Derms on Drugs Debunks the "Benzene in Benzoyl Peroxide" Story

Summary

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Podcast Summary: Derms on Drugs – Debunks the "Benzene in Benzoyl Peroxide" Story

Podcast: Derms on Drugs
Episode: Debunks the "Benzene in Benzoyl Peroxide" Story
Date: February 14, 2025
Hosts: Dr. Matthew Zirwas, Dr. Tim Patton, Dr. Laura Ferris
Guests: Dr. John Barbieri (Mass General/Harvard, acne expert), Dr. Michelle Wong (Lab Muffin, cosmetic chemist)

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Episode Overview

This episode tackles the recent controversy surrounding benzene detection in benzoyl peroxide (BPO) acne products, addressing concerns raised by new studies and public reports. The hosts dissect scientific findings, critique methodologies, and discuss the implications for dermatology practice and patient safety. They are joined by expert guests—Dr. John Barbieri, a leading acne dermatologist, and Dr. Michelle Wong, a cosmetic chemist and science communicator—to critically analyze the data and media narratives.

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Key Discussion Points & Insights

1. Background: The Benzene Scare in Benzoyl Peroxide

• Initial Alarm: Reports surfaced (beginning March 2024 with an FDA citizen petition, followed by an October 2024 peer-reviewed article by Kuchera et al. in Journal of Investigative Dermatology [01:20–02:12]) alleging unsafe levels of benzene—a known carcinogen—in OTC BPO products.
• Peer Reviewed Validation: The October article was the first substantial peer-reviewed study fueling concern among dermatologists and the public.
• Benzene Relevance: Hosts clarify benzene is omnipresent but recognized as a carcinogen, so minimizing exposure is important [02:18].

2. Summary of Key Study Findings

• Methodology:

  • 111 BPO products were incubated for 20 minutes at 37°C (body temp), then benzene measured by GC-MS.
  • 34% exceeded the FDA benzene limit (2 ppm), with some brands (notably Proactive) faring worse [02:18–03:19].
  • Examined effects of storing products at cold (2°C) vs. high heat (50°C/122°F). Heat increased benzene, but they didn't test room temperature due to insufficient sample size [03:44].
  • Additional tests measured how much benzene is released when BPO is applied to skin and exposed to UV, with maximum daily exposures (even under extreme conditions) remaining very low [04:17–05:37].

• Key Flaws Identified in Study Design:

  • Unrealistic Conditions: Testing at 50°C and 70°C is not clinically relevant; skin surface is cooler than 37°C; UV exposure tests exaggerated real-world use [09:13–12:01].
  • Lack of Real-World Exposure Data: Missing room temperature storage and actual-use scenarios for typical consumers.

3. Reactions from Dermatologists

• Initial Apprehension:

  • Dr. Laura Ferris: “Oh my gosh, this is kind of frightening. ...I thought back to the sunscreen benzene stuff that we dealt with a couple years ago.” [05:52]
  • Dr. Zirwas: “I had kind of a...this sounds like crap... And then when this article came out...I need to start telling everybody about benzene.” [06:39]

• Expert Guidance:

  • Dr. John Barbieri: “No, I definitely don’t think we should be terrified. ...I definitely don’t think we need to be going to people’s houses and like hitting the benzoyl peroxide out of their hands before it kills them either.” [08:23]
  • BPO isn’t being removed from guidelines [08:40].

4. Methodological Critique by Chemist

• Dr. Michelle Wong
  • “They've presented their methods as realistic, which...it's not really reflecting real-world situations.” [09:13]
  • Heating BPO to temperatures linked to extreme, rare scenarios (e.g., 158°F for two weeks in a car in Atlanta summer) inflates findings [10:55–11:53].
  • UV tests simulate an unrealistic amount of direct sun exposure while covered in cleanser, which does not mirror normal use. [12:01]
  • Benzene does not easily penetrate the skin—main risk is inhalation, which is still minimal in this context [13:00].

5. Real-Life Exposure and Safety Reassurance

• Epidemiologic Evidence:
  • Large cohort studies (NHANES, Trinetex) find no difference in blood benzene levels or cancer rates between BPO users and non-users [13:41–14:16, 15:26–17:21].
  • “The absolute level of benzene is very small compared to...what we get exposed to from just existing in the modern world.” – Dr. Barbieri [15:21]
  • The “dose makes the poison”—risk remains theoretical at these minuscule exposure levels [17:34].

6. Skepticism Toward Valisure (the Testing Lab)

• History of Overstated Claims:
  • Past examples (Zantac, metformin, dry shampoo) where Valisure's methods led to public recalls, but were invalidated or minimized after independent review. The lab’s methods (e.g., overheating samples) often artificially create or inflate contamination figures [18:43, 18:58–21:25].
• Potential Conflicts of Interest:
  • Valisure has a financial and legal interest (patents on “safer” formulations; involvement in class-action lawsuits) in amplifying perceived risks [21:35–23:32].
  • Michelle Wong: “...they certainly have a reason to want people to be worried about benzene in benzoyl peroxide.” [23:33]

7. What Should Dermatologists Tell Patients?

• Product Variation:
  • Not all products are equal (some like Clean & Clear, Neutrogena performed better), but results may vary by lot and storage, making broad recommendations tricky [25:35].
• Practical, Evidence-Based Advice:
  • Store at room temperature or cooler if possible (but no need to refrigerate; no data shows refrigeration is better) [26:25].
  • Avoid letting BPO products sit in extreme heat (e.g., porch in hot sun for days) [28:57].
  • “If it’s past the expiration date or more than a few months, throw it out.” [26:25]
  • Compounded products: Be cautious—unknown formulations could pose greater inconsistency/risk [29:56–30:19].
  • “Just common sense handling of the product is all we really need to do right now until we learn something more.” – Dr. Barbieri [28:57]

8. Broader Lessons: Communication, Conflicts, and Science Literacy

• Importance of transparency and critical evaluation of both study design and potential conflicts of interest in “scary” scientific news [23:32]

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Notable Quotes & Memorable Moments

• On Valisure’s Methods:
  “Turns out they generated the NDMA [in Zantac] by heating it up too much, which is kind of a running theme here.” – Dr. Michelle Wong [20:00]
• On the Sensationalism:
  “You can make anything sound awful if you, if you try hard enough.” – Dr. Matt Zirwas (re: dihydrogen monoxide joke) [17:50]
• On Storage Advice:
  “I don’t actually really like the fridge advice because benzene is gas...You might actually be trapping the benzene and then getting a giant whiff every time you open the fridge.” – Dr. Michelle Wong [31:27]
• Big Picture:
  “I think we need to take it seriously. But not also means not overreact. Let’s not, you know, freak out and start doing too much.” – Dr. John Barbieri [31:06]

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Timestamps for Key Segments

• [01:20] – Introduction to the benzene-in-BPO story and studies
• [02:18–04:14] – Study design, findings, and initial critiques
• [05:52–07:53] – Hosts’ first reactions and context
• [08:23] – Dr. Barbieri: “Should we be worried?” – Emphatic “No”
• [09:13–13:30] – Dr. Wong’s critique of study methodology; realistic exposure
• [13:41–17:21] – NHANES and Trinetex data: epidemiologic reassurance
• [18:43–21:25] – Valisure’s past and present patterns
• [21:35–23:32] – Discussion of Valisure’s motives/conflicts of interest
• [25:35–26:25] – Practical guidance for patients; heterogeneity among products
• [29:56–30:19] – Compounding and safety
• [31:06–32:08] – Final thoughts: risk assessment, advice, and common sense

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Additional Resources

• Lab Muffin Beauty Science (Dr. Michelle Wong's YouTube channel) – Accessible breakdowns of cosmetic and personal care science [32:31–32:57].

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Conclusion

Despite alarming headlines, both real-world evidence and expert analysis suggest risks from benzene in benzoyl peroxide products are negligible for typical use. Study methodologies often do not reflect actual user conditions, and historical precedent urges skepticism of sensational lab reports, especially when conflicts of interest may exist. Sensible storage habits and critical thinking are, for now, the best defense against both acne and misinformation.

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Transcript

[A]

Hi, I'm Dr. Matthew Zyrus and welcome to Derms on Drugs, a new video podcast brought to you by Scholars in Medicine. Derms on Drugs is where cutting edge derm meets mediocre comedy. I'm Matt Ziers and each week I'm joined by my residency buddies, Dr. Tim Patton and Dr. Laura Faris. And we use our 60 years of combined derm experience to debate, dissect and discuss the hottest topics in dermatology. It's everything you need to know to be on the cutting edge of derm. It's where you get to have some fun listening to us do the work of a journal club. So join us every Friday here at Derms on Drugs, on Apple Podcasts and Spotify and in Scholars in Medicine. So let's go ahead and get into it. This week we've got a very special episode and I am going to pass it off to Dr. Patton to kind of take us through one of the most interesting articles that I've seen in say, the last six months. Dr. Patton, why don't you go ahead and take it from there?

[B]

Yeah, so I'm going to talk about an article that is available online as of October in 202024 in the journal of Investigative Dermatology. It's by Kuchera et al. And it's titled Evaluation of Benzene Presence and Formation in Benzoyl Peroxide Drug Products. The article reported the results of tests that were performed on multiple over the counter BPO products.

[A]

Was, was this the, do you know, was this the first like peer reviewed article that you saw? Because I know the benzoyl peroxide thing.

[B]

Came out a while ago, March 2024. So this is October.

[A]

Right? Had you. But in March it wasn't like a peer reviewed article. Right. It was just like it was a.

[B]

FDA citizen petition or something.

[A]

All right, so this is on that. This is like the first big peer review.

[B]

Yeah, it was like an official, official article.

[A]

Okay. All right.

[B]

As far as I know.

[A]

All right, all right, all right. Our guests might have more to tell us about. Yeah, a little bit better.

[B]

All they looked at multiple over the counter BPO products to see if they could detect benzene. Why do we care about benzene? It's listed as a known human carcinogen. So that's bad. We can't avoid it entirely. It's all around us. It's around us right now. We're getting killed by benzene as we speak. But we should make sure that we are being exposed to as little as it is possible. So this Study performed four tests and I completely understood all of them. I have most of this equipment in my basement. I actually don't have this. If I screw up any of these tests, that is totally my fault. All right, so first test, they took 111 BPO products. They incubated them for 20 minutes at 37 degrees Celsius, that is body temperature. And then they measured benzene levels using GC gas chromatography. Mass spectrum something. 34% of the products tested at benzene levels above 2 parts per million. That's the limit that is set by the FDA. Figure 1 shows the results from some of the products tested proactive. Like doing horribly. What are you guys doing Proactive. The next test looked at one specific BPO product, Epsilay. It contains encapsulated BPO. When the product was kept at 2 degrees Celsius even after 12 days, amount of benzene was negligible compared to heating the BPO product to 50 degree. For normal people, that is 122 degree F linear increase in benzene over time. Did they also test it at room temperature?

[A]

No.

[B]

Why not? Because honestly, they said they ran out of epsilon. So why did you, why did you test it at 50 degrees? That doesn't, that just doesn't seem clinically relevant. They, they make a note in the text that anecdotally something, something or other at room temperature, there's no detectable bpo. All right, so the last two.

[A]

BPO or benzene. Because I would hope.

[C]

No.

[B]

No detectable benzene. I'm sorry.

[A]

All right. I would hope there was detectable BPO in the epsilon. Yeah.

[B]

Otherwise that's not going to work.

[A]

It'd be a terrible drug. Yeah, Be awesome.

[B]

All right, so then the last two tests were. Hey, let's. What's it like when you put this on the skin, does it like evaporate into the air and basically poison you from like a vapor test? So they did, they put the, the really highest level, which was this cleanser by Proactive, which that's kind of a weird test to do, right? You put a cleanser on, you wash it off. It's not like you put it on your skin and leave it there. But they took this really, really high product, they put it on these plates, they did 24 hours in the dark, and then they did it after exposing it to UVA B for a couple of hours. Figure 3 shows the results of these in parts per billion. They, they converted that to like. How many micrograms does this mean? So for the dark study 4 micrograms of benzene and the UV BPO product, it would be 14.7 our daily exposure, maybe on the order of 100 or 300 micrograms. So I guess those are small total amount. And it was a product with really high levels of benzene. And like I said, it was a cleanser. So that's not really how we use cleansers. We don't put them on their skin. But even with the worst product and, and leaving and using it in a way that we wouldn't use, the levels of benzene are really, really low. So you know, taking, that's the, that's the paper. So taking on face value.

[D]

Haha.

[B]

Get it face. What do you guys think? Benzene.

[A]

Are we worried?

[B]

Are we not?

[A]

Well, I, well first I'll let you, I'll let you answer first. What did you, how did you feel after you looked at this article for the first time?

[E]

So when I first looked at it, I thought, oh my gosh, this is like kind of frightening. And I guess it makes sense to, you know, get it really, really hot to accelerate what's going to happen. And this is mimicking real world. And you know, I thought, okay, I guess I should be warning patients are not using, you know, benzoyl peroxide. And I thought back to the sunscreen benzene stuff that we dealt with, you know, a couple years ago and, but you know, on like kind of further critical review and then looking at, you know, putting that into the context of real world application, I think it's less concerning. And then I kind of thought, I, you know, I'm interested to learn more. Like where did this all come from? Why did we start worrying about this? And you know, why are we, are we making much ado about nothing?

[A]

And I'll tell you, I had kind of a, when the benzene stuff first came out, I was like, this sounds like crap, this is ridiculous. I'm not gonna blah. And then when this article came out, I was like, oh my God, this isn't jid. It's been peer reviewed. Benzene sounds awful. Oh my God, I need to start telling everybody about benzene. And good Lord, I've been totally wrong was kind of my takeaway. And that's where I was putting it until Dr. Patton helped me find some alternative information that I'm now going to bring our guests in. So we've got two really interesting people with us. So first, Dr. John Barbieri, who is a dermatologist practicing in Boston, I believe at Mass General, the Harvard system, who's an extremely well known acne expert. And then we've got Dr. Michelle Wong, who is a PhD doctor, so an actual real doctor, not like the rest of us, who is a cosmetic chemist who actually really understands kind of the methodologies that were, that were used. And so first I just want to say hi to the two of you guys and appreciate you coming on the show.

[C]

Thanks for having us.

[D]

Pleasure to be here.

[A]

So let's just kind of get started here. So Michelle, take us through. Well, you know what, actually I'm going to give people the thing that they really want to hear first. So John is a very well known acne expert here in the United States. John, yes or no, in your opinion, should derms be like terrified or worried at all about benzene in benzoyl peroxide?

[D]

No, I definitely don't think we should be terrified. I do think this is an important issue for us to think about how we can optimize the safety of these products. But I definitely don't think we need to be going to people's houses and like hitting the benzoyl peroxide out of their hands before it kills them either.

[E]

You're going to take it off the acne guidelines?

[D]

Yeah, I think it's still going to be in the guidelines.

[A]

Okay, all right, all right. Okay. So let's, let's kind of get into this. Michelle, you know, you are a chemist and so you understand all of this stuff in ways that. And John, I don't know if you happen to be a chemist as well, but me, Pat and Ferris sure aren't. And so kind of take us through. You know, were the methods valid if they weren't valid? You know, how were they not valid? Like how, how would, how do you think about this?

[C]

So I think the biggest problem is the way they've interpreted their data. So they've presented their methods as realistic, which if you actually analyze like the temperatures they use, the, the UV exposure they use, it's not really reflecting real world situations. And they do claim that it is in the discussion. And I think it's one of those things where in peer review papers most of the time people are looking at the methods, they're peer reviewing that part. And then the discussion is kind of like hand wavy. Everyone expects some sort of puffery in the discussion. And so it doesn't really necessarily reflect realistic use. So they did actually publish another paper.

[A]

I have to say, I love it. Anytime somebody uses the word puffery, you've got me sold at puffery. All right, sorry for interrupting.

[C]

Yeah, so they had two papers. They actually had one earlier in Environmental Health Perspectives, which was the one where they presented their partition data on higher temperatures. So they heated up the benzoyl peroxide and measured the benzene. Benzoyl peroxide breaks down to make benzene and that breakdown is faster with things like heat and uv, sort of like that. I don't know if you remember from high school chemistry, but if you heat stuff up, you get more energy in there, you get more bonds breaking, you get more stuff happening. So they heated it up and they decomposed it and they measured how much there was. But then with the temperatures they used, they linked it to situations where it wasn't entirely realistic. So one example is, I mean, the 37 degrees in skin temperature. 37 degrees is like more internal temperature. Skin is a lot colder than somewhere deeper in your body. So skin is probably closer to room temperature than 37 degrees. It's like a good 10 degrees Celsius, but below. So 37 Celsius. I'm Australian, so I'm going to keep saying something. Feel free to jump.

[A]

For us Americans, 10 degrees Celsius is about 18 degrees Fahrenheit. So we're looking instead of 98 degrees, 80 degrees, it's probably skin temperature.

[C]

Yeah. So one of the main experiments they did was putting it at 70 degrees Celsius, which is 158Fahrenheit. I know this one. And they said this was the temperature of a supposed hot car. But if you actually just go on Google and just look up hot car temperature, you'll see that it's actually usually 50 to 60 or 130 to 140 degrees Fahrenheit, which is a good chunk below. And they left it in there for two weeks. So it turns out they referenced a paper where they had a hot car parked in the full sun in Atlanta, and that day was like almost 40 degree day. So they had that in there for two weeks, which not really realistic unless, like global warming gets really hot.

[A]

40 degree day, again, for all of our Americans is probably like 110 Fahrenheit ballpark.

[C]

Yeah. So not super realistic for the JID with the UV. So they put it under a lizard lamp for I think a few hours. But I did some recalculation, so I recalibrated it to the UV index, which is largely uvb, which is what benzoyl peroxide absorbs. So kind of similar to weighting the UV by sunburn. So it turns out to be the equivalent of a full summer's day worth of UV with UV index 9. That's like low for Australia, probably quite high for most of the us. And of course, that was with the cleanser, as Tim mentioned. Generally you don't go outside for a full summer's day with cleanser on your face. And again, that was still quite low. And also if you're outside, that benzene is going to be drifting off. There's actual ventilation, it's going to be massively diluted. The main way we're exposed to benzene is through inhalation. Not a lot goes through skin, but if you inhale it, about half of that goes into your blood.

[A]

I assumed a lot of it went through your skin.

[D]

Huh.

[C]

Yeah, you might think that, but our skin is actually a pretty good barrier to most things and benzene is one of them. So most of the studies done on skin exposure is with occupational exposure. Workers like having their hands in benzene for hours. Usually it's like mechanics, because petrol has 1%, which is, I think, 10,000 parts per million benzene. So that gives you a sort of indication of parts per million, which is the unit they tend to use.

[E]

Has anybody actually done this study just by measuring serum benzene levels? So have people who use benzoyl peroxide every day and see if you can detect serum benzene?

[D]

Yes, I can take that one. We've sort of done that study. So using nhanes, there's data on benzene levels. There's also data on what kinds of medications people are using. So we did a study using nhanes, looking at people who were using benzoyl peroxide containing products. We matched them to people who were not trying to control for any other kind of lifestyle, socioeconomic, et cetera, variable that we could to make these people as similar as possible in every other way. And we found there's absolutely no difference in the likelihood of them having detectable blood benzene and no difference in the levels of blood benzene when they were detected between those two groups.

[A]

So, John, I want to. I want to jump in and ask you a question there for a second. So I'm big into like, dietary nickel and dietary nickel is something where the normal blood tests are looking for, like, nickel toxicity, where, like, oh, my God, you'd have to like, bathe in nickel to be able to get it. They don't. They're not useful for detecting, you know, what I would call normal amounts of nickel that you would get in your diet. The testing that they did in nhanes for benzene, if there was a clinically relevant, potentially clinically relevant amount of benzene getting into people's body, would it have picked it up?

[D]

My understanding is yes. Now again, you know, I'm not an expert in the NHANES method. I wasn't there doing it. I didn't do that part of the study. But I think their methodology is viewed as relatively robust. And the fact that they do detect benzene and you know, a number of individuals in both group, it's not just like everyone's zero and they're having, they're detecting benzene in people because it's unfortunately around us in our daily lives and they're not finding differences in those who are exposed to benzoyl peroxide containing products.

[E]

Okay, that's kind of the answer in the end. Right? And did you look at the answer?

[D]

Yeah, right. It's an observational study. So you know, it wasn't designed for that purpose. There's always the potential for unmeasured confounding. They're relatively small sample sizes. So I wouldn't take it as like that's the answer. But I do think that it's reassuring. We also did another study looking in a larger cohort in Trinetex of 27,000 individuals who are using benzoyl peroxide, again trying to match them as best we could to individuals who weren't dermatologists for like a mole check. And again here we were looking at cancer. So that's ultimately care about. Right. Are you at higher risk of cancer? And with a mean follow up of over seven years for both groups, we didn't detect any differences in hematologic or internal malignancies between the groups. So again, all the caveats of observational data on measured confounding. But I do think both of those studies give us some reassurance that in real world use conditions, people who are using benzoyl peroxide containing products don't seem to be at higher levels of having detectable benzene in their blood or increased risk of cancer. And as Dr. Patton pointed out earlier, just use a thought experiment. Take the worst products that Valisure is including in their studies and just think about the absolute level of benzene in those products. As Dr. Wang mentioned, absorption through the scan is less than like 1 to 5%. So it's not like it's going to give you skin cancer from being on your skin. The risk is that it aerosolizes. You inhale it. And if you think about the quantities of benzene that are even in those worst products that Valisure is testing. And if you give them the benefit of the doubt that all that testing is right, which is a whole secondary issue, but let's assume it's right. Let's take the worst product. That absolute level of benzene is very small compared to, unfortunately, the benzene we get exposed to from just existing in the modern world. And so when you do that thought experiment, that's kind of reassuring too, that it makes sense that it's probably not going to create a clinical risk. It's just like UV is a known human carcinogen and when you sit inside a building, there's some UV goes in the window, you're getting exposed to some. There's no safe level of uv, but the actual risk of that is probably relatively low.

[A]

Oh, John, I'm going to argue with you there because we had a guest on a couple weeks ago, Dr. Richard Weller from the UK, who's actually shown that UV is highly beneficial from a cardiovascular perspective.

[D]

Oh, yeah, there's that aspect of it too. But from a skin cancer standpoint, there's sort of skin cancer they would make. There's no safe level of UV for skin cancer, just like there's no safe level of benzene for lymphoma. But, you know, the dose makes the poison. You can have a low enough level where it's not really clinically relevant.

[A]

Yeah, I mean, that's. I tell people that all the time that if you want to look hard enough, like, water is a horrible. I always, like. I don't know, Michelle. I'm sure in chemistry, in the chemistry world, people talk about this all the time, but the, the horrible dangers of dihydrogen monoxide, which has killed more people than any other chemical in the history of the world. In fact, a tablespoon of it can be absolutely lethal and thousands of people a year die from exposure. And. Right. The famous studies about this are. You can get almost everyone to agree that dihydrogen monoxide should be banned in all shapes and forms. And of course, dihydrogen monoxide is water. Right. You can make anything sound awful if you, if you try hard enough. So would, you know, Michelle, could you.

[B]

Maybe go into the lab? Valisure itself. This is not their first sort of rodeo of telling us that things that we wouldn't expect to kill us are going to kill us. Can you go into that, those details a little bit?

[C]

Yeah, sure. So Valisure's had a sort of history of submitting lots of petitions. I can't remember if this is like maybe number seven or Something. But they started off with Zantac. Actually, they started off with something before Zantac. I think it was Val Sartin. But they found NDMA in Zantac and in Metformin. You might remember those guesses. Zantac's been withdrawn from the market, but now that's being questioned. So they had Zantac, they tested it, and they found ndma, which is a carcinogen. The FDA started investigating. Actually, it was like a worldwide investigation. It was like all the regulatory agencies around the world started investigating. And eventually the FDA realized that what's happening, Valisure did, was they heated it up too much. So GC Ms. Is gas phase chromatography. So you need to heat up your thing until it's a gas and then pass it through a column. And it turns out when they heated it, the Zantac decomposed. And it was. There's a photo in an FDA presentation where it's actually black. Zantac does not start off black. It starts off white. The little sample vial was black. And it turns out they generated the NDMA by heating up too much, which is kind of a running theme here. So they couldn't actually use any of their data because it was all not quite right. They had to rerun all the tests with Metformin. That was also. They detected it. They made a big fuss about it. It was in a whole bunch of newspapers. And it turns out, okay, so this might get a little bit into the weeds, but essentially with gcms, you end up with a line and then a peak, like a little hump. And you measure the area of the hump. It turns out the hump for NDMA overlapped with the hump for something else. And so it got a lot bigger. And they reported that all as ndma, but it was, I think, about half something else as well. So all their values were inflated, all their measurements, and so the risk was like a whole bunch higher than it should have been for just Metformin. So interestingly, pretty much every time a public health agency has made an announcement based on their own analysis of the data, they've always said something like, there is not expected to be an actual adverse health effect from using these products. So the way that Valisure presents their data historically, it's like a good order of magnitude above the risk of what the health agencies end up saying it is. So I think that's pretty reassuring in general for anything that comes from Valache.

[E]

The big question is why? Why are they doing this are they mean? Are they evil? Like what? Why? I don't understand.

[C]

In general, I like to think that most of these incorrect results are mostly from people genuinely trying to do the right thing and genuinely having their just interpreting their results in an honest way. With Valisure, I think there are a few other extra factors which might be relevant. So first off, in every petition they do ask for the FDA to install them as like an extra layer of quality control for pharmaceuticals cosmetics, which is kind of weird because the FDA has actually published papers specifically criticizing their methods, which is pretty unusual. So they specifically talk about like the double hump issue for example, in one paper. But obviously like there's a lot of money in this sort of contract, just like testing everything on the market. They did get a contract with the Department of Defense for this, which well done to them. They do also have ties with class action lawyers. There are some lawsuits that were filed before the petitions became public. So that kind of raises the question of do they genuinely think this is in the public interest or is it some sort of financial motive for benzoyl peroxide specifically? A few people from Valisure actually filed a patent over a year before the petition. And this patent contains the data on how much benzene there is. Same similar amounts to their petitions and their studies. So again, big question mark about their public interest. And the Wall Street Journal has a couple articles about how these lawsuits were filed before the public announcements. They were also responsible for a dry shampoo story about benzene and dry shampoo. And in the court filing it seems like they sent a letter to Unilever to keep their testing info confidential if they paid up. I think it was something like 1 million and then a quarter million every few months or something as a retainer. So supposedly that's been sent to more than one company.

[E]

Extortion.

[A]

And Michelle, I went in. You know, the patent thing is fascinating because I will tell you, one of the reasons I was found this all credible is I couldn't think of a reason like why it's not like Valisure is coming up with an alternative to benzoyl peroxide that's like, oh, you should use our stuff instead of benzoyl peroxide. But the patent that they filed on benzo a way to stabilize benzoyl peroxide so it doesn't release benzene. Well, once you've got a patent on that, you then need to. If you get people worried about benzene and benzoyl peroxide, now everybody's going to want to use your method to make sure there's no benzene in the benzoyl peroxide. So it, it. I don't, certainly don't know that there was anything, you know, nefarious going on here, but they certainly have a reason to want people to be worried about benzene and benzoyl peroxide. And it really becomes just a fascinating topic of sort of these kinds of, you know, webs of conflicts, potential conflicts of interest. And it's something, you know, I certainly even struggle with. Right. I do a lot of work with a lot of drug companies, and then I talk about articles that get published. And so it's, you know, it's not like people are, you know, conflicts of interest are innately a bad thing. But I think it's really important that we are aware of conflicts of interest. Right. That's why we really try and make them well known whenever we're doing continuing medical education or we're talking about a drug or a side effect or a benefit or whatever. So, yeah, it's just fascinating, man.

[B]

John, I had another question about, you know, the, the practical advice you give people.

[A]

Right.

[B]

I mean, there's like, two ways you could go about it. You could take all this data on face value. Like, don't read into the details. There were products that did really well even with these unrealistic experiments. Clean and clear Equate, Neutrogena, Walgreens. None of the products, even with the, the crazy testing that Valisure seemed to be doing here, none of those reached that 2 parts per million set by the FDA. So you could say, use those. You could tell them to refrigerate the product with the epsilon data, certainly, but that kind of lends, like, maybe more credence than you need to. And so the opposite way is to be like, yeah, the slab is kind of shady and don't believe anything they say. Just use whatever you want. Is there an in between? Which way do you lean towards?

[D]

I think there's a few parts to that question. So first you bring up there's a lot of heterogeneity in the different brands. In their most recent paper in the Journal of Investigative Dermatology, and we actually took a look at their data and article on JAMA dermatology. And when we did that, we found a lot of that heterogeneity is actually explained by the formulations in the product and potentially some of the manufacturing conditions, like how much heat might have the product been exposed to when they're making it. And so I think you can actually look at that heterogeneity and it's an important opportunity for us to think about the supply chain but how we formulate and distribute these products and opportunities to make them safer. Overall. I would be a little bit careful of like extrapolating those like this brand is good and this brand is bad. Like they went to, you know, a store and bought a product like, like it could be very different if they bought it from a different store. We don't know how replicatable those findings are. So I wouldn't use those the call out products. But I do think it gives us some good hypotheses to test in terms of what kinds of strategies when making a product keep them to having the lowest levels of benzene in terms of actual suggestions for patients kind of from a common sense approach. I tell people like, you know, benzoyl peroxide products, they do have the potential to break down into benzene when exposed to high temperatures. So you know, try to store them at room temperature cooler. I don't actually think we need to say refrigeration. Balasher has never shown that refrigeration is helpful. Comparing refrigeration to 50 degrees shows 50 degrees is bad. It doesn't show refrigeration is good. I have no idea like you pointed out why they didn't do room temperature. To me that's the obvious comparator if you want to make that complaint, that claim. But even if you only had enough product you want do room temperature versus cool but they didn't do that. I'm not sure why. Maybe we'll find out at some point. Yeah but so I don't tell people necessarily need to refrigerate it. It probably is better just because in general cooler slows things down. But I think room temperature is likely fine. Our data when we looked at it didn't show any real risk with room temperature storage each 100 days closer to the expiration date you get on the products is associated with less than a 1 part per million increase in benzene. So I'm not so worried about that. I just say room temperature cooler. If it's past the expiration date or more than a few months, throw it out. And I do think it has some implications for direct to consumer things. If you buy something on Amazon and sits on your porch on a hot weather and you know, Florida for five days while you're on a trip that might actually lead to meaningful benzene. So I do think we can be a little bit thoughtful about shipping things like direct to consumer stuff and that may be an important part of counseling. But beyond that, I think just common sense handling of the product is all we really need to do right now until we learn something more that changes our data.

[A]

So, John and Michelle, I got an interest. So Patton actually brought up something related to this a few days ago that made me. Right. So I send a fair amount of prescriptions now to these compounding pharmacies that are putting these three ingredients together that you can't get together in any other way, especially for rosacea, that kind of stuff. And Pat was like, do we need to be worried about that stuff? None of that's been tested. Like, we don't know what the hell's in there. Like, I'm still not worried about it because I figure that, you know, the pharmacies are reputable. They're not trying to like, whatever. But do you think there's any concern around that kind of stuff, you know, based on, you know, your experience? Michelle, John, do either of you think, you know, is your answer like, no idea or like, I don't know, maybe, like what's, how would you think about that?

[C]

I think with compounding there's always a risk with compounding, like the formulations just aren't really tested as much as an off the shelf product. So in general, I would probably not really go for the compounding option if it's an option. Yeah, it's really hard to say just because there's so much variability with how it's compounded, what it's compounded into, like what sort of base cream they're using, that kind of thing.

[A]

Okay. And so part of that takeaway is maybe it's worth getting to know if you do, if you send compounded scripts, maybe it's worth talking to the pharmacy you send it to just to make sure that you're comfortable with them, that, you know, you've kind of done your due diligence. But it's another interesting topic that just really never. It wasn't on my radar before this. Well, John and Michelle, I really want to thank you guys for coming on. This has been such a fascinating conversation and I really hope it's going to give our listeners a kind of a different perspective on this whole benzene and benzoyl peroxide issue. You know, anything that either of you would like to say before we sign off.

[D]

I'll say, you know, I do think this is an issue. I'm glad we're talking about it. I think we need to take it seriously. But not also means not overreact. Let's not, you know, freak out and start doing too much. When really, in general, a lot of the clinical data, just the thought experiments, suggest that, you know, it is probably safe to use benzoyl peroxide products when handled appropriately.

[A]

All right.

[C]

Yeah. And I'd also add that sometimes things that you think would improve might not necessarily improve it. So, like, I don't actually really like the fridge advice because benzene is gas. Well, it's very volatile. It turns into a gas and fridges are usually airtight. So it could actually be if you have a room temperature tube sitting in your bathroom, which is relatively well ventilated compared to putting it in a fridge where it's trapped. And fridges, I mean, you're only decreasing the temperature by like 20 degrees Celsius. If you think about actual energy with like Kelvin, the other temperature scale, it's not actually decreasing it by that much. So you might actually be trapping the benzene and then getting a giant whiff every time you open the fridge. So, yeah, it's best not to overreact when the risk is not that great.

[A]

And before we go, I do want to put a plug in for Michelle's YouTube channel where she just said it was the first place that I really was introduced to Dr. Wong. So what. What is your. Is there a name for your. Do you have a name for your show? I actually don't know very much how YouTube works. Is that your main platform or what's your. What's your channel called?

[C]

It's called Lab Muffin Beauty Science. And yep, that is probably my main channel these days.

[A]

And what.

[C]

John also has a great channel, but I feel like most dermatologists probably know about what.

[A]

What kind of stuff do you cover on there? Like, is it. Is it all sort of benzene or benzoyl peroxide or is it into, you know, does this product work? Does that product not work? How do they. Like what. What is your channel like?

[C]

I mostly break down the science behind different beauty products for a general audience. I talk about skin care, mostly hair care these days because lots of people have tons of questions about that. There's things like rosemary oil. There's a lot of debunking of trends.

[A]

Interesting. Okay. Because that is something that we as derms get asked a lot about. And it's just hard to keep up on. I mean, it's really hard to keep up on. You know, does this work? Does that work? Whatever. So I think a channel like yours is super useful and coming from somebody who knows what they're talking about and is reputable and they're really well done videos. I mean, I've watched a few of them now and you just, you do a really nice job. So I really want to encourage everybody to check it out if you're interested. And again, tell us the name again. Where the hell did the name Lab Muffin come from?

[C]

I needed a name to start. I was never gonna start if I didn't think up a name. I thought up the first name. I could change it later. Didn't change it. It's been 12 years.

[A]

Okay, so Lab Muffin on YouTube and really I gotta just tell everybody. They are really well done videos and really entertaining. I actually really enjoyed watching them. So thanks guys for coming on today and again, really appreciate it. So thanks for joining us this week for this fascinating conversation with Dr. John Barbieri and Dr. Michelle Wong. If you've got questions, comments or ideas for topics we should cover on the show, shoot us an [e-mail] again, that's questionsdermsondrugs.com and hope you learned a few things from the interview today. Hope maybe you laughed once or twice. And mostly I hope you're planning to join us next week. And until then, I'm Matt Zyrus.

[B]

I'm Tim Patton.

[E]

I'm Laura Farris. And we are derms on drug.