA recommendation is.
• 42:57
  Dr. Komal Patil-Sisodia: so what is the USDA recommendation around biotin?
• 43:00
  Dr. Komal Patil-Sisodia: Because I'll go to Costco and it'll be like 5,000, 10,000, and then you read like the little thing and it's like thousands of percent of your recommended.
• 43:08
  Dr. Sarah Stierman: My head, don't even remember what the USDA recommended amount is, but, I will say that we no longer recommend doses of biotin in greater than 5,000 micrograms because the risk outweighs the benefit.
• 43:20
  Dr. Sarah Stierman: So I would just stick to the amount that's in your multivitamin or that you can derive from your diet.
• 43:26
  Dr. Komal Patil-Sisodia: That's excellent information.
• 43:28
  Dr. Komal Patil-Sisodia: I think that's the biggest tip for me.
• 43:30
  Dr. Komal Patil-Sisodia: I was in it for all the skincare stuff and now I'm walking away with this cardiac assay knowledge.
• 43:35
  Dr. Komal Patil-Sisodia: Thank you.
• 43:35
  Dr. Komal Patil-Sisodia: I feel very well informed,
• 43:37
  Dr. Sarah Stierman: so, here's the good news if we take away your biotin.
• 43:40
  Dr. Sarah Stierman: There are better things to take for your hair, especially because we can talk about supplements for skin health, but I feel like the nutraceutical, market for hair health has exploded.
• 43:53
  Dr. Sarah Stierman: And so there are a lot of supplements for hair health.
• 43:56
  Dr. Komal Patil-Sisodia: I had love to hear about those.
• 43:57
  Dr. Komal Patil-Sisodia: What do you think are the best ingredients that are out there on the market?
• 44:01
  Dr. Komal Patil-Sisodia: Or if there are supplements?
• 44:02
  Dr. Komal Patil-Sisodia: Definitely.
• 44:03
  Dr. Komal Patil-Sisodia: So,
• 44:03
  Dr. Sarah Stierman: Certainly, and again, I will preface any sort of brand discussion with the fact that I do not have a relationship with any brand.
• 44:09
  Dr. Sarah Stierman: So this is totally just from my personal practice, not from any sort of kickback.
• 44:15
  Dr. Sarah Stierman: Neutrophil and Viviscal were the first comprehensive, supplements on the scene for, hair health.
• 44:21
  Dr. Sarah Stierman: And they work in a similar way.
• 44:24
  Dr. Sarah Stierman: Neutrophil has a lot of wonderful ingredients in it, including saw Palmetto saw Palmetto is a very frequent ingredient you'll see in any sort of, hair loss or hair preservation nutraceutical supplement.
• 44:37
  Dr. Sarah Stierman: It's been around for a very long time.
• 44:39
  Dr. Sarah Stierman: The reason it works for hair loss is because it's a five alpha reductase inhibitor.
• 44:45
  Dr. Sarah Stierman: What is five alpha reductase?
• 44:46
  Dr. Sarah Stierman: It is the enzyme that converts testosterone to dihydrotestosterone, and dihydrotestosterone is the hormone that makes your hair fall out.
• 44:55
  Dr. Sarah Stierman: So saw palmetto is a natural mimic to that enzyme.
• 45:00
  Dr. Sarah Stierman: It will not allow testosterone to convert into DHT, which is the hormone that makes your hair fall out.
• 45:06
  Dr. Sarah Stierman: The downside to saw Palmetto depending on concentration, is that it can have some interactions with medication.
• 45:13
  Dr. Sarah Stierman: So before you would start anything with saw palmetto in it, I would make sure that you don't have a contraindication with the drugs you're already taking.
• 45:19
  Dr. Sarah Stierman: That's fair.
• 45:19
  Dr. Sarah Stierman: And the other fun thing is that, so we talked about saw palmetto being a five al or reductase inhibitor.
• 45:27
  Dr. Sarah Stierman: So it blocks DHT, well, pumpkin seed oil is a natural phyto sterol that blocks DHT.
• 45:34
  Dr. Sarah Stierman: Pumpkin seed oil is incredibly well tolerated and has no sort of drug interactions.
• 45:38
  Dr. Sarah Stierman: And so when I look for a really good nutraceutical, I'm looking for something that at minimum has pumpkin seed oil in it and has vitamin D in it.
• 45:45
  Dr. Sarah Stierman: Okay.
• 45:46
  Dr. Sarah Stierman: Plus minus salt palmetto, which is a very, very effective ingredient.
• 45:49
  Dr. Sarah Stierman: But again, just careful with cross reactions with drugs.
• 45:52
  Dr. Sarah Stierman: Yeah.
• 45:52
  Dr. Sarah Stierman: Those are honestly my favorite ingredients.
• 45:55
  Dr. Sarah Stierman: My favorite nutraceutical, was formulated by a group of dermatology colleagues of mine who are hair specialists internationally.
• 46:03
  Dr. Sarah Stierman: It's called Stresse.
• 46:04
  Dr. Sarah Stierman: X-T-R-E-S-S-E.
• 46:08
  Dr. Sarah Stierman: What I love about it is that it's biotin free.
• 46:11
  Dr. Sarah Stierman: And, because Nutra fall actually won't be biotin free until 2027.
• 46:16
  Dr. Sarah Stierman: The only version of neutrophil that is biotin free at present is the women's vegan version.
• 46:22
  Dr. Sarah Stierman: So if you're looking at nut nutri fall and you really like it, go for the women's vegan version because it's biotin free.
• 46:28
  Dr. Sarah Stierman: But extra say is all of the wonderful ingredients of neutrophil sans the biotin, but it's into sugar-free strawberry flavored gummies.
• 46:39
  Dr. Sarah Stierman: And I'm perpetually 12 years old and enjoy, taking two strawberry flavored gummies as opposed to giant capsules.
• 46:48
  Dr. Komal Patil-Sisodia: Yes.
• 46:49
  Dr. Komal Patil-Sisodia: I think I would agree with that.
• 46:51
  Dr. Komal Patil-Sisodia: I tried some of these other, brands that you had said before, and just how did one of my friends describe it as Earth Forward?
• 46:59
  Dr. Komal Patil-Sisodia: They were very earthy and I could not get them down the hatch no matter how hard I tried.
• 47:05
  Dr. Komal Patil-Sisodia: Some of'em are like four capsules a day and it is a lot.
• 47:08
  Dr. Komal Patil-Sisodia: It's a lot.
• 47:08
  Dr. Sarah Stierman: Viviscal.
• 47:09
  Dr. Sarah Stierman: It's usually one in the morning and one at night.
• 47:11
  Dr. Sarah Stierman: Talk about Earth Forward.
• 47:13
  Dr. Sarah Stierman: I would call viviscal fish forward.
• 47:15
  Dr. Sarah Stierman: It has marine based collagen in it.
• 47:17
  Dr. Sarah Stierman: I did not tolerate viviscal simply because I couldn't stand to swallow it.
• 47:22
  Dr. Sarah Stierman: But it is very effective.
• 47:26
  Dr. Komal Patil-Sisodia: It was great and I wished that I could have tolerated it, but it was not gonna go down the hatch for me, okay.
• 47:32
  Dr. Komal Patil-Sisodia: I will link all of these things in the show notes so people know what we're talking about and they can, take a look and see what works best for them.
• 47:39
  Dr. Komal Patil-Sisodia: This is fascinating.
• 47:40
  Dr. Komal Patil-Sisodia: Thank you.
• 47:41
  Dr. Komal Patil-Sisodia: So those are our nutraceuticals, correct?
• 47:42
  Dr. Komal Patil-Sisodia: Yes, those are,
• 47:43
  Dr. Sarah Stierman: those are my powerhouse nutraceuticals.
• 47:45
  Dr. Komal Patil-Sisodia: Okay.
• 47:46
  Dr. Komal Patil-Sisodia: Tho those were your powerhouses?
• 47:48
  Dr. Komal Patil-Sisodia: Yes.
• 47:48
  Dr. Komal Patil-Sisodia: Okay, perfect.
• 47:49
  Dr. Komal Patil-Sisodia: And then, just because I want to be mindful of your time, I'm gonna jump to the hot topic on everybody's mind, which is.
• 47:57
  Dr. Komal Patil-Sisodia: Topical estrogen data in your skin, right?
• 48:00
  Dr. Komal Patil-Sisodia: We see all of these things that are out there, the Estriol creams, the, different companies that are putting them out there.
• 48:07
  Dr. Komal Patil-Sisodia: I believe they're all compounded.
• 48:09
  Dr. Komal Patil-Sisodia: And, you know, what does the data actually show us?
• 48:12
  Dr. Komal Patil-Sisodia: And would women benefit from this?
• 48:14
  Dr. Komal Patil-Sisodia: And is there a systemic uptake of these that we need to be worried?
• 48:17
  Dr. Sarah Stierman: All amazing and very topical questions.
• 48:20
  Dr. Sarah Stierman: So, topical estrogen has really kind of exploded on the scene there's been some very reasonable data for a while, but I feel like the direct to consumer marketing has become very intense over the last, six to 12 months.
• 48:34
  Dr. Sarah Stierman: The two main topical estrogens that have data are both topical estradiol, which I think a lot of people including your podcast listeners are probably very familiar with it's used for a lot of different things, most of which are not dermatologic in nature.
• 48:49
  Dr. Sarah Stierman: Estradiol, is the much more potent version of topical estrogen.
• 48:55
  Dr. Sarah Stierman: And then there's Estriol as well.
• 48:57
  Dr. Sarah Stierman: So it's, you know, E two versus E three and.
• 49:01
  Dr. Sarah Stierman: Estradiol has a much higher affinity for estrogen receptors, both in the skin and in other places of the body.
• 49:08
  Dr. Sarah Stierman: It does have the most amount of robust data when we talk about stimulatory effects on dermal fibroblasts.
• 49:13
  Dr. Sarah Stierman: So again, your collagen factory cells?
• 49:16
  Dr. Sarah Stierman: Yes.
• 49:16
  Dr. Sarah Stierman: Okay.
• 49:16
  Dr. Sarah Stierman: And for collagen synthesis because of that fibroblast signaling, the only issue Yeah.
• 49:22
  Dr. Sarah Stierman: That we do worry about with topical estradiol is that there is evidence it can be systemically absorbed through the skin, hence transdermal estrogen.
• 49:31
  Dr. Komal Patil-Sisodia: Yes, it is a systemic HRT treatment.
• 49:34
  Dr. Komal Patil-Sisodia: Right.
• 49:35
  Dr. Komal Patil-Sisodia: So putting additional on your face seems like a quick pathway to maybe taking too much.
• 49:40
  Dr. Komal Patil-Sisodia: Correct.
• 49:40
  Dr. Sarah Stierman: Certainly we can see clotting risks with patients who are on excessive amounts of topical estradiol depending on their other risk factors.
• 49:48
  Dr. Sarah Stierman: I have not seen firm data to suggest that there's a direct correlation between applying topical estrogen and activating, you know, hormones sensitive breast cancer, but it's out there in the literature enough that it's worth a conversation with your OB, GYN and or on oncologist if you're wanting to consider topical estrogen.
• 50:09
  Dr. Sarah Stierman: Yeah.
• 50:10
  Dr. Sarah Stierman: Now Estriol, a lot of people, think that Estriol is safer because it is less of a potent topical estrogen.
• 50:19
  Dr. Sarah Stierman: It is pharmacologically weaker and doesn't have the same.
• 50:24
  Dr. Sarah Stierman: Possibility of systemic uptake as estradiol.
• 50:28
  Dr. Sarah Stierman: So estriol generally, we know it's a weaker version.
• 50:31
  Dr. Sarah Stierman: So you're not necessarily gonna get the systemic changes.
• 50:34
  Dr. Sarah Stierman: The problem is that I have no head-to-head studies yet on estradiol versus Estriol about effectiveness versus, you know, risk benefit.
• 50:44
  Dr. Sarah Stierman: But I will say that what does topical estrogen do?
• 50:47
  Dr. Sarah Stierman: Well, estrogen, when we lose that, when we take that out of the skin, again, we talked about barrier dysfunction and skin sensitivity and dryness and breakdown of collagen and elastin.
• 50:59
  Dr. Sarah Stierman: By locally putting it back where it belongs, you can regain some of those youthful things, like more, glowing skin.
• 51:10
  Dr. Sarah Stierman: Or less textural changes.
• 51:12
  Dr. Sarah Stierman: Less dryness, more doingness.
• 51:14
  Dr. Sarah Stierman: More, resilience to your skin.
• 51:16
  Dr. Sarah Stierman: What I will say is that the best studies we have on topical estrogen for facial skin at this time are only for the under eye area.
• 51:26
  Dr. Sarah Stierman: And then a little, a little, another study where we have some neck as well.
• 51:29
  Dr. Sarah Stierman: Data.
• 51:32
  Dr. Komal Patil-Sisodia: That was going to be my next question because I also worry like neck proximity to the breasts, like the safety, I think it's a big question mark right now.
• 51:40
  Dr. Sarah Stierman: And again, if there's ever any doubt about your risk in, starting a topical estrogen I would certainly make sure that if you have risk, that you're in communication with your ob GYN, your endocrinologist, your oncologist, to see whether the risk versus benefit is appropriate for you.
• 51:58
  Dr. Sarah Stierman: And then applying it to just more localized areas of skin concern.
• 52:03
  Dr. Sarah Stierman: So the under eye area has the best amount of data we have, and that's a very localized area to use it.
• 52:08
  Dr. Sarah Stierman: The likelihood of you getting really significant systemic uptake, just applying it under eye once or twice a day, it's probably safe.
• 52:17
  Dr. Sarah Stierman: And then we just don't have long-term data yet for applying it to face, neck, chest, hands, that's a much larger surface area.
• 52:26
  Dr. Sarah Stierman: And so we don't know yet.
• 52:28
  Dr. Sarah Stierman: We don't know yet what the systemic uptake would be if we were to use it in a larger area.
• 52:32
  Dr. Sarah Stierman: I use topical estro.
• 52:34
  Dr. Sarah Stierman: So I started using compounded topical Estriol from a compounding pharmacy that one of my dermatology colleagues founded.
• 52:43
  Dr. Sarah Stierman: That is based in New York City.
• 52:44
  Dr. Sarah Stierman: It's called Skin Medicinals, and my compounded Estriol has niacinamide in it as well.
• 52:51
  Dr. Sarah Stierman: It's sort of a proprietary compound.
• 52:53
  Dr. Sarah Stierman: But I apply it to my under eye area every single night, and then every other night I apply it to my neck.
• 52:58
  Dr. Sarah Stierman: I have yet to be so bold as to apply it to larger swaths of skin.
• 53:03
  Dr. Sarah Stierman: Just again, because I'm now on transdermal estrogen, being perimenopausal, do I really wanna double, triple, quadruple down on that?
• 53:10
  Dr. Sarah Stierman: Probably not.
• 53:13
  Dr. Komal Patil-Sisodia: No, and I would agree with that, right?
• 53:16
  Dr. Komal Patil-Sisodia: Like, we just don't know.
• 53:18
  Dr. Komal Patil-Sisodia: And if you haven't had proper risk assessment to all our listeners out there, please make sure you talk to your doctors, because you cannot be just doing what you're seeing on TikTok or hearing, especially if it's not been vetted and applied specifically to your medical situation at hand.
• 53:37
  Dr. Komal Patil-Sisodia: Thank you so much Dr.
• 53:39
  Dr. Komal Patil-Sisodia: Stierman.
• 53:39
  Dr. Komal Patil-Sisodia: This was such a good conversation.
• 53:41
  Dr. Komal Patil-Sisodia: I feel like there's so many gems.
• 53:43
  Dr. Komal Patil-Sisodia: I might have to split this up into two episodes because there was just so much gold in there and I don't want people, to miss out on anything.
• 53:51
  Dr. Komal Patil-Sisodia: If you could just spend a minute to tell our listeners where they can find you and where they can find your practice.
• 53:56
  Dr. Komal Patil-Sisodia: If you're on socials, we'll link all of that information below in the show notes.
• 54:00
  Dr. Sarah Stierman: Absolutely.
• 54:00
  Dr. Sarah Stierman: So I am located in little Old Northwest Ohio in Toledo Metro.
• 54:05
  Dr. Sarah Stierman: So in the middle of nowhere on the way to somewhere, but no, Toledo has my heart and we'll always have my heart.
• 54:11
  Dr. Sarah Stierman: Our website at Dermatology Associates inc.
• 54:14
  Dr. Sarah Stierman: Is DA ohio.com.
• 54:17
  Dr. Sarah Stierman: And there you can find me and you can find my MediSpa division ADA Aesthetics.
• 54:23
  Dr. Sarah Stierman: I am on Instagram and, Twitter my Twitter handle is, Dr.
• 54:28
  Dr. Sarah Stierman: Sarah Derm.
• 54:29
  Dr. Sarah Stierman: Where all my dermatopathology posts go.
• 54:32
  Dr. Sarah Stierman: So if you're more interested in skincare and skin health.
• 54:35
  Dr. Sarah Stierman: I have two Instagram handles that I think are very educational.
• 54:40
  Dr. Sarah Stierman: One of them is at Dr.
• 54:41
  Dr. Sarah Stierman: Grass Derm as in grass, like the grass is green.
• 54:44
  Dr. Sarah Stierman: D-R-G-R-A-S.
• 54:48
  Dr. Sarah Stierman: BERM.
• 54:49
  Dr. Sarah Stierman: And the reason the mnemonic grass exists is because that was the, yeah.
• 54:54
  Dr. Sarah Stierman: That was the special memory tool that I used to help patients remember the ingredients of a healthy skin anti-aging regimen.
• 55:02
  Dr. Sarah Stierman: G-R-A-S-S-G is for growth factors and peptides.
• 55:06
  Dr. Sarah Stierman: R is for topical retinoids.
• 55:08
  Dr. Sarah Stierman: A is for antioxidants.
• 55:10
  Dr. Sarah Stierman: The first S is a placeholder.
• 55:12
  Dr. Sarah Stierman: It's called specialty products.
• 55:14
  Dr. Sarah Stierman: And it's a placeholder for things like your moisturizer or your estrogen cream.
• 55:17
  Dr. Sarah Stierman: And then the last S is the most important S.
• 55:19
  Dr. Sarah Stierman: And what do you think it is?
• 55:23
  Dr. Sarah Stierman: Yeah.
• 55:23
  Dr. Sarah Stierman: S pf Woohoo.
• 55:25
  Dr. Sarah Stierman: So I learned something.
• 55:27
  Dr. Sarah Stierman: There's a fun story behind my Instagram handle.
• 55:29
  Dr. Sarah Stierman: That's Dr.
• 55:30
  Dr. Sarah Stierman: Derm and those are where all of my educational, medical based skincare posts go.
• 55:34
  Dr. Sarah Stierman: And then if you wanna just follow me like a day in the life of my practice, seeing what I do from like freezing wards to reading pathology slides, to doing Botox, to doing skin cancer screenings.
• 55:44
  Dr. Sarah Stierman: That is at Dr.
• 55:46
  Dr. Sarah Stierman: Stierman Derm.
• 55:47
  Dr. Sarah Stierman: So my last name?
• 55:49
  Dr. Komal Patil-Sisodia: Thank you so much for your time.
• 55:51
  Dr. Komal Patil-Sisodia: I was so happy that I ran into you at the conference we were both at in the Berkshires.
• 55:56
  Dr. Komal Patil-Sisodia: Hopefully I will be able to see you there next year or in person sooner.
• 55:59
  Dr. Komal Patil-Sisodia: I hope you have a great evening.
• 56:01
  Dr. Komal Patil-Sisodia: Thank you so much for sharing.
• 56:02
  Dr. Komal Patil-Sisodia: You're so welcome.
• 56:03
  Dr. Sarah Stierman: Been so fun.
• 56:03
  Dr. Komal Patil-Sisodia: Thank you.