Category Archives: basic

Dark circles: More than meets the eye

Dark circles though very common, can be difficult to address. Many factors are involved in causing dark circles, such as ethnicity, bone structure, anatomy of the skin etc, and most times a cream or serum cannot address all the factors involved, thus resulting in failure of treatment.

Let’s try to understand more about dark circles here.

What causes dark circles ?

There can be intrinsic factors (internal, genetically predetermined factors, inevitable) or extrinsic factors (external, environmental impact, modifiable).

These factors are non modifiable and most topical products such creams/serums cannot completely address these factors
Extrinsic factors can be modified to reduce the risk of developing or worsening of dark circles

Types of dark circles

Understanding the type of dark circles helps guide the treatment options.

Some OTC products that may help

Find products mentioned here
Find products mentioned here

Why are my eye creams not working?

So you have been using eye creams religiously for a long time and you still have not seen results. Why isn’t t it working for you?

  • Lack of sun protection: The under eye area is a commonly missed site during sunscreen application.
  • Not making the necessary lifestyle changes: Ongoing stress, lack of sleep, not cutting down on smoking and alcohol.
  • Underlying cause not addressed: Continuous scratching from eczema irritation.
  • Lack of patience: Depigmenting creams take time to work
  • Incorrect choice of product or treatment: Some form of dark circles benefit more from prescription medications or from a combination of products + in office procedures such as fillers, chemical peels etc
  • Unrealistic expectation: No creams/serum can 100% reduce dark circles. Shadowing effect due to bone structure cannot be corrected by creams. Constitutional pigmentation respond only minimally to OTC products.

An update on body acne (truncal acne)

I’ve written post on this a while ago, and not much data was available then regarding truncal acne.

So here’s an update on another common issue : Truncal acne.

Truncal acne refers to the acne involving the back and or chest. Around 50% of patients with facial acne also suffer from truncal acne while ~ 3% suffer from just truncal acne without any acne on their face.

How is it different from facial acne?

Truncal acne has been neglected in comparison to facial acne. Not much studies are available on this entity and treatment options are limited as well. Creams or gel that are available for face may not be enough or prove to be too costly for application over large surface areas such as the back or the chest.

Triggers for truncal acne

Triggers are external factors that could cause development of acne in genetically predisposed individuals.

Whey protein supplements have been reported to cause acne eruption in body builders

How is body acne treated?

In general, treatment of truncal acne follows the same principles as for facial acne.

The only difference is that one needs to be mindful for the choice of products for truncal acne. A small 15g cream or gel may prove to be too costly as it may not be enough to treat large surface areas such as the back and chest.

Lotion or foam formulation may be a better and more convenient choice for the back/chest.

Few are available as over the counter (OTC), while medications such as antibiotics, retinoids or steroids require prescription and supervision by a dermatologist

OTC products for truncal acne

Products available at my amazon page
Products available at my amazon page

Conditions that can be confused for truncal acne

When to see a dermatologist?

When OTC products fail to work

When in doubt of the diagnosis and how to use these products

If you have a personal history of developing hypertrophic or keloidal scars (thick, large scars), early treatment will help prevent such scar formation

Severe extensive involvement may require a course on antibiotics or isotretinoin

Managing post truncal acne scars either atrophic, hypertrophic or pigmented scars may require in office procedures such as chemical peels or LASERS, etc

Winter skin care

I recently visited my hometown, Shillong in the north eastern part on India during the last few days of November and it was already cold especially at night. The water was freezing cold as well.

The first thing I noticed was my skin felt extra dry, with visible patches of dry spots. My lips were constantly chapped and I could literally write on the skin on my legs. These skin changes were happening with everyone. My family members and I had patients from back home that all complaint that their skin felt tight.

So why does this happen in winter?

To understand this, we will have to do a deep dive into how our skin functions in an optimal environment.

As you can see the protein filaggrin plays an important role in hydrating the skin, protection against UV rays and maintaining a healthy skin barrier. Individuals with mutation in the gene encoding filaggrin protein are more predisposed to developed eczemas and other allergic conditions such as asthma. Studies have found that low humidity and low temperature causes a decrease in the amount of natural moisturising factor (NMF) in the stratum corneum and this causes decrease in skin hydration. This results in the subjective feeling of dry flaky skin during winters.

Animal studies also show that when the skin is exposed to low humidity, a reactive pathway favouring pro inflammation is activated within 24 hours. What this means clinically is that, the skin maybe more sensitive to ingredients present in skin care products during winters.

Certain skin conditions can worsen during winters. Individuals suffering from eczema, psoriasis, rosacea, cold urticaria should be careful not to be exposed to cold weather, water and to aggressively take care of the skin by moisturising and being gentle with their skincare.

Skin changes associated with using radiation heaters during winters

Homes in Shillong do not have central heating and rely on the use of radiation heaters or coal stoves to keep them warm. There are certain skin changes that can be associated from exposure to such infrared radiation.

Erythema ab igne/ Toasted skin syndrome/Fire stains

Reticulate (lacy pattern) erythema (redness) and pigmentation on the skin caused by chronic and repeated exposure to infrared radiation from heaters, wood or coal stoves. This has recently been described to be seen on the thighs of people with prolonged contact with laptops.

Though the condition is benign and resolves when the heat source is removed, the pigmentation can be permanent for some and in rare instances skin cancers such as squamous cell carcinoma or merkel cell carcinoma can develop.

Avoid sitting too close to the heat source (heater or stove)

Wear protective clothing to prevent direct exposure of the skin to the heat radiation

Remove the most heat source the moment redness develops on the skin

Seek a dermatological examination if a non-healing ulcers or wound develops over the skin where the pre-existing erythema or pigmentation was.

Worsening of Melasma

A multi centric cross-sectional study from India found a significant and positive association with the duration of heat exposure and the severity of melasma

If you suffer from melasma, avoid sitting too close to the heat source and always remember to wear a broad-spectrum sunscreen even when indoors.

Illustrations done by Alexandra Kristin Mawlong

Paraben in skincare and cosmetics

Parabens have been been used since the 1920s safely as preservatives in skin care products, cosmetics and various other toiletries items used in our every day life. Parabens are also present in certain food such as blueberries, strawberries, grapes, barley etc though in small quantities. Parabens are also used in pharmaceutical companies in various medications. Even though they’ve been around for 70 years, parabens still remains a controversial ingredients in the skin care industry. They were first victimised as sensitisers that are able to cause contact allergic dermatitis. In the recent years, parabens are again under scrutiny as potential endocrine disruptors acting as the hormone estrogen. They have also been falsely linked to breast cancer and infertility.

Now let’s see if all these claims are true! Before we dive into the research available on parabens, let’s understand a little background on these molecules and how the processed inside our body.

Background on paraben

Parabens are esters of parahydroxybenzoic acid (PHBA). There are different classes of parabens: methyl, ethyl, butyl, and propyl – paraben are the four most commonly used ones with a good track record.

Metabolism of parabens

Why are parabens present in skin care products and cosmetics?

  • Effective antimicrobials at even low concentrations hence acts as preservatives.
  • Minimal toxicity
  • Chemically inert
  • Odourless
  • Low cost
  • pH neutral
  • They have been used safely since the 1920s as have been extensively studied for the safety profile in humans

With such advantages properties, a number of skin care products, cosmetics contain paraben as the choice of preservative.

Parabens as sensitisers

Parabens were labelled as contact sensitiser i.e Able to cause contact allergic dermatitis when applied to the skin. However, cases of paraben allergies have been consistently low with parabens being the culprit in only ~0.6 to 1% of the individuals with contact allergic dermatitis.

Most of these paraben allergies occurs in individuals with compromised skin barrier such as when products containing parabens were applied on eczematous or wounded skin.

An interesting observation called “PARABEN PARADOX” in which the same above individuals who reacted to paraben when applied to compromise skin, didn’t have any problems with the same paraben containing cream was applied to normal skin.

Parabens were even named the contact non-allergen of the year in 2019 by the American contact dermatitis society. Parabens are also the least allergenic preservative present in the market

Parabens as endocrine disruptors

It has been shown in vitro studies (lab studies) that parabens are able to bind to estrogen receptors. Amongst the various parabens, butyl paraben has the highest oestrogenic activity but overall has a weak oestrogenic potential and is 10,000 times less potent than the naturally present hormone estradiol. When lab animals was subcutaneously injected with high dose of paraben it was shown to cause increase in the size of the uterus. Though these findings may seem alarming, they do not represent the effects of parabens in humans.

Though parabens may act as endocrine destructors in vitro, there is no evidence that they are endocrine disruptors in humans.

Paraben linked to breast cancer

As paraben and can mimic estrogen and bind to estrogen receptors, there is a theoretical risk that they could increase the risk of breast cancer. However as stated earlier, parabens have only a weak oestrogenic activity. Even if they can bind to these estrogen receptors, there is no evidence that it can produce any effects in humans. Another reason why parabens are linked to breast cancer is because some studies were able to isolate parabens from cancerous breast tissues. But most of the studies came that came to this conclusion did not assess the presence of parabens in normal breast tissue.

One study found that parabens were present in the adjacent normal breast tissue as well.

One epidemiological study reported no increased risk of breast cancer incidence in patients using antiperspirant or deodorants. However details on the composition of these products were lacking from this study.

So far, there is still no convincing evidence that parabens increases the risk of breast cancer.

Parabens and infertility

Consequences of demonising parabens

  • With companies being forced to cater to a market that embraces “Paraben free“, alternative preservative with lesser known properties and effects on humans are being used instead.
  • Avoiding the use of preservatives in cosmetics and skincare products is dangerous as this provides a favourable environment for micro organisms to grow which can result in various skin infections.
  • Skin care marked as “paraben free” are more expensive due to the use of other more expensive preservatives and because “paraben free” is a great marketing strategy. This would prove to be too expensive for patients who depend on moisturisers or other products to help maintain a healthy skin especially in countries like India.

For these reasons use of parabens have not been banned from cosmetics or skincare products as the benefits of these molecules far out weighs their theoretical in vitro or animal studies risks

I am not saying that parabens are 100% safe, and completely risk free, because nothing on earth is risk free. The best approach in such situation is to try to understand the available data and to weigh the benefits against the risk.

So who should use “paraben free” products?

Individuals with a known allergy to parabens should opt for paraben free products. or if paraben free is your personal choice.

Michelle from Lab Muffin, who talks about the science of beauty, wrote such a great blog posts on this topic as well. Do check that out for an even detailed read.

Do we need to fear the sun?

There is nothing like a bright sunny summer day to lighten up your mood. The sun is an essential component in the process of vitamin D synthesis in our skin, required for normal development and functioning of the bones. Yet exposure to the sun is not without any consequences.

Before talking about the risks associated with sun exposure, let’s have a look at the general principles of ultraviolet radiation (UVR) for a better understanding of what we will be discussing next.

The sun emits UVR which is of three different forms depending on the wavelength: UVA, UVB and UVC.                     

fig. the longer the wavelength of the UVR the deeper the penetration.

Although UVA is less harmful than UVB in its ability to cause cancers, the high amount of UVA that reaches the earth’s atmosphere and the ability of UVA to penetrate deeper into the skin makes protection against UVA it as important as protection against UVB.

How our skin protects us against the harmful UVR?

Besides the ozone layer which absorbs the harmful UVR and preventing it from reaching the earth’s surface, our skin also plays an important role in protecting our body against the UVR.

Our skin acts an effective barrier preventing the penetration of the UVR beyond the dermis (deeper layer of skin) and into the internal organs. Our skin is also equipped with various defence mechanisms such as enzymes and antioxidants which help repair the damage to the cells produced by UV exposure.

But in the process of protecting us from the UVR, certain light absorbing substances (called chromophore) undergoes a photo-chemical reaction that results in damage to the skin cells which results in sunburn, allergic reactions to the sun and if the body fails to repair the damage, the mutations can lead to skin cancers. Therefore the skins bears the maximum detrimental effect of the sun. 

So, do we need to fear the sun?

My answer is “YES”, especially if you’re person with Fitzpatrick skin type I-II, who have the maximum risk of UV induced skin cancers (see the previous blog post: “Do you know your skin type?“). Sun protection in these individuals is necessary from a very young age as risk of melanoma (a malignant cancer of the skin) is more with intense intermittent sun exposure from a very young age.

Sun protection is also necessary to prevent early signs of ageing and for individuals with pigmentation disorders or individuals with photodermatosis ( skin diseases caused solely due to the body’s abnormal response to the UVR) or genetic disorders such as xeroderma pigmentosa (inherited disease caused by a mutation that affects the ability of the body to repair the DNA damage produced by the sun).

That being said, fearing the sun does not mean you live under a rock and never see the sunlight again. As I did mention we need the sun for Vitamin D synthesis, and a few minutes of sun exposure two times a week is adequate for this normal process to occur. My advice is for you to understand when and where the danger lies and how to minimise it.

When and where is the sun’s UVR the maximum?

Areas near the equator receives maximum UVR.

fig. the red band represents where earth receives maximum UVR.

Higher the altitude more the UVR (Shimla, Jammu and Kashmir etc), even though these places are relatively colder, sun protection is still a must due to the shorter UVR path.

The time of the day when the sun is directly overhead i.e around noon time (9am- 3pm) is the time when sun protection has to be at its maximum. Early morning and late afternoon sun’s rays are directed at an angle to the earth’s surface and are mostly absorbed.

What if it is cloudy outside?

Clouds can reduce (though not by a great amount) the UVR reaching the earth but in days with scattered clouds, the UVR may even be more as most of the radiation are scattered. So my fellow Meghalayians (people hailing from a state in India call Meghalaya), you still need that sunscreen even if you live in a state whose name literally translates to the “Abode of clouds”

Abode of the Clouds (CC BY 2.0: Rajesh Dutta)

And what if its snowing outside?

Snow and sand, sea, are a good reflector of UVR which can double the risk of UV exposure.

In future posts we will explore the ways of proper sun protections. In the meantime remember that packing a sunscreen for your skiing trip at the Alps is as important as packing your sunscreen for a day at the beach.

Do you know your Skin Type?

Dermatologist used a scale called Fitzpatrick scale or Fitzpatrick skin type (FST) to classify the various types of skin tone based on the response of the skin to ultra-violet radiation (UVR). According to this scale there are 6 skin types.

fig. Fitzpatrick skin types in Westeros.

What determines your skin type?

The skin is composed of several layers of cells. The melanocytes, which are cells present in the epidermis (the superficial layer of the skin), are responsible for the variation in the skin colour of human race. Note that it is not the number of melanocytes but the size of the melanosomes and the type of pigment produced by these cells (also called the activity of the melanocytes) that determine the skin colour of an individual.

One melanocyte is associated with 30-40 (1:36) surrounding keratinocytes, which are the fundamental cells of skins. The keratinocytes engulf the melanosome containing melanin (pigment responsible for skin color) which results in the skin pigmentation.

fig. layers of epidermis showing melanocytes and keratinocytes

Effect of the sun on skin pigmentation 

A single exposure to UVR increases the size of the melanocyte with increase in the activity of the enzyme required for melanin synthesis (tyrosinase). Repeated UVR exposure leads to increase in the number of highly active melanosomes as well as increase transfer of melanosomes to the neighbouring keratinocyte which results in tanning (see the little brown dots in the above diagram).

What is the role of tanning?

You can think of tanning as a way the skins naturally defends itself against the oxidative stress produced by the sun exposure. Tanning is physiological protective response to UVR. Melanin acts as a natural antioxidant which quenches the harmful oxidative radicals produced by the chemical reaction which takes place on UV exposure.

Melanin provides a natural sun protection factor (SPF) of 13.4 in black individuals and only 3.4 in pale skin individuals.

Individuals with FST I, II who do not tan with sun exposure are at higher risk of developing skin cancers.

Influence of fashion

The fashion trend influences pale skin individual to desire a darker skin tone which leads them to go through extensive lengths to obtain that “perfect tan” either by prolonged sunbathing at the beach or by artificial tanning machines without considering the risk they impose on their health in the name of “beauty”.

On the other hand darker skin individuals with relatively lesser risk of cutaneous cancers from UVR ironically hide from the sun as society has made them believe that fairer skin is synonymous with beauty.

Fun fact: FST also forms the basis for the variation in skin colour in emojis with FST I & II merged together.

Why do you need to know your skin type?

Knowing your skin type helps you understand the risk of developing skin cancers with UV exposure. Individuals with FST I, II need to strictly adhere to proper sun protection in the form of broad spectrum high SPF sunscreen and protective clothing especially if they are living in tropical countries.

Disorders of pigmentation like melasma, or pigmentation that can occur from either disorders such as acne, or as a complication of procedures such as LASERS, or chemical peels, etc. are more common in individuals with darker skin tone (FST III,IV,V VI). Therefore caution must be taken while carrying out procedures in such individuals.

Consumers must also understand that some studies on the efficacy of certain active ingredients for a particular disorder are performed solely in individuals of lighter skin tone and the same results may not reflect in their skin type. Therefore referring to studies done on individuals of same ethnicity holds more value. For example you should search for studies done on Indian population if you are Indian.