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 Belinda Welsh. A Fellow of the Australasian College of Dermatologists and winner of the Australasian College of Dermatologists Travelling Fellowship, Dr Welsh opened her solo dermatology practise in 2002. In 2010 she was joined by friend of the podcast Dr Cara McDonald and the two founded Complete Skin Specialists. Having served as the Chair of the Victorian Faculty of Dermatologists and currently holding the position of Vice President of Australasian Society of Cosmetic Dermatologists, Dr Welsh was who I felt was the ideal doctor to answer YOUR questions on all things skin rejuvenation.
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: A broad one to begin with- a listener has asked “When dermatologists talk about ‘skin rejuvenation,’ what does that actually mean?”
DR BELINDA WELSH: Fabulous question! When we do talk in these broad terms, but rejuvenation is just a word that describes renewal- to make younger. When we’re trying to rejuvenate somebody’s skin, we’re just simply trying to improve its quality, its texture, to make it more youthful. For most people, that is addressing the signs of sun damage. For some people, they [the signs of sun damage] don’t show up for a while and for others, they start pretty early. And so that’s effectively what we’re trying to do- freshen up your skin.
So what are some of those signs that the skin might need a bit of rejuvenating?
The most common signs of sun exposure or sun damage tend to be the development of pigmentation. That’s a pretty broad term and that can mean different things to different people, but pigmentation can be as simple as freckles and that can be something that’s genetic, but over time, that pigmentation can present itself as fixed darker spots, like a big freckle that is just really hard to shift. We call them a lentigo. So that’s just a big freckle generally from the sun.
Then there’s a word we use called dyschromia, or solar dyschromia, which is that muddy sort of background, more diffuse widespread pigmentation that happens over time and can be a bit patchy. So sort of brown pigmentation. And that’s a sign that your pigment cells have just really gone into overdrive as a result of the sun.
The second thing is redness- patchy redness and capillaries. They just represent little dilated blood vessels under the skin. They happen partially because the collagen underneath the skin acts like packing material and it packs around those blood vessels quite tightly, and if you lose collagen in the packing materials, you can imagine that those blood vessels kind of dilate up and they can become more visible through the surface of the skin. So that’s brown and red.
And then finally, you just start to see these little fine lines and wrinkles, and that’s also a representation that you’re losing that collagen and you’re losing that plumpness under the skin, which is meaning that it looks dehydrated. Now that means, again, different things to different people. It doesn’t mean you just need more water, but it means that your skin’s lost a little bit of its tone and elasticity.
We all age in different ways. When I say “age,” most people think of ageing as just what we call intrinsic ageing, which is just our body’s own genetic programming. But actually, most ageing is photo ageing, which is sun induced.
A few listeners have asked “Are there ways that we can undergo skin rejuvenation or renewal at home?”
Okay, well, I am going to be really boring here because I’m going to tell everyone that your skin reflects your general health. And I think it’s so important not to forget that because if you want to start rejuvenating and looking youthful and vibrant and glowing, you’ve got to start with your general health. You can throw as many skincare products as you like at your skin, but if you’re smoking and drinking too much and you’re not sleeping and you’re stressed, it’ll show.
We bang on about sunscreen for good reason, but I’ll start there. Every single day. The next thing is don’t smoke, minimise alcohol and eat well. That is so underestimated, how your diet and your general health reflects. Exercise, again, really important sleep, try and manage stress, it’s different for different people but try and manage it. That healthy lifestyle is critical. So that’s step one!
Step two is skincare products. I’m sure you have a very, very well-educated audience, and they’ve probably heard a lot of the same things from all the dermatologists. We talked about sunscreen, I mentioned that, and then there’s of anti-inflammatory skincare, and then your antioxidants- so vitamin B3, vitamin C and other antioxidants, and vitamin A- we love retinol and the retinoic acid that we tend to prescribe.
You can get home peels, you can get all sort of devices and God knows what, but sometimes it’s a false economy. Buying all that stuff, If you’re not looking after your general health, is a waste of money. You’re never going to look fantastic if you’re not looking after your general health.
So I would say do all those things, have a pretty simple skincare regime incorporating those active products and you’re well on the way.
Another listener has asked, further to what we’ve just talked about, “Is there a way that I can gently resurface my skin at home, a little more intensely than just using a scrub or AHAs and BHAs, or is it best to visit a clinic for anything beyond just exfoliating?”
I think that’s a great question. Gut feeling is to say visit a clinic, because one of the big things that we see, and I might bring this up again a bit later on, but the skin is accessible. So we all have this sort of feeling that if a little bit’s good then jeez, more must be better, but it really doesn’t work like that. A lot of the time when I’m seeing people [in clinic] they’ve actually overdone it. They’ve kind of launched in and thought “Well, I am just going to go for it and peel and resurface,” and they actually have ended up with dermatitis or inflammation as a result of that. So more is not always better.
Now, some people’s skin can hack it. You can throw a lot at it and they’ll really tolerate it quite well. But others, and most, actually don’t. So I would suggest that if you’re wanting something a little bit stronger, for example some peels, which is usually the next step, I would suggest get it done by a skincare professional and that way you just avoid getting yourself into trouble by over resurfacing, which for most people ends up being exfoliating, whether that be mechanical or chemical, and then thinking “Oh, now I’ve got a problem, I better do more!”
While we’re still on home care and topicals- the three things that popped up the most when I asked our audience to submit questions for you were the treatment of pigmentation (Melasma and dark sun spots), the treatment of redness, and just a general lack of glow and brightness in the skin (a lot of people dealing with a really dull, lacklustre complexion). Do we need to treat these three concerns individually?
It depends. I think possibly some people might have these individually without the others. But usually when you’re treating one, you can help the others. So it’s a bit of a tough question because, as a dermatologist, a thousand things run through my mind in terms of possible diagnosis. At the end of the day, that is the issue- is that you need a diagnosis for what’s going on. And if you’re constantly trying to use products to fix these things without knowing what the true problem is, you can end up getting yourself caught.
So I think if it’s primarily pigmentation, there definitely are products that are more geared to pigment and they tend to be products that are anti-inflammatory- so niacinamide, and then your antioxidants like kojic acid or Vitamin C. Unfortunately we always keep telling people what to look for in their skincare ingredients, in their products, but that is the reality. Those sorts of products are very good for pigment. Melasma, as I’m sure your listeners well know, is notoriously hard to treat. Anyone who knows anything will be very realistic about that. So it’s sunscreen, active products as I mentioned, and then sometimes we just need prescription treatments to shift it. Melasma can be in the top layer of skin, so sometimes you can have success with topical products to shift that and peels, and other times some of that pigment can be a a little bit deeper so that is very hard to treat. So I usually recommend starting with those skincare products, then we might go to prescription creams containing hydroquinone. Kojic acid is very good, so I think if you can find something with kojic acid, that’s very helpful and it’s something people can always also find over the counter. That’s a worthwhile adding in. And then of course we will use peels and sometimes even oral medication for melasma, which we’re using a bit more of.
Lasers a fraught with difficulty- usually I don’t recommend lasers [for melasma]. We try and stay away from lasers because even though you can get early improvements, sometimes it will bounce back and it’s not a long-term fix. So it’s money that is not worth spending often in the long term. With dark sun spots, sometimes all the skincare in the world will not shift those, and we need to use other modalities in our clinic to shift them. They are very hard to treat. You can lighten them a little bit.
There’s many causes for redness and sometimes it just represents inflammation. Sometimes it may be capillaries. Capillaries cannot be moved with skincare and we need to laser those to improve them. So I wouldn’t recommend trying for a long time to remove capillaries with any type of skincare, because it just doesn’t work.
A general lack of glow and brightness, that’s a good one. I’m thinking, you know, it depends on your age too. One reason that your skin might be like that is because your general health is not good. And I think that is usually number one. So, you know, you’ve just got to think about that. Smoking is diabolical. The next thing is, if you’re pretty well, and you’ve just got a general lack of glow, the alpha hydroxy acids, that just a little bit of chemical exfoliating is very nice and they can often give you a bit of an instant lift. It’s important to keep moisturising so you don’t dry your skin out too much, but overall those glycolic, lactic acids, a little bit of BHAs like salycilic acid also helps to sort of get you some gentle exfoliation.
We’ve touched on some ingredients there. In the same vein, a listener has asked (I love this question) “Can over-the-counter products actually help with pigmentation or do I need the stronger stuff?”
I think that’s a pretty realistic question! Look, you can help fade it a little bit and there’s no doubt we’ve had a lot of success with people just improving their skincare with over the counter products and appropriate stuff. I think you’ve got to commit, and that’s the other thing- you won’t see results in two weeks. Don’t be sucked into that. You need to hang in there for three months, six months, because it really does take time. So that’s the first thing to do- hang in there. But if you get to four or five months and you are not seeing any improvement, you’ve chosen all those ingredients and you’ve stuck at your routine, that’s when you need to go “Right, I need some help.” You need a diagnosis and, based on that, we need to decide what’s best to do. Because melasma, absolutely, is usually going to need that next level prescription. You can get 2% hydroquinone cream over the counter, but that’s as much as can be legally dispensed by chemists. Beyond that it’s a prescription item. Often for melasma we need to use hydroquinone, which is our go-to at about 4% to 8%, but we usually sit around 4% or 5% or so it’s not irritating. There is a new cream that is out there… they’re not necessarily available in Australia yet, called cysteamine and that shown some good results for skin lightening and particularly melasma, so that’s an exciting thing that’s on the horizon. It’s probably about as good as hydroquinone, but can be a little bit irritating. So that’s a product that we might have to just sort of watch for the moment. Hydroquinone has been around for 60 years and frustratingly we still struggle to find a really good cream that is able to lighten to quite the same degree. We do use oral medication now for some types of melasma, that can be helpful, but that’s obviously a prescription item. It seems to have a good safety profile. And we’ll do some light peels for some people whose skin can tolerate it.
One listener writes in saying “I’m 34, I use retinol 1.25 every night and vitamin B3. Is there anything else I should be using for pigmentation?” Now, I’m going to assume she’s talking more about post-inflammatory hyperpigmentation rather than sort of very dark spots and melasma.
Okay, so post-inflammatory hyperpigmentation is again another tough one. And the reason is that that type of pigmentation occurs because the pigment in the pigment cells is deeper in the skin. And I often say to people think of it a little bit like a tattoo- the pigment cells sit at the junction of our epidermis and dermis and they donate melanin or the colour of our skin in little packages up to the epidermal cells. So, if you’re lucky, if you’ve got increased pigmentation it’s sitting up there high on the skin. And so if we increase that skin cell turnover, we can actually help shed it. But in post-inflammatory pigmentation, there’s been inflammation. The junction between the two layers of the skin has been damaged. And so some of that melanin that’s sitting in a little package, like a little bit of tattoo ink has dropped down deeper into the skin and it’s sitting in there. A little bit like tattooed pigment, so it actually becomes really hard to shift and a lot of topical products cannot do that because they don’t get down deep enough.
With post-inflammatory pigment, we have to wait for mother nature to do her very best, to send in cells to sort of gobble up that pigment and carry it away. So that’s where the topicals are a little bit more frustratingly slow or don’t work as well if we’re talking about that. You could certainly add in some kojic acid and some vitamin C- those antioxidants will help. But I think they will help your overall skin, not necessarily shift that deeper pigment.
To listen to the full interview with Dr Belinda Welsh, subscribe to the Glow Journal podcast now on iTunes or Spotify
