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- [00:02]
A
Welcome to season three of Derms on Drugs, a video podcast brought to you by Scholars of Medicine, the best educational platform in dermatology and provided a no cost to medical providers. Germs on Drugs is where cutting edge derm meets hit or miss comedy. I'm Dr. Matt Zyrus from Doc's Dermatology, and each week I'm joined by residency buddies Dr. Laura Fares from the University of North Carolina and Dr. Tim Patton from the University of Pittsburgh. And we use our 60 years of combined derm experience to discuss, debate, and dissect the hottest topics. Dermatology. It is everything you need to know to be in the cutting edge of derm, and you'll actually have some fun listening. New episodes drop every Friday on Scholars of Medicine, Apple Podcast, Spotify, and other major podcast platforms. And I highly recommend downloading the Scholars in Medicine app to access the full podcast video archive and explore the best educational content out there. Not that pharma AI generated slop, but actual real, nitty, gritty coverage of all of dermatology. The latest stuff, the stuff you learned in residency, the whole shebang. And it's supported by an amazing AI clinical consultant called Ask Simon. So this week we have a unusual episode for Derms on Drugs. We are thrilled to be joined by Dr. Amanda Hill, who is also part of Doc's Dermatology, to talk about regenerative medicine and regenerative dermatology. Dr. Hill, welcome on the show. And why don't you start off by just telling us, where'd you go to med school? Where'd you do Durham residency? How'd you. How. Why should we believe that you, you know, regenerative medicine immediately sets off the word crap in my head of like, that's baloney. Why should we believe you?
- [01:39]
B
Exactly. Yes. Well, first, thanks for this opportunity. Listen to you guys all the time. So it's pretty. It feels pretty surreal to be on the podcast. So thank you and thanks for all that you can contribute to dermatology. See, I've got a big feat to attack here. Try to get the, you know, the crickiness out of regenerative dermatology. So I. So I went to undergrad at Michigan State. I was a nutritional sciences major, so I've always kind of been interested in nutrition and health. I taught exercise classes on campus, and then I went to Georgetown from school medicine for medical school. I then was at University of Chicago for a transitional transitional intern year. I did the Air Force scholarship for medical school, so did a stint as a flight doc, which is primary Care for the pilots and their families up at Beale Air Force Base in Northern California, where the U2 is. So you did some, like, high altitude medicine there. And then I did my dermatology residency at Stanford in the Bay Area. You know, tech that I think shaped a lot of, like, my interest in tech and AI and just a little more forward thinking and design thinking model they have there. I then practiced, did my payback time for the Air Force at Nellis Air Force Base in Las Vegas. And then I moved back home to Michigan, where my family is and joined Doc's dermatology group. You know, for me, the biggest thing that. One of the things that I was seeing as I've kind of emerged from all my training, my Air Force time, you know, seeing patients, particularly a lot of perimenopause menopause patients, was, you know, these profound changes that they were seeing in their skin and a lot, you know, itching, acne, hair, us, you know, aging signs. And they're coming to me for, you know, this wrinkle that they don't like, and their skin's not the same, and they're wanting me to inject filler or Botox. And just part of me just felt like this isn't. I mean, this is just treating us. This is masking a symptom when there's a deeper problem going on. So I kind of dove down into some more training. I think hormones were a big role for me.
- [03:42]
A
You sound a little too much like a medical student interviewing for Derm right now. Well, the skin is really what fascinates me, is it's a window to systemic disease. And it's really. I'm. I'm never gonna do anything. All I'm gonna do is treat pemphigus and psoriasis. I promise, I promise. Go ahead.
- [04:03]
B
Oh, you're good. You're good. So then I started the A4M longevity medicine fellowship, which is through the American Academy for Anti Aging Medicine. They have. It's about a year long. I just finished it this weekend, or about to. I took my oral board exam. But I mean, the main focus of that fellowship was really looking at what's going on, the hallmarks of aging, which There are about 12 defined hallmarks of aging and how we can, you know, potentially intervene earlier to slow the aging process down. It's really trying to optimize our health span, not like, live as long as possible. I think people think longevity and they think Brian Johnson, which is fine, and some people may want to be in that biohacker, but really, you know, it's a lot. So many Americans have metabolic dysfunction, which worsens their psoriasis and hidus. Right. So if we can be a little more preventative and identify some of those symptoms earlier, a lot of it's more lifestyle things too, then we're going to, I mean, improve everything. So I did some training. I did finish the A Forum class. I took several hormone classes with like, Heather Hirsch, Rachel Rubin. I took all their courses because there isn't really a great standard standard for like, what you're supposed to do everyone because of the Women's Health Initiative. So I needed to. I really educated myself from a lot of different angles so that I could feel comfortable. And one of the big reasons I did the training myself was I was trying to find people to refer my patients to. Coming from California, where I think there were more options that I just didn't find.
- [05:33]
A
There's more regenerative medicine in California than in Detroit.
- [05:36]
C
I don't believe it. Hard to believe.
- [05:39]
B
I couldn't find. I couldn't find anybody, you know, who was doing. It was kind of either doing lots of pellets or still saying that hormones cause cancer. Right. So I think the truth often is in the middle. And. And then with the docs dermatology group, over the last six months or so, we've launched a longevity and regenerative esthetics clinic. We're really. The longevity side is just trying to optimize the hormones, inflammation, insulin resistance. I mean, let's.
- [06:08]
A
Let's start kind of right there. So what is the. Like, whenever I think of, like, I think of there as being like, the three specialties of baloney, and them being aesthetic medicine, aesthetic dermatology, longevity medicine, and regenerative medicine. And obviously I'm being, like, facetious. If I really thought this was baloney, we wouldn't be talking about it. It's real. Like, this is. This is real and useful. And we're all going to be hearing a lot more about it. And probably at the end of this episode, we're all going to become your patient. So what is the difference? So, like, how specifically, what is regenerative medicine as opposed to esthetics and longevity?
- [06:46]
B
Yeah. So regenerative medicine is. We're trying to regenerate, like, real human tissue in the same form that it was. And we really, like, there's. That's kind of where stem cells come in. You know, like there's a wound and we're trying to regenerate the wound to be like, exactly how it was before. Or even with the aging process, we're trying to make your skin exactly how it was before. So, like, true regenerative medicine is more hard, is. Is more difficult than trying to, like, slow the aging process or improve the squ. Improve the quality of the skin.
- [07:15]
A
So does laser resurfacing count as regenerative medicine?
- [07:19]
B
We put it in that. In regen. In that regenerative. Like, we're trying to regenerate tissue. I think if you, you know, looked at the JAD article that. I think. I forget. I think you have that one right. That was like, getting it back to the true form, and that's more difficult to do. But I do think. I mean, this is where the lines are a little bit blur, but we are regenerating tissue. It's not going to be exactly how it was before, but we want to try to make it better than it was.
- [07:43]
A
Yeah.
- [07:44]
D
So is it really reversing aging? Is that really what you'd say regenerative medicine is?
- [07:50]
B
I mean. Yeah, I mean, I'm trying to think, like, aging.
- [07:55]
A
So it's like we just asked you to define artificial general intelligence.
- [07:59]
B
Yeah.
- [08:00]
A
You could get all AI experts to immediately be, well, geek, because you can
- [08:05]
B
also use it in disease states, too. So, I mean, aging is like this normal process. I don't necessarily. I mean, is it considered a disease? I guess that's up for debate. Right. I mean, it leads to a lot of diseases, but.
- [08:17]
D
So we're going back to the optimal state of health is maybe.
- [08:21]
B
Yes. Yeah, that's. I would say yes. Yep.
- [08:24]
D
Okay. And then I'm laughing because you're like, Rachel Rubin and Heather Hirsch, and I'm like, I know who they are. And I'm like, do either of you two. Have either of you two ever heard those names?
- [08:35]
A
Nope.
- [08:35]
C
I know Rick Rubin.
- [08:37]
A
That's.
- [08:38]
D
I don't know who that is, but I'm sure. So those are, like. These are, like, two women who have really brought back hormone replacement therapy and, like, really kind of tried to bring this back into general medicine. Tried to dispel a lot of the myths. Tried to, like, you know, sort of point out what the issues are with, like, the Women's Health Initiative. And so, like, if you're my age, they. They show up on every social media feed you have. You're like, I feel like, you know, I'm friends with them because I see them all the time. You know, Mary Claire Haver, like, all these people. But they are, like, women who are really trying to bring back, like, physicians should know how to prescribe hormone replacement therapy and that they're. We have, like, done women a disservice by making estrogen seem like something that's unsafe, so.
- [09:28]
A
Well, let's start with the hormonal stuff, because that's like, I. I feel like when I was. I remember as a kid, like, my mom going on estrogen for menopause. And then like, when I was in medical school, like, mom, you need to get off of that stuff. You're gonna get breast cancer. And then a few years later, I was like, mom, you gotta get back on that stuff. You're gonna get a heart attack. And like, now I have no idea. Like, what is. Is estrogen good? Is progesterone good?
- [09:56]
C
Is it.
- [09:57]
A
Jesus. The more the bit like, what's the. Ferris. You had the article on this? What, did you have any take on it? Or should we just go straight to Dr. Hill telling us what the answer is?
- [10:06]
D
Yeah, I mean, I can kind of go over the article that I looked at. So the article I looked at was called Skin Hair and Beyond the Impact of Menopause. And I felt like, very called out that I was given this, this article to review, but that's okay.
- [10:24]
C
Listen, you're going to be going through menopause in like 30 or 40 years, and we want you to be ready.
- [10:29]
D
Thank you. That's right, because the median age of menopause actually is 51, so.
- [10:34]
C
Oh, that's forever.
- [10:35]
A
Wow.
- [10:36]
D
Forever away. Yeah.
- [10:37]
A
Yeah.
- [10:39]
D
So, yeah, I mean, just like a couple of the things and I'll. I'll kind of focus a little bit on the skin stuff. But like, you know, within four to five years of menopause, 80% of women will have, like, mild symptoms, like within. But, you know, four to five years before they hit it. But up to 20% may start to have symptoms up to 10 years before, you know, you hear phasomotor. Symptoms like hot flashes are the most common thing. But, you know, also about two thirds of women will have skin issues. Some of the big things are dry skin, I guess, is the main one. But then there's also, you know, wrinkles, sagging, all of that stuff. And then there's also things like itching that go along with that. So, yeah, so that. So that is like, you know, we talk a lot about, like, itching and people's met on our podcast and like, oh, think about your old patients and the fact that they're on, you know, diuretics or statins. But we should also think with women, like, maybe it's because you basically don't have any itching. And then there's also like the genital urinal, you know, the urinary and genital so symptoms. So like vaginal dryness. And you know, that causes like a lot of pain, dyspronia. And you know, one of the things as, you know, somebody who now thinks more about menopause and hormones at this stage of my life is like what I have come to appreciate, what was a little bit in this article is profoundly like the impact on the risk of urinary tract infections, right? So we can say like, oh, you're complaining about dry skin and wrinkles, but like UTIs are a huge issue, right? So, so, and a lot of that is like the reason I just thought old women get old, ladies get UTIs, because that's just like what happens when you're older. You're just, you know, you got more incontinence and you get UTIs. But there's actually some decent data that this is related to estrogen. You know, this is very much related to estrogen deficiency. You know, some things like hair like, you know, women complaining about their hair not being growing and there's a reduction in the antigen phase that is associated with menopause as well. So like those were some of the things that I thought were really, you know, interesting here.
- [12:56]
A
So Dr. Hill, what is your most. Should, should women be thinking about, what's the right term here, optimizing their hormonal
- [13:07]
C
state
- [13:09]
A
when they're going through, you know, menopause symptoms are getting significant. Is it something that a 40 year old should be like, it can't hurt to get it checked? Or is it like, what, like what's the age range of this stuff?
- [13:22]
B
It's a great question. I'd say, number one, earlier the better. So let me just step back a little bit. I mean, with the hormones, right? So the big issue I think you talked about was with the Women's Health Initiative that came out in the early 2000 stating, you know, the press release came out before the publication came out and it essentially it was like hormones cause cancer, heart disease, everyone needs to stop. When you actually go back and look at the data, there's a couple of things. Number one, they were synthetic hormones that were used. It was synthetic estrogen or like pregnant mare urine. And then it was a synthetic progesterone, medroxyprogesterone acetate. So there are synthetic oral hormones and we don't use those anymore. But even so, if you look at the estrogen only arm. So this would Be in the women without a uterus. They didn't have a uterus, so they didn't need the progesterone for uterine protection. The incidence of breast cancer actually went down in. Yes, yes.
- [14:17]
D
And that was like never. That was so misreported. Like I remember learning this in medical school.
- [14:23]
B
Yeah, right. So the more you know about it, the more angry you get. Right. And then the. In the arm with the synthetic estrogen and the. It's the conjugated equine estrogen and the medroxyprogesterone acetate, the incidence of breast cancer went from 4 in 1000 to 5 in 1000 with no change in mortality. Right. And then with the cardiovascular risk, this was typically seen in the older women who had been not on hormones. They've had cardiovascular disease kind of brewing without their hormones on board. And it was with. When they reintroduced oral estrogen, which. Oral estrogen goes through first pass metabolism in the liver and can increase your risk for clots. So number one, a lot of these risks were completely overstated. And number two, we don't use those hormones anymore. Now we use bioidentical hormones which are exactly the same structure as your body makes. And we typically use estrogen in a transdermal like patches or creams or sprays. So it's absorbed through the skin and it's not increasing risk for clot. So. Or transdermal estrogen does not increase your risk for blood clot from baseline. And then.
- [15:27]
A
Wait, wait, I get, I got. I have to interrupt you there because the word bioidentical always. That sets off some things for me is that sounds like. That sounds made up. Sounds made up. Like what does bioidentic. Where do you get a bioidentical hormone? Are these like kidnappers?
- [15:44]
D
It's not. It's not. Think about what was, you know, estrogen was. Was equine estrogen. It was purified from horse urine. So we were giving women oral horse estrogen versus making human estrogen. Right.
- [16:01]
B
So it is. It's derived from a yam or a potato, but it's chemically, it's structurally the same as what our bodies make, which is where the bioidentical comes from. So. Okay, but it's FDA approved. So these, you. You can get this through your normal pharmacy. This is an FDA approved medication and so is the oral micronized progesterone, which is the bioidentical progesterone. Just meaning it's the same structure that your body makes. So that's okay.
- [16:30]
A
And so I, I had thought of bioidentical is like we're going to mix up this and that and the other and now I'm going to charge you 37 times more than the actual ingredients costed themselves.
- [16:42]
B
But that's the unfortunate truth is that for so many years there weren't options for women and they couldn't go to their regular doctor and so they were going to these places where unfortunately I do think they were taken advantage of with these compounding pharmacies and spending a lot of money when it's not necessary, it's. It's really not necessary.
- [16:59]
A
So what is your. So do you. So a woman who, what, what should trigger like a 4045, 50 year old woman to like want to get tested? Want to get. Or should it just be everybody ought
- [17:14]
D
to get like and should they get tested or is it symptoms? Right. So I think a lot of the dogma now is you don't go in and say like let's check all your hormones like you, you are you. When you have symptoms, then you address symptoms. Or do you advocate testing?
- [17:29]
B
So I do, I do a combination of both. I'll be to be honest with you. So I. When women, when usually it's when a woman feels off like something's not right, like I am not how I was before. And this can, this is typically like this early perimenopause which can be 10, 15, sometimes even 20 years before menopause. But they sense something is off. Unfortunately there's not pathology at that moment. So a lot of times these people are dismissed when they go to their regular doctor in a traditional care where it's like in and out, like you don't have a disease state. And I think we can all agree our system is great for acute care. You have a disease, we're going to treat it. But for preventative care or for these earlier symptoms, like you know, it's not necessarily set up for that. So for me it's when somebody feels like something is off. And that's when we come in and I do, I do some testing. I usually do start with blood testing, but there's limitations. Right. So it's looking at everything in conjunction with each other. But I will spot check their estroge, their progesterone, their testosterone levels. That's a whole nother topic to get in with women in testosterone because we don't currently have an FDA approved testosterone for women. But testosterone is important in all human bodies. So. And I also check micronutrient levels in insulin sensitivity you know, insulin resistance starts 10, 15, 20 years before diabetes and that fasting insulin starts rising before the glucose. Glucose does. So if we can, you know, identify that in that insulin resistance and intervene with oftentimes lifestyle, exercise, strength training, dietary adjustments, you know, we can delay the onset of disease. And so to me, that's like what longevity medicine is. It's really good preventative medicine trying to optimize our, optimize our internal health with hormones, metabolic inflammation so that we can, you know, have the longest health span.
- [19:17]
A
I, I don't like the sound of that. I would rather just have some peptides that I can inject once a week and not have to exercise, not have to diet, just get some melanitan. I get some tirzepatide.
- [19:34]
C
That's what patent does from a, I do all that stuff. Yeah, do from a skin standpoint. I mean, if a female came in and said, I want my skin to look healthy and I know that means sunscreen and I want a retinoid prescription and vitamin C and all that stuff, but I also have heard that hormones can prevent that. And so I want to be thrown on one of those too. Like, there's no way I'm doing that as a dermatologist. Are you doing that as a derm or are you going to say, well, I need some other symptoms beyond just I don't want to get wrinkles. How do you approach that?
- [20:14]
B
So you're, I mean, correct. I mean, there's no FDA approved indication for estrogen for skin. I, I am not just if you come in and say I want hormones because my skin has wrinkles, like, no, I'm not prescribing that. I do as part of like our practice, I do a full assessment. So I am looking at a comprehensive picture. So if I see some, they're having symptoms of low estrogen, right? And they, that's typically if you're having symptoms of low estrogen, maybe your fsh is rising a little bit. I will start some. An estrogen pat. I will start hormone therapy. And often you are going to have a secondary improvement or at least slowing of the aging process in your skin. And al bones are a big one or with the aging process just in general. But if you're looking at, for facial aesthetics, the bony structure, that's our support where women, I mean, all humans, our bone is getting smaller. And so when that scaffolding is smaller, that's when the skin starts to fall. Then you have the changes in the fat pad, the skin quality. So estrogen is approved for the treatment like for osteopenia for the prevention of osteoporosis. That is an FDA approved indication. So I think of it is going to help the bone structure. And so many women have osteopenia. We just don't check dexas until 65 because I, that's what the guidelines say. But I do look at all of that because I do think it's, it's very important. And if one in two women are going to have an osteoporotic fracture in their lifetime, like that's, that's significant. And if estrogen, you know, in the appropriately selected candidate in a well informed patient, you know, decides it's a good option for them, I feel like that actually may have less risks and potential benefits over some of the.
- [21:54]
D
What about like thinking in the dermatology world. So you could say, all right, I'm not going to say skin quality. There's no evidence. But you know, like I'm in a place where we have a special vulvar disease clinic and we have, you know, a lot of women. I mean when I see who comes in, I'm like, it's obviously all women. They're all, they're. The vast majority of them are kind of in like the perimenopause to menopause to postmenopause age. I mean I would have to imagine at least some of the dermatitis that we see in, you know, and women is because they are estrogen deficient. So given that if you are somebody who treats women with vulvar disease, do you think it makes sense to say yes, it is within our purview to be doing.
- [22:43]
A
I'm calling a timeout on this because we've got a, in a few weeks here we have a double board certified OB GYN dermatologist who was one of my residents coming on to talk about Nick. Nothing but Volvar problems.
- [22:59]
D
So we're taking the vulva out of
- [23:01]
A
today's Taking the vulva off. No vulva today. Forget it. Forget it.
- [23:08]
D
Fine. Okay. And can I. Okay, so we're not. We're going to take is like do you want to move beyond estrogen?
- [23:14]
A
Because I guess the one question I still have Amanda can do you think it's normal derms? Could. Could reasonably prescribe hormones. Like is it right? You did a year long, you did a year long fellowship so like taking
- [23:32]
B
a lot of courses? Yeah.
- [23:33]
A
Yeah.
- [23:34]
B
So Dr. Rachel Rubin, she's the urologist, she said on the FDA panel to help take the black box warning off estrogen. She Says yes. I mean hormones affect every single organ. I think nobody is owning hormones, but hormones impact all of our patients, whether, regardless of your specialty. So that, I mean she advocates for. Yes, I think, think if you have an interest in it, you should learn it because if you're not, I mean, patients don't have access. So the FDA approval, the warning is off. Excuse me, the black box warning label is off. We're getting. Where are patients getting their hormones from? Right. There's whole generations of physicians that haven't been trained. There's not enough obgyns or primary care. So I mean, I don't. If it's not something you're interested in, sure, like don't do it. But I think when we're. There's a lot of patients that have a great need, the skin is greatly impacted by the hormones and just like the overall health. And so this is where I'm more longevity dermatologist. Right. So I took that extra training. I don't think you need to, but you need to be aware of it. And there is an impact of the hormones. I mean, think about all the things that start postmenopausal. Right. So I think hormones are playing a role there.
- [24:35]
C
But if, if the thing is no FDA approved indication for the skin, then now, like, I would be like, look, I think they could help the skin. But if you want to take it because of your bone health. There are doctors who have spent their careers studying bone health. And there's more things than just estrogen. Right. There's the bisphosphonates, although nobody uses those anymore because of jaw fractures. But there's other IV therapies. Like, I don't know anything about that and I'm not going to start learning now. And to say, well, I, I know a little bit about estrogen.
- [25:09]
A
That's just what we, that's just, that's just the right attitude for a Dr. Patton. Learning stuff.
- [25:15]
B
You, you don't have to, but I mean you're. Osteopenia leads to osteoporosis, right? So yeah, but I'm not a bone doctor.
- [25:23]
C
I, I'm not saying that that's not true, but it would.
- [25:25]
D
What do you do when you put patients on a bunch of prednisone? Because you always tell us we need to use prednisone for bp. Are you like, I'm not a bone doctor. Go talk to somebody else about it.
- [25:34]
A
Go find someone who gives a damn.
- [25:36]
C
There is so much more about osteoporosis management and prevention than what a dermatologist knows, you know, I, I, there used to be like, oh, put them all on Fosamax. But then there are these rare fractures and osteonecrosis of the jaw that I didn't know anything about. And there are things like, well, did you check urinary calcium and check pth? And I'm like, you know what? I should not be addressing the bone, the osteoporosis at all. Because that is a whole other field of medicine that people have gone through residency and then, you know, subsequent training to do. I am not qualified to do that. I tell them, you're not qualified to do much scan. Let's do all that stuff. But I'm not going to manage the osteoporosis.
- [26:19]
B
Not appropriate.
- [26:19]
C
It's just not appropriate.
- [26:20]
B
And I'm not managing their osteoporosis either. I'm not, I'm not managing their osteopathy of osteoporosis or seen endocrinologists. I'm seeing more on this earlier side of things. And most of my patients meet FDA approval criteria. They're having, you know, severe vasomotor symptoms. They have genitourinary syndrome of menopause or they have osteopenia. Right. So I am prescribing it on FDA label. But there, my point, I guess is that is there is a lot of other potential impacts and I mean even just on overall health. And my point, I guess in optimizing the hormones is that if we're going to do regenerative therapy, we're trying to regenerate tissue, but we have suboptimal hormones. You've got insulin resistance, you have inflammation. Even if we're doing things like Sculptra, you know, or hyper dilute radiesser stimulate or laser treatments, you know, it only makes sense to me that if your internal health is, you know, in a good state of homeostasis, which most Americans are not, you're not going to get as good of a response.
- [27:15]
A
Fair. All right. Before we move on to. I know Patton is dying to talk about the skin span, but before, before, before we get to that, I occasionally come across an article that talks about topical estrogen, like for your face, for wrinkles and anti aging and that kind of stuff. Does anybody do that or is that like. Nobody does that?
- [27:36]
B
People do it. A lot of the compounding pharmacies, you know, online are doing it. I think it's, I, it's not something I'm putting all of my patients on. The data like isn't super clear. You know, we don't have great data on it probably won't because it's generic and cheap and who's going to do the studies? Unfortunately, if my patient like wants to try it, I think at a low strength the systemic absorption is low and if there's, if I'm seeing them, I am checking their levels to make sure we're not getting super physiologic. So I'll do it if somebody wants to. But we don't have like great data saying that like this is, you know, or when this initiated or who to select for.
- [28:10]
A
Okay, all right, let's move on. Patton, what was your is here by yours?
- [28:16]
C
My deep dive paper November 2025 edition of Mayo Clinic Proceedings and is titled Skin Span A Healthy Longevity Framework for Skin Aging by Wiles et al. It's a review paper that talks about skin aging in general and what therapies we can encourage our patients to pay us thousands of dollars to infl clicked upon them. The first section is on epidemiology. Society's getting older with age. Skin complaints are common. Figure 1 summarizes all the things that happen different layers of skin and the effects that those changes have. Figure 2 Histologic changes. Most of this is is kind of review, but it, I mean it's a, it's a very good review. Figure 3 kind of like a review of figure 1. Just things that happen to skin as we age. Skin aging is the result of the exposome which I I if I encounter
- [29:00]
A
that word that is pronounced exposome exposure,
- [29:05]
C
intrinsic and extrinsic processes that age the skin. Genetics is felt to contribute to less than 25% of skin aging, the rest coming mostly from external factors. They mentioned two specific mechanisms damaged by reactive oxygen species and telomere. Telomere shortening maybe starting to focus on, you know, some targets for therapy. It discusses the detrimental effects of UV radiation, smoking, air pollution. All things I think we're aware of. The top paper talks about sasp. This was another thing. I had no idea that this existed. Senescence associated secretory phenotype. I don't ever remember coming across that. It al so SASP allows senescent cells, which are bad, to continue to exist. It goes into assessment of skin aging and I don't really care about any of that. There's like 18 things that they go over. I vaguely remember rotating with Obagi and scoring people with the glowal scale and like remembering not to chew gum or lean on the walls and listening to like an endless loop of Enya songs. The paper talks about the confocal score for the assessment of extrinsic skin aging, the CESA score. And you have to have a confocal microscope to do it. So this will totally be marketed as a necessary tool for any derms that want to have a high end skin spa. Like the CESA score is an essential part of your management plan. It costs $350 a. Are you implementing the CISA? Do you have a confocal?
- [30:31]
B
I don't have a confocal.
- [30:32]
C
Credibility of Dr. Hill is rising significantly. Table 1 with a bunch of strategies to maintain skin barrier stuff that we tell all the patients. Gentle cleansers, fragrance free this and that. Moisturization. My favorite recommendation, keep the skin covered in the winter. Like, I remember going outside in January, nothing but my underwear. And people were like, that's so bad for your skin. I was like, second favorite recommendation, don't wear wet clothes. It's in there. Table 2 gets more into the how do we make money part of skin care. Top part is the more reasonable things. Sunscreens, retinoids, vitamin C, niacinamide, hydroxy acids. Middle categories, all the cosmetic nonsense like peels and lasers and prp, which I think is crap. Surgical lifts are in there, but I'm sorry, a surgical lift is not in any way physiologically reversing skin aging. Maybe I'm wrong about that. And then the bottom section is where all the snake oil stuff really kicks into high gear. Xenotherapeutics and exosomes and peptides and growth factors. If there are any patients that listen to our show, if your dermatologist starts talking to you about any of these therapies, grab your wallet and get the hell out of their office. No, actually, the xenotherapeutic stuff is. That's interesting. So these senescent cells, sometimes referred to as zombie cells, they're like hanging out.
- [31:55]
D
That's why you like it?
- [31:56]
C
Yeah.
- [31:56]
A
Now you know my patent likes it. Every zombie movie ever made, they're hanging
- [32:00]
C
around in the skin. They're making a mess of everything via the SASPs. And we want to get rid of them or at least be able to block the effects they have. And that's what cenotherapeutics comes in. And this is like the, like, it's, it's interesting. It's crazy. You know, there's this regimen of dasatinib and what was it?
- [32:24]
B
Quercetin.
- [32:25]
A
And so I'm like, what's, what's.
- [32:27]
C
The Saturnib is like a chemotherapeutic agent. It is A cancer drug. It's like. What was the first one? The ib.
- [32:36]
A
Is it like an EGFR or something?
- [32:39]
D
Or something, yeah.
- [32:40]
C
Imatinib.
- [32:41]
D
It's.
- [32:42]
C
It's basically that. It's like the second generation of imatinib. It is a cancer drug. And quercetin, I'm like, okay, yeah, you put that on your face and it is like, no, you take an oral version of this cancer drug mixed with quercetin. You don't do it every day. It's like three days a month. Right, Dr. Hill?
- [33:00]
B
I mean, I am not doing that type of thing. But there was.
- [33:04]
A
Credibility continues to rise.
- [33:06]
B
There was a recent article like suggesting that, hey, actually this maybe not be so good. And so like to me I'm like, there's so much low hanging fruit before that type of thing. Like you're still like eating fast food four times a week, like that. That's not going to be helpful for you. So I have not. I'm with you there.
- [33:24]
C
I thought it was interesting. They got into kind of along the same lines because dasatinib is a tyrosine kinase inhibitor. And so they said JAK STAT inhibition, maybe that has anti SASP activity. So that is a study that is totally ripe for, you know, all these patients on jaks. And then you take the people maybe on non jacks and do some sort of assessment of like skin aging. Right.
- [33:51]
D
Versus JAK inhibitors who ages faster.
- [33:54]
A
Yeah.
- [33:57]
C
So I'm almost done. Second to last paragraph talks about the Yamanaka factors. And Yamanaka was like, won the Nobel Prize in 2012. Shared a Nobel Prize with another guy. These are these factors that they studied where you give them to differentiated cells to like reverse engineer them so that they have this. They call them ISPCs, which stands for
- [34:26]
A
their pluripotent stem cells.
- [34:28]
C
Yeah, Induced pluripotent stem cells. So that stuff was interesting, but. Right. I mean, it sounds like that's kind of even maybe some of the things that, you know, like you said, just the stuff that makes more sense. The retinoids, the vitamin C, the uv, the come. I made fun of the cosmetic things because I don't. I just don't do it. And so I disparage it because I don't understand it. That's a life philosophy, literally approach.
- [34:55]
A
Somebody should have. This is like an example of like whenever somebody's getting bullied and they're like, that's just because they're jealous. Yeah, that's Pat. No, that's Pat over here talking bad about the aesthetic dermatologist.
- [35:07]
C
Absolutely. Absolutely dripping with jealousy.
- [35:10]
A
It's.
- [35:10]
C
It's horrible. But. All right, so any, like, what did you take away? It's a good. It's a good article, and I'm reading it. I'm like, well, we know all this. But then I was like, the SASP stuff, the senescent cells, the zombie cells. We take zombie cells and we want to turn them into vampire cells that live forever. That's what really grabbed me about this paper. The Yamanaka factors. All pretty neat stuff.
- [35:33]
A
And for. For any. I might be getting this wrong. So if I am. So the way that you think about the SASP cells, they are senescent. They're like an individual cells that are senescent, but they don't die. They. They hang out and make all the cells around them be crappy. Like, that is the basic ID of them. They're like your downer friend who makes everybody else like, blah. And if you can get.
- [35:58]
D
You don't want your kids to hang out with.
- [36:00]
C
Yeah.
- [36:01]
A
And if you can just get rid of them without getting rid of the other cells.
- [36:04]
B
Yeah.
- [36:04]
A
Then the other cells will perk back up. Is that basically that. Is that Dr. Hill? Is that fairly.
- [36:11]
B
Yeah.
- [36:11]
D
Okay, target them. Since I didn't really, like, look at that paper all that much, like, is there something. Are you like, ah. I mean, is that where the quercetin comes in? Like, quercetin targets them? Or is this like this idea of autophagy? Like, where are.
- [36:27]
A
Like, yeah, you've got to shoot them in the head. That's the only way to get rid of the zombie cell.
- [36:33]
B
This is where we're trying to go with, like, skin aging, though. Rather than, like, you have a brown spot, you need a lightning cream, you got a red spot, you need something for red. It's really trying to target that aging process, like, from an earlier cellular level, which I do think could have, like, translates translational application to potential potentially other organs of our body too. And if we think, you know, these hallmarks of aging are precursors to most of the disease states that we, you know, heart disease, diabetes, so forth, if we can slow that, again, slow that process down or reverse it, then it could have, you know, potential, like, benefits for just overall health as well. But I'm not using anything at this moment to target those. That's where a lot of the, like, research is going. And that's. That's one of the things that I'm, like, paying close attention to because I think we're. Again, you got an NAD cream, a methylene blue You've got your tretinoin. You know what, what are these all doing and why are they doing it? How do we know they're getting into the skin? Like it's all like a lot of it is, I agree, like a money grab. And patients don't know, clinicians don't know. So it's really trying to make sure that to me like going upstream of the aging process a little bit about
- [37:41]
C
like exosomes because like that exosomes drives me crazy because it's like, well, they're like umbilical cell exosomes, but we stress them with heat and they're like, no, no, no, you need to stress them with hunger. Or I don't like, don't feed them. And then it's like adipocyte. Like so literally there could be millions of different exosomes. Is there any science and sense to that whole process?
- [38:10]
B
Yeah, depends on which company you talk to. Right. And what they're they're going to. You tell their philosophy is. So I mean I've done like a good amount of on the exosomes. You know, there are different exosomes, these extracellular vesicles, they're messengers between cells. They carry different signals, if you will. You, you can get them from adipocytes, mesenchymal stem cells, and then also the platelets. So I do think some of the platelet derived exosomes have some reasonable data. Meaning they did skin biopsies before and after showing actual change in the collagen and elastin of the skin. And they're well tolerated, they're not irritating. Right. The safety profile and their manufacturing processes are good. So I do like those ones. But some of the other ones, I mean, no, we don't have these like great data as placebo controlled and things like that. So I'm not like keep layering different things on for my patients.
- [38:59]
D
So do you use them topically or how do you use exosomes? Like are you like, here's exosome lotion or are you like, I'm going to micro needle your face and give you exosomes.
- [39:10]
B
Yeah, so I typically will use that. So there are some formulations. Again, their manufacturing factoring processes, quality control, like are pretty top notch. And they've had studies like with skin biopsy data, so I feel more comfortable in that that are shelf stable. And so then this is something like they use at home. There have been some studies with like tropical exodomes like ex deposit derived exosomes and PRP kind of split face Showing equivalent. I don't. We have them. Some I don't know if I'm with. I'm kind of juries out if it's hugely different, is it worth that extra expense or just micro needling with good pre and post care and making sure to me and like that you're in a healthy state when you have that micro, micro needling done? Yeah.
- [39:56]
C
I, I have determined that Dr. Hill is going to be the poorest regenerative medicine dermatologist. She is like, I don't know if that works. I don't know if I would do that. Her office manager is like, what are you doing?
- [40:12]
B
I will say I'm right and they really appreciate it.
- [40:17]
A
It's true. I would say I'm pro exosome because two different people who I think of as really smart guys, Dr. Ted Lane and Dr. Justin Harper, have both, who I don't think would bullshit me. They might, but I don't think they would. They have both told me like, no, exosomes are like the real deal. Like, they are as a delivery. It's not the, it's not the exosome itself. It actually gets growth factors and other baloney into your living epidermis. That's, that's what I have been told. Dr. Hill, is that vaguely how you think of exosomes is like, I, I
- [40:57]
B
agree, I do agree, but I think where you're like, where you're getting from the company, their manufacturing process, their quality control, it all really is very, very important. And so right now everybody's got their spin on their exosome and you're like, is your exosome the. One of the big problems is one of the companies actually took a whole bunch of other companies and looked at their products and there weren't even any exosomes in like half of them. Right. So this is where we're at. So to me, it's just making sure the source is from like a good reputable place that has studies to prove some efficacy.
- [41:25]
C
Is there like a, Is there like a stamp of approval on a product where you could say, oh yeah, that was rated, you know, their national ex.
- [41:35]
A
National Exosome Foundation.
- [41:37]
C
There's not, there's not as, as like the run of the mill dermatologist who, you know, your patient comes in and is like, what about the exosomes? Is there like any advice you give to just the general dermatologist about, here's how you could tell if it's a good exosome product or not?
- [41:54]
A
Is there an exosome Product you would recommend like just as a general patient.
- [41:59]
B
And yeah, I really, I mean I really like plated. It's a platelet derived exosomes. A lot of the studies. Dr. Wiles who did the skin span, she's doing some. She's a dermatologist, MD, PhD, doing a lot of really great research in regenerative dermatology and regenerative medicine at the Mayo Clinic. So I do like, I, I have read all their studies with their exosomes and their manufacturing process. So I do now I come. They did just ask beyond their advisory board. So a little conflict chest there. I haven't gone but gone yet. But I do like their product so that's the one that I feel most comfortable using. I know there are some other ones, but you know.
- [42:34]
A
Okay, fair. That's all right. We're gonna, we're gonna wrap this up just with the, the paper that I did was a JAD CME article that came out earlier this year. The first half of it, which was trying to get back to the top. Regenerative medicine for dermatology for skin, basically. And what was interesting in here was it had a really, some really useful tables talking about the different types of stem cells, the different types of cellular factors. And so just the first thing. Cause this was interesting to me some things that I didn't really understand. So the two things with. Two first functional things with stem cells, there are self derived stem cells and then there are autologous stem cells where not autologous would be self. I don't know, whichever. Some come from you and others you get from somebody else. And the ones that come from somebody else, they have to be immune cloaked so that they don't generate. Because you can't just take like Patton's stem cells and give them to me and like my immune system would get rid of them. So the, the sort of choices that you've got these pluripotent embryonic stem cells, right? The problem with those guys is that they are, you know, there's ethical concerns with the idea of them and they can form teratomas. But then you've got pluripur potent induced induced pluripotent stem cells. Where in theory you could harvest these from your, from somebody and then like grow them up and have them do stuff. Then you've got these. Now those are ones I think you like have to harvest them and then send them away and like then they send you the stuff back. Then you've got the ones that you're. You're harvesting more Quickly in the office. So you've got mesenchable stem cells from bone marrow, which I don't see any germs doing bone marrow to harvests, but you've got mesenchable stem cells from adipose tissue, those ones you hear talked about a lot. Because I think that is something that there are some derms and plastic surgeons doing where you basically get lipo and then you somehow process the fat that got sucked out and you get the mezincip adipocytes and then you've got the stem cells from umbilical cord blood. Those seem like good ones because there's no ethical problem. And they are immune cloaked, so the immune system doesn't. Doesn't take them. There's actually been a few studies with those in atopic derm that they might actually help. You've got mesenchymal cells from placental tissue. You've got epidermal stem cells where again, you heart. I think those are the ones. I remember people were doing like, biopsies behind the ear and then sending them off to get harvested and they would come back. But I don't see stem cells as being something that derms are using a whole lot of right now. But PRP falls into the same category of a cellular, you know, regenerative medicine thing. So first, Dr. Hill, with all of these cellular ones, my first assumption is that they have to be injected that like, I suppose if you lase, if you did resurfacing laser, maybe you could use them topically. But with like most of them, it seems like you're going to have to inject them for them to do much. But prp, like, I remember a few years ago, PRP was really hot. Like, people were like, I was microneedling it in and vampire facials, and you use it after laser and there's all kinds of stuff and you're injected into joints and like, is PRP still? I feel like I don't hear as much about it as I used to, but that just might be that I'm not listening as much like what's happened. So I feel like that's a hot topic in Durham, or at least was what's going on with prp.
- [46:26]
B
Yeah, So I think people. PRP is still used. I think just the issue with prp, like, it's very much a patient. Patient variable. Right. It's the. Depends on the patient's prp. So it's not as standardized. And even the methods of extracting the prp, like which method you're using how many platelets there are. There's a lot of different, like, options out there. It's something that I will still use, but it's not like a huge, you like, it's not like, to me it's, it's safe. I'm not going to do any harm. I think it can help with the wound healing. But is it going to create this like, huge, massive change? I haven't necessarily seen that. Do think for hair, when you're looking at other factors involved in hair loss, it could be an addition. But I, I add that later once I get you more, you know, medically managed as well. And then I do think it can be helpful. But I, I have not from the peer. And people will still like inject it too. So if you're, you know, if you're doing with microneedling, then we can still inject some of that after. I don't think to me, I haven't seen these huge, significant changes. I think the issues you talked about. Yes. With these other stem cells, mesenchymal stem cells, whether they're epidipocyte derived, you know, from the umbilical cord or so forth, it's like we can't inject those right now. Right now. Like, that's not, I guess if you actually harvested it in your office, which I don't know. I'm not doing that. I don't know any derms that army that if you, you harvested their bone marrow and then you injected it. I know some like regenerative spine people are doing that, but I haven't seen a derms doing that. I'm not doing that either.
- [47:52]
A
Yeah, mainly I think you hear about it with ortho of people doing like, oh, for 10,000 instead of a knee replacement, you can get, you know, mesenchymal stem cell harvest and then we'll inject those into your knee. And maybe you don't need a knee replacement. Like that kind of stuff I, I hear about. But it sounds very like, just get the knee replacement. Like it's $10,000. Like, unless you, if you're, you know, if you're a regenerative doctor, then sure, you can afford to regenerate your own knee, but otherwise that $10,000 probably could go to better use.
- [48:27]
C
You know.
- [48:27]
D
Also seems like a setup for infection.
- [48:29]
B
Right.
- [48:30]
D
Like you're, I'm going to trust somebody to pull out some stem cells, go grow them. Right. Presumably you got to grow or separate them out and then inject them back in. But so when you say inject in the Skin. Are you like injecting subcutaneously or are you.
- [48:45]
B
Not you.
- [48:46]
D
Because I know you're saying you're not
- [48:47]
B
doing that, but like PRP or for these stem cells.
- [48:50]
D
For the stem cells.
- [48:52]
B
Oh, yeah. I, I'm not sure I have. I don't.
- [48:55]
D
And how about prp? Do you ever do PRP injections? Oh, just the scalp.
- [49:00]
B
Mainly the scalp. I will after micro needling. You know, like, you know, just abdermal or intradermal. I don't know if it helps, you know, to. It's not like this huge difference. Right. But again, to me, I'm like, I think it's never just. To me, it's not just one thing, it's just trying to get your body as healthy as possible. To me, making sure we're not doing like harm by adding all these things that probably don't work and, and trying to get your. To me, I want your skin to be as healthy as possible. I'm not just chasing a wrinkle with some, you know, shoving some. Something in a wrinkle. Right. Like why is that wrinkle there? We're losing collagen, Elastin. What are some things that we can do to slow the aging process down? Looking at a more like a holistic view.
- [49:41]
A
So before we go on to Patton's trivia, we've had some debates on the show about collagen supplements, oral collagen supplements. I have. I believe that the company sponsored studies. Patton of course brought on some that's. Well, if a company study, one show they work, the non sponsored ones show that they don't. What's your take on that?
- [50:04]
D
And I have a whole. I have a bin of collagen powder in my kitchen to throw in my coffee every day.
- [50:10]
A
So that's it. So Ferris is it. Ferris is in. Ferris is literally, she's literally drinking the Kool Aid. Yeah, the Kool Aid has collagen in it. Yeah, the collagen and the Kool Aid. So what's your take on. Do you, do you do collagen supplements for your patients?
- [50:25]
B
I do and I take collagen supplements as well. So I think getting it from a good source, I used one from like Designs for Health that does have some because again, supplements are not regulated by the fda. So are you getting what they're telling you you're getting? Right. So you want to get it from somewhere that's reputable. And the one from Designs for Health, the Whole Body Collagen does have some kind of trademarked sources in there. If you will. So they've been. There's been some studies on. I think it can help, you know, with the skin, hair, nails, also just joints and overall tissue. And I know it's not going to do any harm.
- [50:56]
A
Yeah, that's the key.
- [50:59]
C
We talked about estrogen and then all the topical stuff. What. What have we not talked about that you think is an important thing that you. That is an important aspect of regenerative
- [51:12]
B
care and with kind of the focus on dermatology, I would say. That's a good point. That's a good question. So we didn't really talk about a lot of the bio stimulatory injectables that I think could potentially be helpful.
- [51:26]
A
People know about. People know about all that.
- [51:29]
D
What would you say? What's bio stimulatory? So things like Sculptra, like calcium, appetite, what else?
- [51:37]
B
Hyaluronic renuva. I think is a pretty interesting one. The acellular fat matrix allograft where you inject that and then it stimulates your body to make fat. Because loss of fat pads in certain areas. That's definitely one that I really like as well. Yeah, those are the main ones.
- [51:55]
A
Okay. All right, let's move on. Patton, what do you got for trivia? What's our. What's our topic this week?
- [52:02]
C
Category is getting old.
- [52:06]
A
Dr. Hill has no chance. None.
- [52:09]
B
All right.
- [52:10]
A
Actually, we may have all forgotten the answer.
- [52:12]
D
The oldest person here. I feel like this is my topic.
- [52:16]
C
All right, so the plot. A man remains eternally youthful while a painting of him ages and bears the consequences of his transgressions. Name the novel and authority.
- [52:28]
D
Is it like Benjamin Button something?
- [52:31]
C
That's the. The Curious Case of Benjamin Button was a movie with Brad Pitt where he like, aged backwards. But that is not the, the, the novel of this classic plot.
- [52:43]
D
This is a classic. Dorian Gray.
- [52:46]
C
Yes.
- [52:47]
D
Okay.
- [52:48]
A
What?
- [52:49]
C
The picture of Dorian Gray. And who wrote that?
- [52:54]
D
I can't remember.
- [52:55]
A
This isn't related to 50 shades of gray, is it?
- [52:58]
D
No, that is not.
- [52:59]
C
It's a secret.
- [53:02]
A
Once he's old. Once he's old.
- [53:06]
C
It was written by Oscar Wilde. All right.
- [53:10]
A
Okay.
- [53:11]
C
All right, all right. Number two on the Beatles album. Sergeant Pepper's Lonely Hearts Club Band. Paul McCartney wonders if his significant other will still love and care for. For him when he turns what age?
- [53:23]
A
80?
- [53:25]
D
No, 64.
- [53:28]
C
Oh, my. Ferris is bringing it today. Bringing it when I'm 64. No, that's not ringing a bell for anyone.
- [53:36]
A
Nothing.
- [53:36]
D
Will you sing it for us?
- [53:38]
A
But it was actually 64. That was the answer?
- [53:40]
C
Yeah. When I'm 64, will you still need me? Will you still feed Ferris?
- [53:45]
A
Was that honestly just a wild guess?
- [53:47]
D
No, I've heard the song.
- [53:49]
A
Oh, okay, okay, okay.
- [53:52]
C
I thought those were, were really easy. So the third one I made impossible. All right. The oldest Olympic gold medal winner was Oscar Swan Swahn. I don't know if that'll help you or not. He was 64 years old when he won gold medal in a shooting event at the 1912 Olympics. For what country?
- [54:16]
A
What country?
- [54:18]
B
Germany.
- [54:19]
C
No, that's a good guess. It's in the area.
- [54:22]
A
I'm thinking would have been a bias. I'm sure he was real close. Finland.
- [54:32]
C
You have named every country except this one in the area.
- [54:36]
A
Sweden.
- [54:37]
C
It is Sweden.
- [54:39]
A
Well, that was going to be my first guess.
- [54:42]
C
Yeah, this was great. So this was the event. It's called team running deer single shot shooting event. They would have like a little cardboard cutout of a deer and shoot it across the thing and you had one shot and had to hit it and the team Sweden won the gold medal. And he was on it crazier even still. He won a silver when he was 72 years old, same event, but it was like obviously later and it was a double shot.
- [55:13]
A
Oh, you got two chances.
- [55:14]
C
Yeah. So he was probably on that Desatinib Quercetin. Probably before. Yeah, before it was a thing. Yeah, lots of exosomes.
- [55:23]
A
He was, he was, he was an early adopter.
- [55:25]
C
Yeah. All right.
- [55:26]
D
That's an awesome sport. You know, now we have things like break dancing, but like I love a sport like a paper deer.
- [55:36]
C
Why would they ever get rid of it?
- [55:38]
D
I can't imagine like you can be like kids if you go paper deer shooting someday. You two might be an Olympian. Damn it.
- [55:49]
A
Well, I want to thank everybody for joining us this week. I hope. Dr. Hale, I really want to thank you. This has been a really fun episode and I learned a substantial amount this episode. I want to thank everybody for joining us this week. We hope you laughed once or twice. We hope you learned a few things, but mostly we hope you're planning to join us next week. And until then, I'm Matt Zyrus.
- [56:11]
C
I'm Tim Patton.
- [56:12]
D
And I'm Laura Ferris. And we are derms on drug.