The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify
Isolation skin. It’s real, and you’re not alone.
Our skin is affected by our environment, our mind, our diet and our topical skincare routine, and recent times have thrown our skin out of balance. Our skin barrier is compromised and, when we are stressed, our skin is stressed. I have never before received so many questions on one, specific topic in such a short period of time, so I have taken your questions to a qualified skin expert- Dr Ryan De Cruz.
In the name of full disclosure, this episode is sponsored by CeraVe, however as per all of my expert interviews, the doctor is never here to push specific brands and products. For this reason, you’ll hear Dr De Cruz recommend specific ingredients, rather than products, and offer more general advice, giving you the tools you need to make your own, educated purchasing decisions.
On a personal note, given that the range has been developed with dermatologists, I do use CeraVe myself and have repeatedly come back to it over the last 12 months whenever I’ve overdone it on active ingredients and sensitised my skin, and when my skin is looking and feeling stressed. Although a large part of my job is to trial new products, I have a roster of products that I consider staples- products that I know my skin loves and that I can use to “reset” and restore balance to my skin between trials. For me, CeraVe products are at the core of that roster.
If you are suffering from what has been dubbed as “isolation skin,” I firstly want you to know that you are not alone. As you’ll hear in this interview, many of the skin concerns a lot of you are working through right now are caused by stress, and while we can’t control the state of the world right now, there are steps we can take through our topical skincare to help restore that calm and balance to the skin.
I took to Instagram recently to collate your skin questions, and in this interview Dr Ryan De Cruz discusses the effects of stress on the skin, how we can avoid the irritation brought on by increased hand-washing, the skincare ingredients we should all be looking for and the steps we can take to strengthen the skin’s all important protective barrier.
GLOW JOURNAL: I’ve been receiving so many questions about dry and irritated skin of late. To start with, what is it that causes the skin to become dry?
DR RYAN DE CRUZ: I think the most important thing to realise is that there are many reasons, not just one. We’re all human. We’re all different people. We’ve all got our own genetic makeup. Some of us will have the genes that tell our skin to be on the dry side. Others will be combination and some will err towards oily. It comes down to what we call the “skin barrier.”
The skin barrier is this buzzword that we’re all talking about at the moment, because it’s essentially the likening of the skin to a brick wall. Like the bricks of a house, your brick wall is only as good as the cement that keeps those bricks together. It’s our genes that determine how good (or not) our cement is.
That cement in the skin is made up of a number of different chemicals. Some of these are cholesterol, some are called sterols, fatty acids- it’s quite a unique mix of chemicals that make the cement. If, for genetic reasons, our cement isn’t quite good, our skin cells separate, so the cement breaks down through these gaps between the skin cells and we lose moisture. It sort of opens up our skin, and through these gaps we lose moisture constantly, on a daily basis- even when it’s not particularly hot, we’re still evaporating water from our skin.
This causes dehydration of the skin. Add into that the fact that we live in Melbourne, Australia. It’s an incredibly dry climate, and the humidity levels are much lower than they are in, say, beautiful Queensland. You go there and, already, our skin is much happier because of that gradient. We’re losing moisture from our skin, trying to almost correct the environment. That’s what our body is trying to do. Environmental factors such as lack of humidity and dryness, particularly over winter, will only aggravate preexisting genetic tendency towards dry skin.
Heading into winter, and particularly now in isolation, we’re indoors all the time…
Yes! Isolation skin is a real thing.
It is a real thing! We’ll be calling it Iso Skin 2020, I’m sure. We’re starting to crank up our heaters a little bit more, we’re wearing more layers, and all of that increases body temperature so we’re going to lose more water through “transepidermal evaporation” or water loss as well.
So it’s a combination of genes as well as environmental factors. When they come together, that’s when we really notice that the skin dries out.
Coming back to this concept of our genetic makeup- when we’re thinking about the cement that holds our skin cells together, there are a few key things that we need in that cement. Water doesn’t just float around by itself. It’s actually held by various molecules. One of those molecules is called “hyaluronic acid.” Another key molecule that helps keep moisture within our skin cells are called “ceramides.” They’re two of the most well-researched and evidence-based chemicals that we need in our skin to help our cement stay stuck together, which then prevents the skin drying out further.
Is there a way we can differentiate between general dryness and dehydration and more serious skin conditions?
The way I analyse it is that dry skin forms the basis of a lot of different skin conditions. People might have it as a starting problem. They might say, “Oh, look, my skin is flaky and dull, and I just don’t like the way it feels. It also feels slightly tight and uncomfortable.” That may be something that they’ve lived with for several months or years, and they’ve coped with it. Maybe they’ve been using their common sense and applied a good moisturiser and used a good soap-free cleanser. It’s when you’re doing those things and your skin is not getting better and, in fact, your symptoms are deteriorating [that it may be a more serious condition].
Classic symptoms would include the symptom of itch (we use the medical word “pruritus,” that’s just another fancy way of saying itch), and pinkness (again, we use the word “erythema”). So pruritus and erythema, itch and redness, may be signs of a skin condition- that’s if the skin is not responding to the general measures of soap-free washes and moisturisers. When you start to feel like “This is just not normal for me. My skin is exceptionally sensitive despite using good products, I’m starting to feel very self conscious,” or if it’s interrupting your daily activity or sleep, that’s when alarm bells should ring to say “Hang on, this is not just dry skin. There’s something else that could be going on.” And that’s when I’d seek medical attention.
You’ve mentioned the skin barrier and how important it is. What can we do to strengthen our skin’s barrier?
The skin barrier is something that requires a lot of respect. I think that the most important thing to realise is that it’s not just skin deep. It actually starts with things like our diet and our mental state. It does sound a bit strange- how could what we’re eating or even how we’re thinking relate to the skin? But it certainly does, in terms of inflammation.
We’ll start with diet. The most important thing to remember is that there isn’t a specific diet that people can consume that will help the skin barrier or eczema, psoriasis or acne. It’s actually about general, sensible things to eat. For example, foods that are high in antioxidants, our green leafy vegetables and lots of fresh fruit and vegetables that are high in fibre, because all of these contain natural minerals and vitamins that then help directly facilitate cell activity and development. Drinking plenty of water, of course, is critical. That’s been really proven, time and time again, that when we’re literally dehydrated we’re going to feel more desire to drink water, and that will translate, indirectly, to supporting us our cell structure, both internally and externally.
Once you’ve got a good, clean, healthy diet (and that doesn’t mean you can’t have the high GI foods in special times like confectionary and cheat foods now and again), generally if we keep our diet as clean as possible, we are going to see improvement in our skin. That’s just a fact.
Our mental state is really important to me, because I think the way that people feel in their heads and hearts actually translates to how we then respond to our skin and how are we going to interact with other people. Stress is a really common trigger.
That’s my tell! The second my skin starts to show signs of something, I know I need to take a breather.
Absolutely. We know that, from a biological point of view, we have something called the “stress response.” We have increased cortisol, so increased stress hormones floating around our body, and that will directly trigger things like acne, we know that people’s eczema will get worse, we know that psoriasis will get worse, and again it all comes down to loss of water from our skin. That’s one of the first things that will happen.
Once we’ve got our dietary measures under control and we’re trying, as much as possible, to maintain a well balanced mental state, it comes down to what we’re actually applying to our skin. This is where there’s a big Pandora’s box because, as you know, there are thousands to millions of different products out there that people can choose from.
It can be intimidating!
Hugely intimidating, and hugely expensive as well. My big bugbear about the cosmetic industry is that a lot of what patients are sold and what they’re actually paying for is a lot of fancy marketing. What they’re not really paying for is truly evidence-based active ingredients that we know make a genuine difference [to the skin].
So I think the first step is having a good soap-free cleanser. Soap is a significant aggravator of dry skin conditions. That’s because soap contains surfactants, which just break down fat. They break down fat in order for water molecules to come into closer contact with the skin surface and take away dirt, grime, germs etc. Over the last 20 years, a lot of soap-free products have been developed, which contain synthetic detergents. Synthetic detergents have been proven not to break down the skin barrier anywhere near as much as true soaps. There are lots of different names for these- soap free cleansers, soap-free washes, synthetic detergents or gentle cleansers. These are all synonyms for soap-free products, and that’s what we should be washing not only our face, but also our body with.
We can actually supplement soap-free cleansers with hydrating agents, for example ceramides. When you have this chemical that we know helps the skin hold water, and we put it in the detergent, you’re actually going to counteract a lot of the harmful effects of any detergent by promoting the skin’s ability to hold moisture. Having a soap-free cleanser is our first step.
I then like to use a good moisturiser immediately after the cleansing process, because that’s when the pores are going to be the most dilated. I use that word “dilated,” or opened up. Our pores are generally always open. They’re openings on our skin for our oil and hair follicles to come out, so they’re always open. The question is how large are they or how small are they? That depends on temperature regulations and genes. They’re going to be more open when the skin is warmed up, and that’s the best time to then replenish moisture through a good moisturiser.
We could have a week-long discussion about what makes the best moisturiser, but I think the principles, for me, are the ones that contain ceramides because we know that this is a building block of the skin, ones that are free from fragrances, and ones that don’t contain a lot of preservatives. Preservatives and fragrances have been proven to potentially cause a lot of skin problems. They are the things in products that people can develop allergies to. You could be using the same product for five years, and suddenly your skin says “Hey, I don’t like that particular ingredient anymore.” You can develop an allergic reaction to it. As long as your moisturising cream doesn’t contain these extraneous ingredients that don’t have a good evidence base, I like to be really simple. That’s my key criteria for a good moisturiser.
I think if you’ve got those four factors- diet, water, soap-free cleanser and good moisturiser- that’s what you can do to strengthen the skin barrier.
I had a few listeners who wrote in saying they had dry, irritated skin when they were younger, then went through their teens and early adult life with “normal” skin, and then recently those irritations have flared up again. You’ve touched on triggers, you’ve touched on how we can develop an allergy, so I imagine there’s countless things that could cause that.
What your listeners have asked you about is something I see every day in clinical practice. This actually reflects more on our genetic and hormonal changes over time and as we age. When we are young and our skin barrier is “new,” we’re not subjected to the same hormonal fluctuation pre-pubertaly that you are when you’re a teenager or in your early twenties. Hormones, from a skin point of view when you’re younger or in that age group, will actually trigger more oil production. If you think about when you generally get acne, it’s when you’re a teenager. When you’re really young and you don’t have as much oil floating around, that’s when you’re going to feel slightly drier. Patients will say “I had eczema or dry skin when I was at primary school, but then improved a lot.”
That just reflects the fact that our oil glands start to work more and counteract that dryness. Then as we leave the teens and 20s age group, our oil glands stars to calm down, and preexisting dry skin can come out again.
Your skin as a lady in your mid twenties compared to a lady in her mid fifties can be vastly different because, again, when we’re approaching perimenopausal or postmenopausally, we’re going to see an aggravation of dry skin- not because of oil gland activity or lack thereof, but actually because of estrogen changes and the fact that estrogen will plump and moisturise the skin. As those levels drop, our skin dries out again. So the skin definitely changes with age.
I had a lot of people write to me with really dry, irritated skin around the lips and eyes. These are obviously quite delicate areas, so should we be treating them differently to the way we’d be treating the rest of our skin?
Definitely. We’ll start with the eyes. The eyes and eyelids are one of the most common sites for skin irritation. This is because the eyelids are very, very thin. The thinner the skin, the more sensitive it is and the more likely it is to show signs of skin trauma, if you will, before other parts of the face.
Eyelid skin, weirdly, will be quite commonly aggravated by your shampoo and conditioner. This is something that a lot of people don’t realise. They’ll be using an expensive brand, and they’re really convinced. I ask them what they’re using and I look at the ingredients on the back, written in that minute writing on the label, and I analyse it. It’s chockfull of fragrances, preservatives, foaming agents- all things that can irritate the skin. Where they see that irritation is not necessarily on the scalp because the scalp is quite thick, but actually on their eyelids, because in the shower it washes down over their face and triggers eyelid dermatitis. Patients are a bit stunned when I say that.
The eyelids, because they are so thin, need lots of good moisturiser. I don’t necessarily differentiate between the moisturiser for eyelids versus the moisturiser for the face. There are a lot of companies that specifically produce eye creams, and I’m a little bit dubious as to how true it is that those eye creams are that much better than moisturiser. I think it is a bit of fancy marketing, if I’m to be quite honest. So I think a good moisturiser is really important for the eyelids, and because it is so thin it can definitely take a bit longer to repair that skin barrier.
The lips are slightly different though and, funnily enough, the lip skin is similar to nipple skin. People who develop nipple dermatitis or eczema will quite commonly say “My lips are also quite severe.” It is a different type of skin, which I consider differently to the eyelids. It’s thicker, and I’m slightly more aggressive with what I would prescribe for lip problems. The commonality is that people will have loads of different lip balms that they’ve tried, and the problem with lip products such as lip balms, chapsticks, paw paws etc is that they can also trigger allergy. The lips, although it’s rare, can actually react to dietary triggers as well.
Similar to what I mentioned earlier about the development of allergies many years down the track, you could be using the same lip balm or even lipstick, and have been using the same product, same colour or shade for X number of years, and suddenly develop a reaction to it. So I’m wary of what people are putting on their lips.
Lips I do differentiate from the eyelids, but they’re a special site and they’ll present with symptoms more commonly than the rest of the face.
While we’re on the treatment specific areas, I had a lot of people writing in to talk about their hands. Everyone is washing their hands more often, they’re sanitising and it’s great, but dryness, irritation… this is where it’s happening. Should we be treating the hands differently to the way we would treat the face or perhaps the rest of the body?
The key difference is the number of times we’re exposing the hands to both water and detergents as a result of the hand washing process. We’re not washing our faces anywhere near the number of times we’re washing our hands, given what’s going on in the world at the moment.
This is something that I’m really glad you’ve asked about because there is misinformation, and it’s probably accidental, by the government and in a lot of authorities talking about hand washing with soap. As a dermatologist, yes, I recognise that soap will enable us to get rid of germs, bacteria and viruses from our skin better than water alone. However, what I would like my patients and the general community to know is that you can use soap-free cleansers and soap-free washes- they are as good as using true soap. You do not have to use “soap”. You can use a soap-free cleanser. In fact, the research has shown that it’s the 20 seconds of running water over the hands with the cleanser that is doing the work. It’s not just the soap, it’s the water as well.
It’s excellent that people are taking this really seriously, and I’m seeing it every day. People are coming in with really dry skin on the hands. I’m not, in any way, criticising that. It’s just that you don’t have to use [true] soap. There’s many different products out there that are very good and can be used as a soap-free substitute.
Yes, it is true that cleansing your hands with a soap-free substitute and water is better than alcohol-free hand gel, but the alcohol-free hand gel and antibacterial agents also serve a really important role. What they’re going to do is kill off a lot of viruses and bacteria that exist on the skin. If your hands aren’t visibly soiled, using those sorts of products are good. The issue is they sting like buggery when you’ve got dry, chapped hands! So the most important thing that I think is the piece of advice that is lacking is the need for a good hand moisturiser.
My advice is that whenever you cleanse your hands for 20 seconds using a soap-free wash, immediately follow it up with the use of a good hand cream or hand moisturiser. We are literally destroying the skin barrier of our hands every time we wash them using straight soap. I really want to communicate how important it is to use soap-free cleanser and follow it up immediately with a hand moisturiser.
You’ve touched on a few of the ingredients that we should be looking for, one of those being ceramides. Can you go into a little more detail on ceramides? What are they, what are they doing for the skin, and why do we love them so much?
Ceramides are the ingredients that float around in between skin cells and within skin cells- within the cement that we mentioned, but they’re actually contained intracellularly, so within the bricks of the house and not just the cement.
What they do is facilitate the holding of water better within the skin cell and within the cement. Our bodies naturally produce ceramides. This is not something that is artificial or manufactured. What they do is help maintain hydration levels of our skin. It is our genetics that determine how well or not we are producing ceramides. People who suffer from eczema and psoriasis are significantly lower in certain types of ceramides than people who have “normal” or oily skin.
The ceramides help trap the water in together with a whole lot of other free fatty acids, cholesterols and sterols, and that keeps that cement I referred to earlier as healthy as possible to hold our skin cells together.
We want to work some ceramides into our skincare routine. Is there an optimal way to do that- say, a moisturising cream verses a serum?
It’s actually about the technology that the cream has to release the ceramides. It’s not just good enough to say “We’ve put some ceramides in our moisturising cream!” It’s not magic. It comes down to science.
CeraVe is one of my favourites for this exact reason. It actually packages the ceramides in these little vehicles that are released in a nice, slow manner at different layers of the skin- not just the surface. You’re not just putting ceramides on the very outermost layer of the skin, but it actually absorbs deep into the skin, is taken up by the cell (so it goes from the cement into the little skin cell) and is then released back into the skin’s environment through this particular type of emulsion that has been patented, I believe. It’s about how it’s delivered to the skin.
Does pairing ceramides with other ingredients effect the efficacy of the cermaides?
The best way of thinking about it is probably an “additive” effect or a “complimentary” effect. You would have heard about hyaluronic acid as well, and I think that you should talk about the two almost simultaneously.
Hyaluronic acid. The way that I explain it is that it’s like a dry sponge. It will suck water to it and it holds that water. When it holds the water, just like a sponge, it increases in volume. A dry sponge will be small, a wet sponge will be much bigger. That’s exactly the same concept with hyaluronic acid. When it doesn’t have water molecules attached to it, it’s smaller. It’s still a large molecule, but it’s smaller. When it has water, it gets larger and it will plump up the skin.
The ceramides will then work in a complimentary manner of drawing in that water and releasing it in a controlled fashion. So the two work hand in hand.
Hyaluronic acid is a really large molecule. Large molecules, when you just shove it into a moisturising cream or a serum and put it on the skin, it actually doesn’t penetrate into the skin at all. It just sits there. What it does, if anything, is give this very transient and temporary look of plumping of the skin, then maybe 20 minutes later their skin starts to go back to normal.
The difference is when products contain something called sodium hyaluronate. Sodium hyaluronate is a little salt, so think of it like a little crystal. It’s a smaller version of hyaluronic acid that can then penetrate deeper into the skin and, by the salt form of it, it actually is more efficacious. It’s literally penetrating the skin. So again, not all hyaluronic acid containing products are the same. You have to be very careful, research it, and decide “Is this just containing true hyaluronic acid? Large molecules that are going to be very temporary? Or is it sodium hyaluronate, which will be taken up by the skin?”
So now we know what we should be looking for- but what are some of the things we should be avoiding?
Fragrances and a lot of preservatives are the top two. When people suffer from dry skin, they inevitably have more sensitive skin, and sensitive skin will be easily irritated by fragrances and certain preservatives. So when you’re choosing skincare for that skin type, it’s about going basic and simple. I think that less is more approach is really important.
Other products that I’m cautious about advocating are those that contain a whole lot of actives- so the alpha hydroxy acids, beta hydroxy acids, retinols and certain types of vitamins, like certain vitamin C products. It’s not that they’re necessarily bad, it’s just that you have to be very careful about when you use them, what you’re pairing them with and what your skin type is. It’s hard from me to make a specific recommendation, like “Don’t use alpha hydroxy acids,” because no, we know that the evidence suggests that they are good products. It’s just about having a tailored skin care regimen to your, your skin type and you skin needs.
I think a lot of people will blindly use well-advertised actives, but that’s not necessarily the best for their skin problem. If someone comes in with acne, I’ll be recommending certain actives that may compliment a medicated treatment plan, versus someone who’s coming in with pigment problems. It has to be tailored.
While we’re on actives, a lot of us (myself included), are going through this weird time with our skin, we do instinctively reach for all of these really intense actives and they think “Okay, well this has got X, Y and Z in it, so it’s going to solve all of my skin problems.” Then we end up over-sensitising the skin, an we’re back to square one. If we have over-sensitised the skin, how do we bring that balance back?
The first thing is to remember the two basic principles- your soap-free cleanser and your basic moisturiser. The skin is actually pretty good at repairing itself if it’s allowed to do that. That statement, “if it’s allowed to do that”, refers to removing all of the triggers- that active ingredient, that medicated product, that expensive serum that you purchased five weeks ago because you were told it’s going to solve all your problems. You have to stop those and just use your basic cleanser and moisturiser.
There’s this concept that it takes three months for the skin barrier to fully repair itself. Now, that doesn’t mean you’ll be suffering with dry, sensitive, red, inflamed skin for three months, but it does take a long time to undo a lot of damage. You’ll probably see improvement within the first two to four weeks if you simply use a good moisturiser and nothing else. Once you’ve really got that level of control, it’s about introducing products in a stepwise fashion.
Often we talk about this thing called the Repeat Open Application Test. If you’re not sure if you’re allergic to a product or if a product is irritating you, you just apply it to the inner part of your upper arm, just above the crease. You apply it there twice a day for a full week. If you come up with a little red or irritated patch, it might mean that you’re allergic to it.
So we want to strip our skincare back. How can we calm our skin without sacrificing things like anti-ageing benefits? A lot of people feel that if they take actives out of their routine, they might suffer in the long run.
My favourite ingredient for this would be niacinamide, or vitamin B3. Vitamin B3 or niacinamide has good evidence to show that it does many things in the skin, including being anti-inflammatory. We think that closer to 10% is good for anti-ageing, so serums that contain a good percentage of niacinamide, applied up to twice a day, can be helpful over months to years to be anti-ageing. In the initial stages, you would only need a lower concentrations to be anti-inflammatory.
The CeraVe range definitely has some niacinamide, but there are other ranges as well that will contain a little bit of niacinamide as a nice anti-inflammatory. That’s generally what I would recommend. And if things are still not getting under control, that’s when I’d suggest seeing a medical practitioner (either a general practitioner or a specialist dermatologist) for medicated therapy to help that that level of inflammation down.
Something that I was asked a lot about was if there is a cost effective solution to skin conditions like dryness and sensitivity. Do we need to be investing in high-end skincare to treat our skin conditions?
I think that’s probably one of the best questions that we’re going to discuss all day, because the short answer is “absolutely not”. And I have a real problem with this.
The reality is that there’s really no reason that skincare should cost the earth. The products that I generally recommend as a specialist dermatologist are not the ones that are costing hundreds of dollars. The products that you can buy at good pharmacies can be as good, if not better, than what I call the “department store brands”. It’s about being smart with where you spend your money. Why would you spend a hundred plus dollars on a cleanser? It’s probably worthwhile buying a much cheaper cleanser and then putting a little bit more money into a good moisturiser or good active.
I am a big believer that skincare shouldn’t cost the world. I think for the average Australian, particularly given the current climate, we have to be really sensitive to the fact that you just can’t afford the sorts of products that you might’ve thought would benefit your skin. But the good news is that you don’t need to. You don’t need to spend that money.
Finally, what would be your number one, top piece of advice for anyone looking to heal dry, irritated skin?
Save your money and invest in a good, evidence based moisturiser that contains ceramides, some hyaluronic acid, and maybe some small amounts of niacinamide. These top three ingredients can be found in really good, basic moisturisers, and they’re not going to cost you the earth.
To learn more about CeraVe, visit cerave.com.au
