The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify
In this instalment of our Ask An Expert series with our friends at Candela Medical, we’re taking YOUR questions to Dr Shobhan Manoharan. A Fellow of the Australiasian Collage of Dermatologists, Foundation Member of the Australasian Society for Cosmetic Dermatology, member of the Australian Medical Association and a Senior Lecturer at the University of Queensland and Griffith University, Dr Manoharan has worked in both the United Kingdom and Australia and has sub-specialised in cosmetic and laser dermatology. Having been published extensively in local and international medical journals over the last decade and with a special interest in pigmentation disorders, laser rejuvenation and skin cancer management, I found Dr Manoharan to be the ideal doctor to objectively answer your questions surrounding the skin on the hands and the neck.
Away from our regular brand founder conversations, I am frequently asked so many highly specific questions about the skin. Given that I am an educated consumer and by no means an expert, it would be extremely unethical for me to even attempt to address your skin concerns- which is why I have long insisted on taking those questions to a medical doctor. That’s why I sincerely love producing this Ask An Expert series with Candela. Although the series itself is sponsored, doctors legally and ethically have to remain completely objective in interviews like this. For this reason, this series is the single most authentic way for me to integrate branded content into the podcast because it’s giving you, the listeners, completely unbiased expert answers to your most specific skin questions.
GLOW JOURNAL: Let’s begin with something that we hear all the time- that being that the hands and the neck are the very first areas to show any visible signs of aging. Is this true? And, if so, why?
DR SHOBHAN MANOHARAN: It may be true for some people, Gemma, but a lot of the big surveys that have been done, both in Australia and overseas, have perhaps suggested that the eyes and the lower face for a lot of people are [the areas to show the first signs of ageing]. But having said that, I don’t discount it. I certainly understand that certain individuals will notice it in these areas, and it can certainly show more advanced changes because the skin is very different. It’s very different from the skin on your face. So the further away you go from your face, particularly on the hands for instance, the there’s much lower density of oil glands, the skin’s much thinner, you get the environmental insults as well as UV radiation, so a lot of hand-washing, detergents, things that you can come into contact with, they can all then sort of predispose to premature ageing. The same applies to the neck- sun exposure, genetic tendency, people wearing fragrances and colognes.
These are all things that might give you a predisposition to early ageing signs.
You mentioned that the skin on the neck and the hands is quite different. I received a lot of questions about topical skincare for these areas. The big one was “Can our facial skincare be used on the neck and the hands, or do these areas require more specific care?”
For most people, you definitely can use it. It just ends up being more expensive. Your facial skincare routine is a magnitude more expensive than what you’d often use for hands. I’m a bit of a princess, so I’ll use the same thing that I use on my face on my neck and my hands as well. You can certainly use it if it’s within your means. The only thing you need to be aware of, I guess, is that for some people you might be a little more oily on the face and dry on the hands. That doesn’t mean you can’t use your facial skincare on your hands, you might just need something a bit more nourishing on your hands.
Also, sometimes if you’ve got a lot of sun damage and things like that, your active ingredients on your hands might sometimes be actually a little bit heavier and more concentrated than what you use on your face for instance.
A listener has asked “Is retinol a bad idea for the neck as it’s quite a strong ingredient, and is the skin on the neck too thin for retinol?”
Absolutely not- retinol is good for everyone. Everyone should have a Vitamin A unless you’re pregnant and breastfeeding, or are a very young individual. Most people should have a retinol in their life, and you should be prepared to use it on much of your body. We understand that some people have more sensitive skin, particularly on the neck for instance, so you might choose to use a low concentration retinol. You might alter your retinol routine, so instead of using it every night, you might use it intermittently two or three nights a week. You might choose to layer it with moisturiser first, so you get less irritation. Sometimes I’ll prescribe quite strong retinols, but get people to use it for short durations- a short contact regime, where you leave it on for, say, two hours a night. So these are all ways you can, even if you do have sensitive skin, use an appropriate retinol in sensitive areas. Areas you’ve got to be super careful about are occlusive areas like armpits, the groin, underneath the breasts, where there’s a lot of friction and the skin is very sensitive. These are probably the only areas that you should avoid a retinol. I’ll get patients to use it on eyelids and lower eyelids, all the way up to their eyelid margin- carefully, and washing off before they go to bed.
Along similar lines, another listener asks “Are there any face products that we should not use an excess of on the hands?”
Not really… No, let me take that back. The question was you shouldn’t use anything in excess on your hands- you shouldn’t use anything excessive on your face either. So technically, yes.
But you can use most of the things that you use on your face and your hands as well. It’s also a very appropriate area. It’s also an area that gets a lot of sun damage and ageing changes. You want collagen remodelling. You want sun damage, sunspots, field change to improve. So you can use retinols, you can use a alpha hydroxy acids, and there shouldn’t be any issues there.
I received a few questions about SPF (which I’m thrilled with), particularly for the hands. We are told that we should reapply our facial sunscreen throughout the day. Do the same rules apply for the hands?
Absolutely, especially if you’re outdoors. Reapply whenever possible. If you’re swimming, reapply immediately post swimming, regardless of what your sunscreen markets themselves as. Hands are an area where, especially with us living during the pandemic, we’re all washing our hands more than what we usually were, so your sunscreen is not going to stay on for very long. So apply it, and if you’re indoors and you’ve done hand washing, make sure you reapply before you go outdoors especially if you’ve got fair skin and have a higher risk of skin cancer and ageing.
Good point there about “regardless of what it markets itself as”…
Exactly. Take everything with a pinch of salt, do your own research, get advice from from medical professionals, professionals in skincare, and make some good health decisions there.
Now, can we use a hand cream with SPF in it or do we need to use an “actual sunscreen”?
You can use a hand cream with SPF in it. But I guess it depends on your SPF coverage. What you’re going to find is a lot of moisturisers, for instance, that you use as a hand cream might have SPF 10, SPF 15, you know, lower SPFs. Most of us living here in Australia still have a very high rates of skin cancer, and most of us who are trying to reduce your photo ageing as well would recommend SPF50+. So if your moisturiser doesn’t have that, consider layering. Layer your sunscreen with your moisturiser- add a 50+ sunscreen on top of it. Aim to have the highest possible sunscreen that you can tolerate, based on your skin type.
What are some of the most common signs of photo ageing on the hands and neck that we should be looking out for?
On the neck, the first sign is often what we call poikiloderma. Poikiloderma is a combination of pigmentation, redness and textual change. You can often see that on necks and chests, particularly in fairer skin individuals. The risk factors for that is fair skin, sun exposure, and also fragrances.
You’ve got to be careful about wearing fragrances in that area.
On the neck and hands you can also develop freckling, or worsening of pre-existing freckles, and you can also then develop wrinkles. You can develop fine lines and wrinkling. You might even get heavier lines and wrinkles as time goes on. So these are things that you need to be aware of.
Keep an eye out for sun spots, so little flaky red spots, for instance, or spots of lumps or bumps that aren’t going away- these need to be looked at by specialists to show that there is no development of our early skin cancers there as well.
A listener tells me that she has “ongoing dermatitis” on the back of her neck and that steroid creams haven’t worked. Are there any treatments that you might suggest for her?
I guess it depends on getting the diagnosis right here. So, is it truly dermatitis? If it is truly dermatitis, often a combination of good, intensive moisturising and combining it with steroidal or anti-inflammatory non-steroidal creams can clear it. But it will often require maintenance with the right moisturiser, et cetera. If it’s more severe, stronger steroids, other creams or even oral medications are sometimes used.
But the problem is if it’s not settling, seek a proper diagnosis because there are a number of other conditions that can present as dermatitis- everything from psoriasis and contact rashes and drug rashes, all the way to a condition called cutaneous T-cell lymphoma, which is a lymphoma of the skin. So it’s a broad spectrum of things that can present. So, if it’s not going away, I always tell patients if a lesion isn’t going away or a rash isn’t going away just with simple therapies, seek some medical input or specialist input.
While we are talking about the neck, another listener tells me that she’s waking up with fine lines on her neck each morning, which are presumably creases from sleeping. How can she prevent these from turning into wrinkles?
It’s tough. It’s a genetic predisposition here. Moisturising before bedtime might be useful. Using a retinol or retinoid intermittently probably helps as well.
The other thing is I’ve been asked to trial a number of compression garments and Silicon garments, Silicon dressings that you can use. There’s a number that you can Google, which have actually worked when you can sleep and apply it consistently. What people find is the consistency is a problem. People get uncomfortable with it and don’t follow through. But these are all small things that you can do to continue to minimise your risk of this progressing quickly over time.
What about skin elasticity around the neck? This seems to be an area where the skin first becomes loose, for lack of a better word. What treatment options would you recommend?
This is a very tough area for rejuvenation. All of us specialists who do a lot of rejuvenation will tell you it’s one of the toughest areas to treat appropriately, adequately, and to give a good long-term outcomes.
Now with severe changes, if someone’s got a lot of laxity, you’re looking at surgical options. So you’re looking at a neck or lower facelift, often in combination. But people who have early changes or are looking for non-surgical options, there are a number of devices and technologies these days that we can tap into. These include radio frequency treatments, radio frequency needling, micro-needling, high-frequency focus ultrasound, you can even think about thread lifts, which have all sort of progressed over over the last decade to have some very good results in a more subtle way for earlier changes for a patient. So these are all things that help tighten and rejuvenate the skin. Sometimes you can also add fillers, for instance, to contour the lower jaw line and add lift as a result. If you’ve got little stubborn pockets of fat underneath the chin, there’s a fat dissolving injection. So these combination approaches are ideal in this situation.
A listener has written in saying “I’ve tried topical skincare to firm my neck, but I’m not sure if it’s working.” Her question is “Do these sorts of firming, lifting neck and décolletage treatments actually do anything?”
To be honest, many of them don’t.
It’s a loaded question!
It is! And especially, if you think about the anatomy of this. If you’ve got skin and lose tissue and volume loss all the way from the skin down to bone, there’s no cream in the world now or anywhere in the near future, that’s going to lift and tighten like that.
Having said that, there are creams that are useful to improve the surface, especially in combination with other treatments. I always still recommend gentle cleanser, a moisturiser based on your skin type and some actives- you know, your As, your Bs, your retinols. These are all things that, as a package, will help you have good skin longterm. But then you’re looking at what we talked about earlier, as some of the deeper devices to help lift and tighten for you. And don’t forget your sunscreen! That’s vital as well.
The same listener asks “Is laser a solution to a firmer neck, and what would you recommend?”
Once again, it varies from individual to individual and based on the severity of a changes, how much laxity you have, your skin type, and what surface changes there are as well. I mentioned a number of devices before, and those were all lifting devices and tightening technologies. They’re great, and for the appropriate patient they can give you good long-term outcomes.
But for more surface changes, for instance, there are lasers that we can utilise. We describe some of the changes, like poikiloderma or elastosis, which is an even more sort of a ragged, cobble stoning type changes on the neck and deeper wrinkles, and there are lasers like non ablative lasers that we can use with low downtime, and there are ablative lasers. I specialise in utilising CO2 erbium ablative lasers, and these have a bit more downtime, but can definitely penetrate more and break down some of that collagen a bit more effectively to promote new collagen and elastin forming through. It’s still a tricky area. It’s not an area where we can treat it quite as aggressively as we can treat your face with laser treatment. For instance, on a face we might do one session and it winds back. I call it my trademark ten-year flashback. On your neck you’re looking at much more subtle, lower settings, more subtle improvements, but something that you do over a series of three or four sessions, and then is maintained by doing a session every three or four months. We’re going to give you improvements, but slower.
Moving away from elasticity, I received quite a few questions about really prominent, visible veins on both the neck and the hands. How can we make these veins appear less prominent?
This is really dependent on the size of these veins or the size of the vessels. So for very small capillaries and even veins and vascular lesions on the face and neck, for instance, there are lasers that we can use. We use vascular lasers like the ND YAG, or for finer vessels we might use pulse dye lasers like the V Beam. These are great devices and they can give very good results. However, when you’re looking at bigger vessels, especially on the backs of hands for instance, you’re probably looking at techniques like sclera therapy where an agent is injected into these veins, under the appropriate experienced professionals (we usually send them to vascular surgeons) and these agents then shut down, they’re like detergents that shut down the vessels. The bigger vessels often need this, and even bigger vessels might be a surgical candidate. It depends very much on the size of the vessels.
Another skin concern that I received a number of questions about was age spots on the hands specifically. What causes these and is it possible to erase or even just to fade them?
I hate the word age spot. It is true and it’s more likely as you get older, but they are a genetic tendency predominantly. It often runs in families and often they start off as little freckles for instance, and over time, sun exposure and genetics make them get darker and some of them can get thicker as well.
We can definitely make big differences with this. If you only have a few little isolated ones, you can use a picosecond laser or pigment lasers, which do a beautiful job just making them frost up and flake away over a few days. Absolutely no downtime. And then if you’ve got a lot of them and a lot of freckling that are dispersed all through that area on the back of your hands, you might use that or you might use IPL device, because they blend in quite nicely. And that might be a series of sessions. For instance, it might be between one to four sessions and that could reduce and clear your pigment, your brown spots. And there are non ablative lasers that can be used as well. So there are lasers like frax which is a wavelength laser, which you can even combine with the IPL devices. The nice thing about using combination treatments like that is you don’t just pick up the pigment, but you also improve the tone and texture of your skin. So you’re getting collagen remodelling and better elastin production there as well. So a bit more downtime, your hands look like they’ve had a sunburn and they’re a bit flaky for five days or so, but you might get a bigger result by that combination technique.
With those options that you’ve just mentioned, are the results of those permanent or does the client have to come back for repeat treatments over time to maintain it?
They’re not definitely not permanent. These will return and you’ll probably get other ones because, like I said, it’s a genetic predisposition. Maintenance is ideal. So, sunscreen, you can use your retinols and your alpha hydroxy acids topically to slow down new ones coming through, and then you might do intermittent IPL sessions, let’s say once every three to six months to try to keep them away as well. Nothing in skin is permanent. So like anything else in regards to healthcare and skin health, maintenance is key.
Perhaps a nice note to wrap up on- I’ve had a listener ask “What are your top few recommendations for things we can do to prevent ageing of the the neck and hands before it occurs?” I don’t love ‘prevent ageing’, so let’s say things we can do to keep our neck and hands looking healthy.
I like that! Tip number one, as I mentioned before, sunscreen. Photo protect yourself, and do that regularly and reapply. I’ve got my, as most dermatologists do, my ABCs. A is your retinol, everyone should be on it, like I said, there’s more evidence for retinols than any other molecule in terms of keeping skin healthy and reducing the signs of ageing. Your B and C serums are antioxidants, they reverse or prevent damage from happening to your skin as well.
Then there are things that you can do that are a bit more intensive if you come into a practice. I would say a high concentration chemical peels, for instance, that you can have done, some light laser, it doesn’t have to be heavy things. You can get some non ablative laser treatments done intermittently as what I describe as a treat for your skin. You can remove the surface damage, remodel, get some new, nice new skin coming through. And by doing those things both on your end and from what we can do on our end, we should be able to keep your skin healthy and fresh long term.
To listen to the full interview with Dr Shobhan Manoharan, subscribe to the Glow Journal podcast now on iTunes or Spotify
