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 John Sullivan. A dermatologist with over two decades of experience in both clinical practise and academic teaching in Australia and Canada, Dr Sullivan is leading the way in clinical research and is at the very forefront of advances in laser dermatology as the principal investigator on numerous dermatology trials. This in mind, I felt that Dr Sullivan was the ideal doctor to answer your questions on one of my most frequently queried topics- sun damage.
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 insist on taking those questions to a medical doctor. That’s why I truly 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: Before we dive into the listener questions, I do think it’s important to first touch on the signs that our skin actually has suffered some damage from the sun. So firstly, a broad question, but what is a sun spot and how are they caused?
DR JOHN SULLIVAN: With sun damage, it is something that does creep up on us. Although a lot of the lesions on our skin can be called sun spots (“sun spots” usually means the pre-cancerous ones), but a lot of the things that people would think of as a sun spot are just what we call sun damage. That could mean the skin has lost a bit of its lustre, it’s a bit dry, not quite as shiny, a bit uneven or with a few crusty spots. Often the first thing that we see is uneven pigmentation. A true “sun spot” that’s actually pre-cancerous itself, is often a bit rough, a bit like sandpaper, and it can get irritable when you go in the sun.
And what about a mole? Does a sun spot differ from a mole?
A mole is made up of skin pigment cells called melanocytes. You can be born with moles, but with sun exposure moles can develop as clusters of these pigment cells. If they’re on the surface of the skin they can be very dark in colour and often flat to start with. As they evolve, they can lighten in colour as the pigment cells go deeper into the skin and, with time, they can even just be raised, skin coloured lumps.
We also know that freckles can be a sign of sun damage. I’ve had one listener who has asked “Are all freckles are the result of sun damage, or can they be genetic?”
In places like Australia, most of our freckles will be sun damage. There are some families where freckles are definitely a part of their makeup, and even with the most stringent sun protection, in summer they’ll still get a few freckles darkening on the nose and cheeks.
But in Australia, if someone is getting a lot of sun and they’re not protecting themselves, freckles are a telltale sign [of sun damage], especially when they’re not just limited to the face and they’re over their shoulders, chest, hands and arms- that’s definitely some sun damage in that form.
What would you deem to be the very best clinical treatment available to reduce the appearance of sun damage?
Our “gold standard” treatment for sun damage, and a lot of what we call sun damage as it accelerates the changes of ageing, would be the CO2 laser. We’re lucky now- we’ve got really good, fractionated CO2 lasers, such as the CO2RE, and that really does tighten the skin, get through a lot of those pigmented spots and help to shrink down pores and reverse a lot of the changes we think of as sun damage.
So that’s the gold standard. What about home treatments?
As I mentioned before, sun damage does sort of creep up on us and it’s not until we get a bit older that we realised we should have done better when we were younger. The most important thing is that it’s never too late to improve your sun protection and sun precautions.
We’re also really lucky in Australia in that we have the best ingredients from Europe and really good formulators in Australia, so Australian sunscreens generally offer really good protection, made to last in our harsh climate. I suppose the big thing to note is to not get American sunscreens, because they’re 25 years out of date- European and Australian made sunscreens are usually a lot better.
The other thing I should say is that fruit acids are really good all-rounders. If you’re starting with something [to treat sun damage], my favourite ones are usually things like lactic acids or mandelic acid. They have all the benefits of the normal fruit acids, but they’re a lot more gentle than some of the glycolics or the other ones. So lactic acid or mandelic acid would be a good place to start.
You have kind of covered this, but I had a number of people write in to ask if serums and creams can actually work to fade sunspots. We see it plastered across the front of products, saying “This is going to remove sun damage and wind back the clock,” but is that possible?
I actually do think they play a good role. For a lot of people, if you don’t have badly sun damaged skin and even actually if you do have quite sun damaged skin, you can see quite a marked improvement when you start using fruit acids.
The big thing that you’ve got to make sure you do is introduce them slowly and a bit more cautiously, because if you cause irritation, dryness, or make your skin more red or worse, you’re going to get disappointed and give up. Fruit acids, especially when you’re young and don’t have too much damage, they help to soak in and maintain the strength of the collagen elastin layer. Skin functions best when it’s well hydrated, and those fruit acids actually hold in those enzymes so all the functions work a bit better.
Later in life, when you get that lustre-less skin with all the scales, roughness and sun spots that you mentioned before, they [fruit acids] can really help to strip off the dead skin cells and even out the skin. So fruit acids definitely have a good place, and they’ve got a good role either in mild sun damage or more severe cases.
I feel like you’ve touched on something there that we might come back to a few times, which is “Just start now”. While we’re on home care, some listeners have written to me about vitamin A and vitamin C in that they’re often recommended to treat sun damage, but they can also make the skin that bit more susceptible to new sun damage. So is SPF just the solution here?
Vitamins A and C are good things to have, because vitamin A is very normalising and has an anticancer effect and strengthens the collagen, and vitamin C is also good because we do have a lot of pollution and other insults to our skin, and that does reduce some of those effects on the skin. Again, if they’re a nicely formulated product, they should work well in combination with the fruit acids.
The other ingredient that’s good to look out for is nicotinamide or vitamin B3, which has been shown in combination with a sunscreen to reduce the damage to your skin from the sun. When taken as a tablet, it has also been shown to actually reduce skin cancers and that later, and in products is going to have the same benefits. So nicotinamide is another good ingredient to look out for. But as mentioned before, although they take away some of the dead skin cells from the skin to make it look more even and give it more lustre and shine, they top layer does provide some of our protection. Although [the skin] may be a bit more sensitive to sunlight, if you combine it with some of the newer sunscreens which a nice, cosmetic ones to use, the sunscreen is going to provide you with far more protection than those key cells that have been removed would have provided otherwise.
So we’ve got a few home care options, which is good to know. If we do decide to take that gold standard laser route, after how many treatments should we expect to see our sunspots, our freckles, and any of that sun damage start to fade?
It depends on what sort of treatment you have. If you’re starting out, you probably don’t want to jump into doing our super strong gold standard one- it has dramatic, excellent results, but it also has a bit of downtime so you’ve got to know if it’s worth that downtime.
Things like medical intense pulse light, such as a Nordlys laser, has been cleverly made in that it can be tuned to target either the skin redness, the brown spots, or just for collagen stimulation or things like temporarily reducing pore size and helping maintain the skin. With a good operator, you can really see good improvements after just one treatment.
If you’ve got more sun damaged skin, you might want to do a series of two to three [treatments] where the first one really removes that mantle of uneven pigmentation, so that in the subsequent treatments we can really target the redness and other sort of changes. If you do have quite damaged skin, each time you have the intense pulse light it does keep improving that collagen and elastin layer at the same time.
If you’re just starting out and your skin is not too damaged, one treatment might be enough and there’s good evidence that when doing a single treatment each year for five years, you can see cumulative benefits over that time. But if you’ve already let a whole lot of sun damage happen, or if you’ve got something important coming up later in the year that you want to look good for, plan two to three treatments, four or six weeks apart, to really see a good difference. With intense pulse light you don’t have all the downtime of potential CO2, but you still get a lot of the good benefits.
What a luxury to have something exciting to be planning for! Are those treatments permanent, or should we expect that some of those spots might return?
I think with a well done treatment, some of those spots will be permanently removed, some will be partially removed and might come back a bit over time, then there are other spots that might have been a bit treatment resistant and maybe we needed to target them harder. But again, even if you’re doing the best treatment and have the best operator, with something like intense pulse light you can improve things significantly but we won’t shift every single spot. That also gives you a natural look- you won’t suddenly have no freckles on your face, and then [have freckles] starting on your neck and chest later on. So I suppose that’s sort of good and bad!
But we keep ageing, we keep getting sun, and unfortunately a lot of our sun damage from, say, the last three to five years can slowly start to appear over time. So with some of these treatments, say if you do the strong, gold standard one, a year or two later you won’t see those spots returning at that stage. But with, say, the intense pulse light, you would get lots of compliments especially in that first three months, you skin will still be improved, but you probably do get a drop of the benefits and it might be something that you’ll want to plan to do as a yearly treatment for a few years to keep seeing that improvement and help maintain the skin. After that time, the way the skin works, it’s nice to trick it into responding really well again. So although it’s nice to repeat the same treatment and get cumulative benefits, sometimes after a series of treatments we’ve got to do something different to make it more effective again.
It’s such a personal thing, too. I think everyone’s skin is different, and as you’ve said, it can also depend on things just like what you’ve got coming up- so we have to go see the experts. Now, one listener has asked about microneedling. She asks “Can microneedling help at all with improving the appearance of sun damaged skin?”
Yes! The needling of the skin was actually developed by a South African dermatologist, and he does these microtraumas to stimulate a whole lot of healing and growth factors which does lead to some of that contraction and it does activate the skin maintenance mechanism. So we do think that microneedling is beneficial.
It can be varied from being nice and superficial to be deep, it can be done lightly or more intensively. It definitely does lead to some benefits, don’t expect miracles from microneedling. Often you need to trick the skin more to heal more. Some microneedling devices combine radio frequency, or if you do the equivalent with the fractionated laser, it can really tighten the skin and do more.
But as you said, microneedling is good in that there’s not too much downtime. It’s very safe and it’s a nice maintenance [treatment] to do. If you’re not expecting a dramatic change and want to just improve things and keep your skin a bit younger, then mix in your treatments with some light microneedling as well.
We love keeping the skin younger. I’ve had a few listeners ask why their freckles have faded as they’ve grown from being a child to a young adult…
Especially if you haven’t had too many bad sunburn days or a lot of sun damage, if you’re being pretty good and you’ve just got some freckles that appeared in the sun when you were younger and you’ve protected yourself well and they fade in the winter, normally they will become a bit lighter with age and time. In fact, when you get older in life, those freckles may completely disappear.
If you are getting a lot of sun, ongoing sun, and too much sun, then you’ll actually get more and more [freckles] over time and you won’t observe that nice fading that you’ve just mentioned.
How come some people still do get new freckles, even when they’re wearing their sunscreen and they’re limiting their sun exposure?
It definitely can be a genetic tendency. People with really fair skin, blue eyes, people of a Celtic background, it is in their skin makeup. Even with really stringent, excellent sun protection, they’ll get a few freckles. It’s a healthy, sort of normal thing, and you really do want to get the benefits of sunlight and being outdoors in Australia (but you can do it safely with sunscreen), but unfortunately if you’ve got that skin type, you’ve got to expect freckles- and a few freckles aren’t bad!
No, and people are drawing them on now anyway, so they can be a very nice thing! One listener has asked (and based on the tone she’s used, I think maybe she’s already tried a few different things), “Can you REALLY get rid of freckles- in particular large, dark freckles?” Can you get rid of them?
Pigment laser or intense pulse light, the medical ones, they are very smart and you can adjust the length of the pulse and the strength to really target pigment. If there are some stubborn spots, you can really just target those spots to really shift them. If you’re just having a sort of general, photo rejuvenation, there might be some resistant lesions and some people do have quite difficult-to-tear spots. [The skin] can be tricked with that device to actually get a really good outcome. But if you’ve had IPL and you’ve been disappointed, and you really are looking at going for that CO2 laser, that will shift those lesions. You’ll have a nice, crusty sunburn reaction for a week afterwards, but there always has to be some sort of negative for every positive when it comes to cosmetic things. With the most effective [treatments], you really do lose up to a week of your life or occasionally a bit longer. So if they are really bothering you, you should ask about a stronger treatment.
Now might be the time to do it, now that we’re all working from home. Is there a way to treat pigmentation without removing all of a patient’s freckles?
Depending on the [laser] settings used, you can just lighten them or only remove a certain amount of them. I think that’s important- to tell your clinician or therapist what you want out of the treatment. Maybe do a test area so you can talk to them and give them feedback on what you want to see.
If someone wants just their freckles lightened a bit, but mainly just rejuvenation, if you use more anti-red or vascular settings, the collagen layers helps get rid of the redness and broken capillaries and, indirectly because melanin absorbs all frequencies of light, it will also partly target those [freckles] and will lighten them without removing them. So if you are still attached to your freckles, but maybe you don’t want them quite as prominent, a good vascular intense pulse light or vascular treatment can often give you good lightening there.
Ask and you shall receive. A listener writes “My cheeks are always slightly red. Could this be a sign of sun damage?”
Yes, it could be sun damage. In Australia, our elements do often cause red, rosy cheeks. It can be partly that you inherited a tendency for that red skin from your parents, but if you go from indoors to outdoors, from hot to cold, that flushing can be exaggerated over time. If you combine that with lots of sunlight, which can damage the supporting collagen and elastin, you get more blood vessels that dilate more readily, and that can slightly get worse with time. Lots of Australians have been very much outdoors, like surfers going from hot to cold who haven’t been good with sunscreen when they were younger, they can have really red faces and broken capillaries.
This lady, it might just be an inherited tendency, and even with strict sun protection some people do just get really rosy, flushing cheeks. That doesn’t mean that we can’t improve them with laser, but it’s sometimes sun, and sometimes it’s just someone’s constitution.
Another listener has written in saying that she has pigmentation around her lip line that she believes to be sun related. Being such a delicate area, what would be the best course of action here?
Often, particularly if it’s the upper lip area, it might be partly hormonal as well. Initially, it is actually always important to treat this with creams and, the key part as you mentioned, a good SPF 50 sunscreen every day. With people who are getting a bit of hormonal pigmentation, it’s partly their skin type- often the skin that does actually tan fairly readily, combined with sunlight, will cause it. Sometimes it might be the oral contraceptive pill that also contributes.
A really good broad spectrum SPF 50 sunscreen is the first thing to use, and then there are sort of fading creams- a lot of over the counter ones are nice and gentle and safe. Fruit acids can also help as well. But you can get a strong fading cream made up, and if your sunscreen keeps it away, and you just have to re-fade it after holidays that’s good, but if that’s not working it might be sun damage and maybe laser will be appropriate. But for a lot of people with pigment, you’ve got to make sure it’s not hormonal first because you’re going to be disappointed when you treat it with laser and it just comes back three months later. There’s a good study, a lot of studies, that if you actually use vascular laser if you’ve got a red skin component, treat that and even hormonal pigment will be improved down the track. But for normal hormonal pigment, we try the creams first.
While we’re on treating different, specific areas of the body, how do we treat sun damage and freckles on the chest. I feel like this is a very common one. Do this need to be approached differently to the face and to the rest of the body?
So the chest does really, really well with treatment, but as you’re sort of implying there, it can also be an area that’s very sensitive and if treated too aggressively, it is more prone to a bad outcome or even scarring. We have seen people get the zebra stripes when it’s worked well, but hasn’t been even there. So on the chest, it is actually one of those areas that’s important to [treat] in winter, so we don’t have too much background pigmentation that can take more energy and increase the risks. It’s nice to have a clever device to do it, and that’s where I actually do really like the Candela Nordlys laser. It’s got a clever dual filtering that removes all the infrared heat so you don’t get unnecessary heating. It just has the wavelengths that improve the pigment or the vascular changes.
That area actually does really well with intense pulse light, generally, because it’s partly pigmentation, partly redness and vascular changes and uneven skin. Intense pulse light is not just one wavelength intensely, which has a bigger risk of scarring and other things. By having a broader spectrum of light, it is very effective to target that redness and pigment, but it also can do it a lot more safely. But to make sure it’s safer still, it’s good to do it in winter. Because there’s that risk of getting striping, it’s always good to be warned that you might need a second or third treatment to even it out. It’s good to do it at the beginning of winter, so you’re looking good for spring.
On the chest, if you’ve got a lot of pigmentation, don’t expect just one treatment for the results. You might need two or three.
Very sound advice. I’ve had another listener mention that she has had a tan line for years following just one really bad day of sun exposure many years ago. Would this be the same as hyperpigmentation?
Yes. If there’s increased freckles and that there, I think by treating it you can merge and improve it. It will be a bit like sunburn, freckles, a sudden appearance of a lot of damage over a short time. That just shows how damaging our sun can be. You do have to be careful on every holiday you have. You’re going to regret that really sunny holiday that you didn’t take good sun protection on. Sun protection is always key- avoid American products, use Australian and European.
But that should respond to laser or light treatment, that sort of damage. It won’t be hormonal.
They’re coming back to haunt us, all these holidays of years past. Another listener has asked about pigmentation from sun exposure after hair removal- I assume she means laser hair removal. Would this be due to premature sun exposure while the skin is still quite sensitive and, if yes, how would you treat that kind of pigmentation?
As you mentioned, this sort of hair removal laser, it does target the melanin in the hair follicles and will indirectly target the skin, and it will make the skin more sensitive. When you’re having that series of treatments, try to keep to skin as pale as you can- so using sun protection doing it in winter rather than summer means you’re less at risk to have those changes occur.
I’d have to say sun protection, but a little bit of light exposure might even it out. I would probably throw in a fruit acid cream such as a body lactic acid cream. Usually when something has happened after [laser hair removal] we don’t jump into doing laser, because people are worried it might make it worse. But if the creams, and time, and just a little bit of regular sun doesn’t do the job, that might be where things like the needling and fractionated treatments are really good ot even the pigmentation up again afterwards. But as you said, [the damage] would have been after they had a bit too much sunlight at the time they were doing the hair removal, unfortunately.
Let’s talk about mole. We have kind of touched on this already, but how come some people naturally have more moles? And is it possible to have moles that aren’t caused by sun exposure?
Some families have numerous moles and it just takes a little bit of sun to get a lot more. We can get moles even in areas that have never seen the sunlight. You can actually get some moles on the inside [of the body] as well. Australians have a lot more moles than Canadians, in comparison, because they didn’t get as much sun when they were growing up. But moles can occur anywhere- they can happen between the toes, between the buttocks area, which would have never seen sun. So they do form naturally, but sunlight does definitely increase that number over time.
There’s some families, even with the most stringent sun protection, if you’ve got a really mole-y family you’re going to get moles. But if you have a lot of sun, you could have moles as well.
Now I understand that we can’t just laser off a mole right away, as that mole could be a sign of something really serious and we’re just trying to erase it- so what is the protocol here? Do we need to have a skin check before having our moles lasered?
Yes, especially if there’s any history of skin cancer or melanoma in your family, or funny moles. It’s critical that you do have a thorough skin check first to see that there’s nothing that could be worrying there.
Although dermatologists aren’t keen to remove moles with laser, things like the CO2 laser can be useful to help remove moles on thee face and other areas, and hopefully doing it without too much of a scar or mark afterwards.
Generally if the mole is normal, a dermatologist will say that it’s okay to leave it. But we know that people do hate their moles, so then we can negotiate the cosmetic outcome, because you don’t want to risk a bad outcome for moving a mole. But lasers can be used for removing moles, and if you’re doing things like intense pulse light, often a number of moles will be lightened.
This is another thing that we have touched on a bit, but if a patient has quite sensitive skin, how would you start to introduce treatment for sun damage and pigmentation? Would you suggest that they start with the home care and those fruit acids?
Yes. In that case, it’s good to use a gentle wash- a sort of pH balanced, non fragranced, dermatologically gentle wash. Then introduce one of the fruit acids. If you’ve got sensitive skin, lactic acid or mandelic acid are really good ones to use. You might just start two or three nights and week, and if you’ve got very sensitive skin, you might just stay at two to three nights a week. But over time, after a month or two, you can slightly increase that to four nights a week, five nights. Some people would tolerate every night, but maybe in winter when the skin gets a bit dry and more easily irritated, you might back down. With sensitive skin, even if you can only go two to three times a week, you’ll still see some good benefits.
One listener has asked about treating historical sun damage. She wears sunscreen every day now, but she didn’t in her teens, so she does have some freckles and some sun spots as an adult. With treating historical sun damage, do you have to approach that differently to, say, a fresh spot or is it the same kind of treatment?
Basically, a treatment will depend on what you can see at that point in time. So I’d have to say we would have a similar approach but, depending on things, we might be a bit more aggressive or a bit less aggressive, or choose things differently, but there’d be a similar range of options there.
If there’s a lot of pre-cancerous options, we’ll often combine things like intense pulse light with some photodynamic therapy to help reduce that precancerous change, but otherwise it would be very similar.
Perhaps a cautionary note to end on- one of our listeners has asked “If I don’t use SPF every day, is my skin in trouble?”
I would always protect my face all year round in Australia, particularly if you live in Queensland or the upper half [of the country]. In winter we do need a little bit of UVB for our vitamin D, so in winter you want to get a little bit [of sunlight] on your arms and your legs if it’s not too cold. We are made for a little bit of sunlight, but I would do it earlier in the day, or later in the day, just for five or ten minutes, but always protect your head and neck and decolletage. People always hate age tans too, so protect your hands and just get a bit of sun on your arms and legs in winter- but not in the middle of the day, and only for five minutes in one day.
Sunlight is good. It keeps us happy, our skin adapts to it to a certain degree, but the face you want to always protect.
