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- [00:04]
A
Welcome to the youe Are Not Broken podcast. I'm your host, Dr. Kelly Casperson, a
- [00:09]
B
board certified urologist, thought leader and conversation
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A
starter on midlife living, hormones and sexuality. Enjoy the show.
- [00:18]
B
Hey everybody. Welcome back to the you Are Not Broken podcast. This is the long awaited skin and hair episode that I have not done yet. And I have the very awesome, very kind, very knowledgeable Dr. Ellen Gendler here, who is a widely respected New York City dermatologist who in addition to already being busy enough, is a consultant to lead cosmetic and pharmaceutical companies lectures nationally. Basically had the most talked about Menopause Society NAMS lecture of 2023. People would not shut up about your lecture. And she's actually getting quite popular on Instagram, so. And besides the fact that you publish extensively, like all important people do. So thank you so much for joining me on this podcast.
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C
Thanks for having me.
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B
Tell me, how and why did you care enough to get on social media? What's your story?
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C
That's a crazy story. Did I care enough? I was kind of bored and I had some back surgery and I was on steroids and I had nothing to do. So I started just surfing and seeing how much crap there was from my field and it was getting me really crazy. And it was the summer and I was outdoors trying to lie down like a locksmith and using my sunscreen. I decided, I don't know, I got nothing else to do. Let me just make a post. And it went crazy. It went absolutely crazy.
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B
It was.
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C
It was really nuts. I mean, these are things I talk about all the time, but I never actually did it on social media and it just happened. I don't know, I thought it was a joke.
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B
You're like, this happens to everybody who gets on social media, right? No, I'm telling you, Ellen, some people are just naturals. And I think you're just a natural. You have a good way of talking.
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C
Well, I don't know. It's kind of fun and I made a lot of friends. I've learned a lot. I hope I've shared a lot of information, but it's actually something to do other than online shopping. So it works for me.
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B
I love it. The most talked about presentation at The Menopause Society 2023 was talking about estrogen on the face. Estrogen's role in collagen, estrogen in skincare. Where do we start? What do you want people to know?
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C
Well, where do we start? We start by saying, why should you not be using this on your face? You use it in your vagina and it seems to work there. So why would you not use it on areas of your face? It made a lot of sen to me. And 25 years ago I started using it on myself. And I mean, I'm kind of old now, but I think that the areas in which I've used it are really pretty good and would not have been as good in my opinion as had I not used it. And I've been using it on patients for that long. I use it in patients in their 40s and upward. I don't use it in 20 year olds.
- [02:50]
B
If anything, they've got too much testosterone. You're trying to combat that problem with the skin.
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C
Exactly. And then we have the hair loss issue. There's just so only so many things you can fight. But it seemed to me that when you started feeling symptoms of vaginal dryness and other things, or maybe just before you anticipate feeling that your skin's having the same issues, so treat it as such. And it was. I was the only person doing it, but it was off label, but I knew it made sense, so I did it. And it kind of caught on recently with this whole menopause craze that's people started saying, you know something, I've heard about that and I think that's how it happened, but it's not new to me.
- [03:26]
B
That's awesome. The naysayers will say there's no data. Can you share that with us?
- [03:31]
C
There is plenty of data. Some of it is not all that strong. But let me tell you what is strong is the data saying that there's nothing harmful about it. And there are small studies, good studies, but limited studies saying that it does help in local areas. So the problem that I have with topical estrogen is I personally don't believe you should be smearing estrogen all over your body. It's just too much. It's not possible to do that. So what I've chosen to do is choose selected areas of the body that I see women complain about most. The first area that all women complain about on their face is the area under their eyes. And that's the thinnest part of our face. So why would you not compare that to a vagina? It seemed natural to me. Your vagina thins, it's going, you know, inside your vagina fins. So it does it under your eyes. So start by using limited areas. And many women already had topical estrogen for their vaginas. So just take your finger, put it other places, just put it underneath your eyes and it really Seemed to work. I'm not someone who at this point advocates, until studies are really firmer, of smearing estrogen all over your face, all over your neck, I just am not sure about it. I'm not unsure, but I'm not sure. So I choose to have people do it under their eyes and on the tops of their hands, which is another big issue for women. You'll see as you get older, your hands give away your age if the under eye doesn't. So sometimes I'll use it on the neck, but I try to have women do it similarly to how they would do it in their vagina. You know, how you apply it for the first two weeks and then you kind of cut back to twice a week. So if you use the smallest dab under your eyes once or twice a day and a little bit on the tops of your hands, those. That takes care of areas that are problematic. And it works. It does work. There are studies. I can send you the studies. They're working on some other studies now to make sure that it's not systemically absorbed. And so far it doesn't appear to be. And that's what's important.
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B
Beautiful opinion on estriol versus estrogen for skincare for skin application, I don't know
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C
the answer to that. When Estriol is used topically, it's used as 0.3 and estradiol 0.1, and it's probably pretty comparable. And in Europe, they use Estriol more than estradiol. So I believe that it's similar, but I don't have the backup. There are some studies going on right now to prove this point. So I think we have to do this with some caution. And that's another reason why I don't advocate that people smear it all over. I don't know. How do you feel?
- [06:02]
B
Yeah, I mean, to me it makes sense. You know the data more than me. But the Estriol is a lower potency, probably less likely to be absorbed. So maybe if I do want to put it all over my face, I'm going to do an Estriol.
- [06:13]
D
The sun is calling. Are you ready? From beach days to soccer plays. Blue Lizard Australian sunscreen helps protect your family's skin so you can focus on the fun, not the sun. With no fragrances, parabens or phthalates, our mineral sunscreen is designed for your sensitive skin and trusted by dermatologists, pediatricians and parents alike. Be fearless in the sun with Blue Lizard Australian sunscreen. Shop now on Amazon.com but yeah, I
- [06:44]
B
mean, you know, they've done. Somebody had said a year's worth of vaginal estrogen cream is equivalent to 1:1 pill.
- [06:52]
C
That was me, I think in my NAMS lecture solo. And you know, there was that report of the woman who died of endometrial cancer. Do you remember that? She was 92. There's a big report she had been smearing for 74 years. Some compounded full body twice a day for 74 years of no documentation whatsoever of what her. That's that me getting that the balloons. No documentation of the strength of her estrogen cream. So we don't even know what she was using. So I don't think that's a fair study to use as a.
- [07:25]
B
At best, most people are like, I'd love to live to 92. That's fantastic. You're going to die of something.
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C
Exactly. So I don't even, I discount that. But we definitely need to do longer term studies. But you know, just like with any skin care ingredient, it's very hard to use something active all over your body. And it's very expensive. Just think how much the estrogen creams cost. They cost a lot of money. Shockingly, they used to be cheaper. They're really expensive. Now patients are calling to complain that it's $200. If I write them a prescription.
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B
I don't know, three fixes for the estrogen cream should be $30 or less. Amazon Pharmacy, Mark Cuban cost plus drugs and GoodRx.
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C
But I've tried that, I've tried that and it hasn't been, I don't know what the issue is. I haven't been able to see your
- [08:07]
B
New York City address and jack up the price. Do you think that's my fifth arbitrage?
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C
That I'm a dermatologist?
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B
Yeah, yeah, they got the cash. We're just going to mark it up.
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C
She can do it, right?
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B
I love it. Okay, so estrogen cream, you know, the other, here's the other argument against the estrogen cream. That's like I post about sex, I post about hormones, everybody loves what I do. And I post about me using estrogen cream and I break the flipping Internet. And then doctors say, I can't believe you're getting into aesthetics. That's aesthetic. And like it's almost this like put down. I mean first of all, it's putting down all of dermatology, but this put down of that women don't care or shouldn't care. There's a judgment to being like, it's fine for vaginal health it's fine for brain health, it's fine for bone health, but when it comes to vanity, you can't use it. So, like, I think there's a problem there. How would you digest that?
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C
I digest that every. I talk about this every day. And it's becoming more accepted that women have concerns, especially when successful women have those concerns. But it's always going to be something that's looked at as frivolous and, you know, so be it. It's not. It's not frivolous to me. Not frivolous to you? Because we deal with this all day, all day long. I have serious people in my office who diagnose skin cancers on. We diagnose melanoma is all kinds of infections. And then they say, but before you leave, can we just talk about my hair loss? Can we just talk about what's this on my face? So this is life. This is what humans are thinking about. You know, wasn't long ago that sex was considered taboo to talk about. So it'll have its day and I want to be ahead of it.
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B
I agree. I'm like, nobody complains when I talk about orgasmic equality. And like, all the sex stuff is fine now, but man, estrogen on your face. And the Internet fricking flips out.
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C
They flip out. I know, and I've gotten some really nasty comments.
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B
But dollar for dollar, I would argue estrogen on your face is more effective per dollar spend than all of the bullshit that people spend.
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C
And the snail mucin.
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B
Talk to me about snail slime. Is that even snail slime or do they just say it's snail slime?
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C
I think they say it's snail. Snail. I think they say it's snail slime. It's slime, but it's ridiculous. It's just one of those ingredients that if it does anything, and I'm not sure that it does, it's a fad. So nothing does anything unless you use it consistently. You can use something this week and something next week. It's meaningless. It's a big waste of money. You need to commit yourself. You know what that's like? You know, you commit yourself to jogging and you jog for a month and then you quit. Oh, why did that. Where did that get you? It's the same thing. There's nothing. Nothing. There's no story. It's all the same, right?
- [10:42]
B
Do you like going back to vaginal estrogen for one more hot minute? Do you like the consistency of the vaginal estrogen cream for the face? You don't have a problem with it being like, too oily or.
- [10:51]
C
Well, there are different formulations, you know, so I've been getting some complaints. There are some online ways you can get it. There are different companies now that are marketing topical estrogen. And I've gotten some complaints recently about one of the companies that people have getting whiteheads. And I've gone online to see what's in it. And there's all sorts of stuff in these creams. They're not really formulated to be for the face and many of the compounding pharmacies are not expert compounders, so they just put stuff in. I think it needs to be refined a little bit. But frankly, I've used premarin cream for 25 years. I poo, poo, poo. Never had a milia under my eyes. And it's a very nice consistency. Nicer than most cosmetic eye creams.
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B
Yeah, the Millia is annoying for people who get it. So it looks. It's not like your typical teenage whitehead.
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C
No, no, no. These, these need professional removal. You need to use a lancet or a scalpel, open it and get it out. But when you have them, they're annoying. And if something is too creamy in the thin skin of the under eyes, you're going to get milia. So but, you know, gels, people use estrogen gel and that's a little harsh for the under eye area. So I prefer the creams and, you know, try it out. If it's not working for you, you try another one.
- [11:58]
B
What do you say to the people? You know, I have a cream vad going to, going back to estrogen in the vagina. I have a cream bias. I love it on the labia. I like it on the urethra, I like it on the clitoris, like so. I like the cream for the coverage of the vestibule. Some people are poo, pooing it because of the additives and the preservatives and all the stuff that's in. What is my comeback to people who are like, I don't like the polyethylene, blah, blah, blah, X, Y and Z.
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C
That's what you say. Oh, please. That's what you say. I mean, there is the preservatives that people talk about. These people don't know what they're talking about. We need preservatives. Anything that has any water in it needs a preservative or it will become transit. If something is an ointment, it doesn't need that. But ointments are sticky and disgusting and Greasy, and you can't use them under your eyes and you hate using them in your vagina. So you stick with creams. It's not a lot of exposure if you are someone who has a bonafide allergy to a preservative, which is rare because these things have been tested and they don't put known allergens for most people into any kind of cream. These creams are always tested. But just because something is not allergenic to, say, 200, 1,000 people that they tested and doesn't mean it's not allergenic to you. If you have a real allergy, you'll figure it out and you'll stop using it. I've never, ever seen anyone, never in over 30 years of practice, allergic to the estrogen cream that I prescribe.
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B
I really appreciate that. Let's move on to. So people ask me what I do on my. I'm going to. We're going to talk about how to simplify your life, and then we'll talk about what we can and cannot use. So I say tretinoin, estrogen, sunscreen. How'd I do?
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C
Okay. And I'm gonna add. You did.
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D
Not bad.
- [13:38]
C
You got a three out of five. It's not bad. But what would I add to that? I would add vitamin C, an antioxidant in the morning. And for me, something I'm passionate about are DNA repair enzymes, which are kind of a cool subject, different from what you're used to. But DNA repair enzymes, they won the Nobel Prize, I think, in 2015, for discovering there are things that we have as humans that we're. That we don't have enough of. And these are internal enzymes in our skin that reverse sun damage on exposure to ultraviolet B. The prime case of this is children with xerodermapigmentosum. You know what that is? It's a terrible disease, genetic, where these kids cannot go outside at all. By the time they're eight years old, they have 300 skin cancers called XP. They're Moonlight Children, midnight children. I volunteer at the camp for them, and they can't even be outside. So we. These enzymes have been tested in kids with XP and they've diminished by 35 to 40%. The instances of basal and squamous cell. Nothing to do with melanoma and pre cancers. And at the camp that I volunteer at, we give these kids these enzymes, and it's remarkable. I get the nicest comments from the parents of these children. So it stands to reason that all of us have some Deficiency. We don't have the xp, the genetic problems, but most of us have some deficiency. That's why we sunb. Why we get skin cancers. So using them in normal people who don't have a known deficiency is unbelievably helpful. And you put them on and you're exposed to the sun and it blocks the effect of the sun. It's pretty incredible for ultraviolet B. So I tell all my patients, especially in the summertime, to use them. They're found in all different, you know, all different products. They come from bacteria, they come from algae. And it's really, they're really some really interesting type of skin care ingredient. That's something I'm passionate about myself because I don't think, I don't practice adjust cosmetic dermatology. I practice regular dermatology to dealing with skin cancer all the time. And it's something that I feel is really important. Why? How do you take care of the appearance of your skin without taking care of the health of your skin? And that's something I, it's important. Now, they're not cheap. That's a problem.
- [15:47]
B
Right? I was going to ask what's, what's your most cost effective but still like high quality?
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C
I would love to figure out how to make one that's less expensive. But they run, you know, in the $80 range. But they last a long time and they're not bullshit.
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B
And there's a lot of $80 bullshit. So, like, if you're gonna spend $80 on skincare, spend it on the stuff that's not bullshit.
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C
Exactly. You should spend it on. We don't need to spend it on vitamin C, but spend it on DNA repair, spend it on retinoids. That's what you should spend. And spend it on sunscreens. That's the biggest issue for us is sunscreens. In the US we're so far behind Europe and Asia in our approved sunscreens. But now it's easy to get sunscreens from overseas. It didn't used to be 20 years ago you had to smuggle them in. It was a problem. But now you can, you can get ingredients, you can get sunblocks from all over the world, from Asia, from Europe, that have UVA protecting ingredients. And that's critical. And I don't know why dermatologists don't know more about this, why they're not passionate, why they aren't pushing their, their patients to get these kind of sunscreens. It's very, very important. That's, that's largely what I do on Instagram is talk about things like that.
- [16:52]
B
I love it. Any names for the DNA repair enzymes for brands that you are, you are fine. People buying?
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C
There's quite a few of them. There's one that's called Neova, there's one that's called Photozyme, there's one that's called Priori. Those are companies. There's one that's called Rationale, that's a company from Australia. There used to be a company I love called Cellular Maryland. They went out of business there. Yeah. And there's another very expensive line, Dr. McCreen, she has them in her products as well. But the ones that I generally recommend are from Niova and Photozyme and Rationale because they're all different formulations and you have to see which one a patient likes. One is heavier, one's lighter one's serum, one's drops and they play around with them and use the one that appeals to them most.
- [17:35]
B
What about good? I worry about the vitamin C, like buying placebo. I'm like, I'm such a skeptic. I'm like, I don't want to buy placebo.
- [17:43]
C
You shouldn't so trust that these companies are actually doing some degree of vetting to make sure they have actives. There are very expensive ones. You know, the gold standard is SkinCeutical CE Ferulic and that's the gold standard. But it's 100 something dollars and most people can't really afford it. I post frequently on Instagram about affordable brands of vitamin C. You can use L ascorbic acid, which is actual vitamin C. And then there are analogs of vitamin C that I also talk about and some of them come in creams. But if a vitamin C irritates you and sometimes high potency L ascorbic acid can be irritating. You go to, you cut the percentage and you can spend the day in Sephora looking at the backs of bottles. And again, this is too many to list it on Instagram. I test all sorts of products but I think that they're a very useful thing to put on your face as first line before you put on heavier creams. And if you live in a sunny part of the world, you should do it every day. If you live in New York City, I don't see daylight half the year so it's not so critical for me. But for those of you who live are outdoors all the time, yes, it should be part of your everyday routine.
- [18:48]
B
Perfect. The going back to the retinoids, the prescription tretinoin Versus over the counter retinols, the plant based ones. Like there's is the prescription strength best and then cream versus gel.
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C
Well, if you have acne, gel might be okay, but I always prescribe the cream and then there are some lotions that are actually nice. But I think of prescription retinoid like going to Barry's Boot Camp. I don't know if you have Barry's Boot Camp where you are, but it's like if you didn't do anything and you went to Barry's Boot Camp, you'd probably die. You couldn't walk. So if you really are someone who's never used a retinoid, then you could start with baby retinoids. Retinol, retinaldehyde, those are steps below. So retinol takes two steps to be converted to tretinoin. Okay. To retinoic acid, retinaldehyde takes one step. So if you want to step it up like this, you can start like that or I give my patients really strict instructions on how to start with prescription strength tretinoin. And if you start slowly and if you use small amounts, everyone can tolerate it pretty much. But you may have a little flaking at first. And the best analogy I can give is the exercise routine. If you just start to workout, you're going to be sore. And if you do it for two weeks, you're not sore anymore. And that's how I, you know, listen, there's no free lunch, you will be a little flaky. Okay, you put some cream on, you'll be fine. But if you're super irritated and miserable, then it's not for you. But ultimately, what's really fascinating is that the studies have shown that even the people who had terrible irritation when they first started and redness, it went away and they had fabulous results long term. And you can use tretinoin on your arms. You know, it's hard to apply one tube of 45 gram tube of tretinoin on your arms, your face, your legs. You just can't. So be selective when you're using these things because you have to focus on a particular area, cover your legs with sunscreen or clothing and protect that.
- [20:39]
B
Love it. So with sunscreen, what about if you live in the Pacific Northwest and work indoors? Still still need a sunscreen every day?
- [20:45]
C
If you sit by, if you don't sit by a window? No, honestly, no. If you're indoors with windowless room, forget it. If it's a miserable rainy day, probably not. Except that you could be caught outside when you have A sun shower and suddenly it's bright sunshine. So if you don't want to put it on in the morning, keep it in your bag. Keep it in your backpack or your purse and then put it on. But have it at the ready in case you need it.
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B
Fair enough. What's more important, the SPF or that there's UVA coverage in there?
- [21:13]
C
Well, the combination. So SPF refers only to ultraviolet B. Ultraviolet B are the sunburn rays. And in the US we have very good UVB protect ingredients. So you know that if you put on sunscreen, really well, most people don't burn if they reapply it, but they tan. And uva, those are the tanning rays. So when I see a patient who says, oh, but I was wearing my SPF 50, I know that they were using either an American chemical sunscreen or a mineral based sunscreen which gets so much press as though they're natural. They're no more natural than the chemical sunscreens and they're not as good protectants. The only way a mineral sunscreen is as good is if you put your baby's desitin ointment on your face or the lifeguard. Zinc oxide. That's very good, but no one does that. And the more nanoparticles you put on, the smaller the particles, the less coverage you actually get as far as UVA and UVB. So, you know, it's a catch 22. You try to be natural and you're not as effective. It's really tough. And I'm like a broken record.
- [22:17]
B
We need IT people. I think there's so much confusion and marketing in the skin care world that to actually be like, here is a resource who cares about you not buying placebo and using effective things.
- [22:28]
C
It's highly valuable and it's easy, but it's easy. It is so easy to have great skin. It is so easy. And it doesn't have to be expensive and you don't have to use a lot of steps and you don't have to use the same thing all the time. You can switch it up if you want. Use effective products, but maybe change them up and make it, make it enjoyable.
- [22:47]
B
I love it. Hyaluronic acid.
- [22:50]
C
Inject, injectable, good, topical nothing. It's really nothing. It feels good. And if you like the way it feels, feels, feels good. So use it. If you think your skin glows when you use it, okay. But it's not to be used as a good humectant. It's not a good moisturizer. No Matter what anyone tells you, it's really not. And there's so many forms of ha. There is sodium hyaluronate, there's hydrolyzed, there's small particles of ha. There's broken up particles of ha. There's every different formulation. They're all different. None of them is actually a good moisturizer.
- [23:21]
B
Got it.
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C
Unless it's injected, of course.
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B
Okay, cool. Drinking alcohol and skin. What's alcohol do? Your skin.
- [23:28]
C
Alcohol dehydrates you in general, so therefore would dehydrate your skin. And it definitely causes flares of rosacea. It causes the capillaries to dilate on the face. As you know, the old classic, you know, whatever his name is, W.C. fields with the big red face and the rhino FEMA nose. That's a bit extreme, but many people would tell you that when they drink alcohol, particularly wine, they get a facial flush. And the more you flush, the more likely you are to have permanent capillaries on your face. So. So be smart when you, when you drink.
- [23:56]
B
That's good to know. Let's talk about hair loss. Midlife hair loss. Patient comes to me, kind of my go to now is hair loss is complicated because that's what all my derm friends have told me. Are there labs I should be checking? Are there supplements, biotin, neutrophil, that I should be telling people? Absolutely. Can we talk about midlife hair loss?
- [24:16]
C
Well, most women will tell you they have midlife hair loss, but just like they have everything else. So that's kind of a given female pattern alopecia, one of the most common things we say. And it's usually what happens when I have my hand on the door and I've done everything else, the skin check and I'm leaving. Oh, one more thing, I'm losing my hair. It's like, oh my God. So there's so much involved in hair loss. There are people that have hereditary hair loss and that's an important factor. We look at all family members, but the classic is the mother's father. That seems to be the biggest connection. But just because your father was. Your grandfather was bald doesn't mean you will be bald. We look at that. You know, there's different patterns for female pattern, male pattern hair loss. And then of course there are diseases of the scalp that people mistake for female pattern, like frontal fibrosing alopecia, which has become more and more common. But let's say you're garden variety female alopecia. You're just thinning because you're getting older and you Have a family history of whatever genetic propensity there is. There's lots of things you can do and lots of things that don't do anything. So the first thing that does nothing is biotin. Total waste of time for hair and nails. And it can alter some of your blood tests, as you know, it can change some of your thyroid functions, the blood levels, and you know, it can change troponin. So if someone's on biotin, I warn them that if they get hospitalized for any reason thinking they're having a heart attack or they're, they're in thyroid storm, they really need to tell their doctor they're on biotin. It doesn't help anyways, I try to stop it. That's the first thing. Then there are, obviously there are hormones that you, that you take that can accelerate hair loss. Like women who take testosterone in certain doses will have accelerated hair loss, like male pattern hair loss.
- [25:55]
B
And would you say this is dose dependent and that dose dependency might be different per individual?
- [26:01]
C
Absolutely. But it's something to think about. So if you, if I see a woman who's a bodybuilder and I know she's taking supplements of some sort and she's losing her hair, I know that somehow she's, she's likely to be getting testosterone somewhere in her, in her treatment and whatever she drinks, whatever things she takes, and you got to be careful with that. And that's, that's not the norm. The norm is someone like me who comes in as my hair is thinning and there's lots of things you can do. So this is the paradigm. Drawing blood is almost never useful. You know, you can draw things for looking for pcos. And as you know, for patients who have polycystic ovarian syndrome, they have, they tend to have acne, sometimes they're overweight, they have some stretch marks, they have some excess hair on their face, excess hair around their, on their breasts or on their abdomen. But many people don't have that. So, you know, drawing bloods, unless there's some obvious sign that there's something hormonal up doesn't usually get us anywhere. So assuming that that's normal, that there's no stigmata of a real hormonal disease, what do I usually do? My first line treatment is frequently something called spironolactone, which I'm sure you've heard of. It's a diuretic. And you water pill. What? And it's more useful in younger women. And it does help two things. It helps hair loss in many women. And it also helps acne. We use it all the time. Way more common than using accutane for acne. Spironolactone in female acne. And that's helpful. But it's rare to find a woman who can actually use that. It needs to be rubbed into your scalp twice a day. It makes your hair sticky and disgusting and no one ever sticks with it. And it sometimes gives you hair, you know, on your face, which is, which is annoying. If you don't want to do that, then many women will take these hair vitamins. They take Nutrafol, they take Viviscal. In my experience though, I have many patients who think they help. It helps them. I don't really think it's a big help. And they're also expensive, so I would much rather prescribe the things that I prescribed. But if you want to take Nutrafol, you want to take Viviscal, be my guest. I wouldn't rely on it to grow your hair. The next thing that I use a lot of is low dose oral minoxidil, which really works, but it does turn some people into a werewolf. You definitely get hair on your face. They say 35% of people, but maybe they're all in my office because virtually everyone that I know who takes it gets some hair.
- [28:23]
B
What's the mechanism for minoxidil?
- [28:26]
C
We don't really know. They think there must be some impact on dht, but also increasing blood flow to the hair follicle. And this was discovered, I don't know, 35 years ago. People taking oral minoxidil for their high blood pressure. Remember when that was used as a blood pressure medicine and these people were growing unbelievable hair. So that's when the topical minoxidil studies were done. And it definitely does something to alter the pattern of hair growth, turning fine vellus hair into terminal hairs. You know, as you get older you look, if you look at your hair, you see that you have these fine hairs in the front. For some people they might be new hairs growing in, but for more people they are what we call miniaturized hair. So these are your old thick hairs that are now shrinking up, becoming shriveled and they never grow to be full length hair. And what we know minoxidil does is it will help convert vellus hairs to good terminal hairs or anagen hairs, which are the good growing hairs, the thick growing hairs. So that's important.
- [29:26]
B
One of the things about Spironolactone is what I've heard is you want to Use the lowest effective dose because it can partially bind the androgen receptor and low testosterone, affecting libido, affecting lots of other things. So we kind of have, we have to watch people who get side effects from having lower androgens.
- [29:43]
C
Yes, yes. But I don't find that to be a problem in my younger patients. But as you get older, I find that spironolactone has less value in hair loss loss. And those are the patients that I have found experience those side effects. It's a great thing to use for younger patients with hair loss. It really is. In older women it's not quite as effective. And there's some other things that we, we can do. There's oral and topical finasteride, there's oral and topical dutasteride. Those are other, as you know, hormone analogs that inhibit dht, dihydrotestosterone, and we use those. But many women for some reason don't really want to take them. They're unsure. They don't really want to use hormone manipulators and they'd rather, rather use things that aren't hormonal. They'd rather get injections of PRP plasma, a platelet rich plasma, which you probably know about. There are studies on that. They're not hard studies, but in clinical experience I have found many women think it's super helpful, but it's expensive. What it involves is drawing your blood. We spin down the blood, we separate the red blood from the plasma, which is rich in platelets and other growth factors, and then we inject it back into your head and you do it once a month for say, three months, and then you let another three, four months go by and see what you think. I've had wonderful results. But I always tell patients, listen, this is a crapshoot. It might work for you and it might not. In female pattern, it seems to work better than in actual diseases like frontal fibrosing, alopecia. It's not very successful in that. But you know, some people would rather do that than take a drug.
- [31:16]
B
Yep. What data do we have on systemic estrogen replacement therapy and growth of, of hair, nails? Do you think we're just giving two? We're just giving two. Like when we replace estrogen, it's still at such a low dose, it's not hitting the threshold needed for hair.
- [31:33]
C
Right. And I don't even know that there really is a threshold for hair because there are many young women who have high levels of estrogen and they still have thin hair. So the connection between estrogen and hair is not yet there, in my opinion. It's not. I don't use it for that. I think there's so many other ways of treating female, female pattern hair loss that I don't rely on estrogen as my primary, as a medication to be dealt with as a primary treatment. That's me.
- [32:00]
B
Good to know. Awesome. Let's move on to eyebrows. I see serums, microblading, lots of things. The 90s were very cruel to eyebrows. So what do you see as far as like what's safe, what's effective for eyebrow growth? If that's what you want.
- [32:15]
C
Let's talk about eyebrows and eyelashes. So that's another common problem. And you see this, this preponderance of eyelash serums. And let me tell you, the only thing that I believe impacted on my lovely estrogen eyes was the fact that I use some lash serums, prostaglandin containing lash serums, which literally took all the fat out from under my eyes, the periorbital fat. And one of the side effects of these prostaglandin containing lash serums and lash and brow serums is that it can remove periorbital fat and it can cause hyperpigmentation and redness. We see this all the time in patients with glaucoma who need to use these drops for their eyes. They use Lumigan for their eyes. They need to. And you can recognize somebody who has this. You see these red eyes with these hollowed out periorbital areas. This is fascinating, but back in the, in the 1980s with the AIDS epidemic, they were treating some CMV retinitis with these glaucoma drugs. And the first AIDS patients that I saw with that had had eyelashes that came out to here, it was crazy. I'll never forget. But now you can grow these beautiful lashes with them and then you end up with permanent loss of fat. So I've become a real enemy of lash serums, which is unfortunate because you could have the darkest, most beautiful lashes and brows. Now using them on the brows does not seem to have the same problem with loss of periorbital fat and pigmentation. So I tell patients I'm okay with their using it on their brows. Not everyone has this problem. Problem. But if you, if you are using a lash serum with prostaglandins and I post about this all the time, if your lash serum says we don't have prostaglandins and you see any ingredient on the list that has P R O S T in it, then they're lying and there are prostaglandins analogs in it. And if you are one of the people who doesn't have a problem, well, you're just really lucky. But at the first sign that you see, see redness and dark pigment around your eyes, stop because it's reversible if you stop early enough. Not reversible if you let it go too far.
- [34:22]
B
Fascinating. Talk to us. Give us your opinions on Botox and fillers.
- [34:28]
C
Botox is one of the miracles of the 21st century. It actually is maybe the 20th century for the right person. So what can Botox do? It can lift your brows. It can smooth lines around the eyes. It helps with all sorts of things, things like that. It can also turn you into a freak where you have no expression whatsoever, but it's only about who injects you and where they inject you. I think that injecting Botox too often is a mistake. I think it does thin the muscles. I'm a really conservative Botoxer and if you're of a certain age, and this is a complicated question, but an important one, if you are like I am where when I'm talking to you, my eyebrows are raised just talking. That tells you that I need my frontalis muscle to keep my eyes open. And if you treat someone like me in my forehead with Botox and I can't move it, my eyebrows drop and it looks horrible. So it's not a one size fits all. This is why you shouldn't be doing Botox on a strip mall. You know, I don't think you should be doing it in a med spa because you never know who's injecting you in a med spa. And that's a really important consideration.
- [35:37]
B
Yep. Love it. Talk to me about fillers.
- [35:40]
C
Fillers are like hair color. You know, you can can inject people's cheeks, their nasal labials, their lips. You can do all sorts of things and turn them into monsters or you can just make them nicer versions of themselves. In my opinion, I would stay away from permanent fillers. I think permanent fillers can give permanent problems. I don't use them. I use fillers that can be reversed. I think that if you are an injector, and I'm a very, very big injector and trainer, you need to know how to reverse them if God forbid, there's a problem. You need to know how to dissolve the fillers and you need to know how to look for an advers event like an occlusion. I think we need to be Trained in ultrasound. I think it's really important. But I also think that there's a trend toward having gigantic cheeks and people thinking that they can inject under their eyes. It's my least favorite place on the face to inject because the filler lasts way too long and patients develop under eye swelling. The filler can move when placed in very muscular areas where there's lots of expression. So you need an experienced injector. This shouldn't be done by any Tom, Dick and Harry on the, on the corner. You really need someone very well trained. I always like board certified derms to do it, but we are not necessarily experts in every area. There are plenty of nurses who are very well trained and really good at injections. I would say, you know, I shy away from estheticians injecting, but there are very well trained people. It's not just board certified plastic surgeons and dermatologists who are the experts, but it needs to be someone who's been doing this a while and has great experience and has the ability to fix a problem. My days are ruined when I get calls from a plastic surgeon from a med spot. Oh my God, can we send this patient over? And it's terrible. It's really time consuming. I love to help them, but it can ruin your day. If you were a heart surgeon and you didn't know how to fix something, if you tore the aorta, you wouldn't be doing it. And if you're an injector, you should know what to do if you have a problem. Problem.
- [37:41]
B
Yep. One of the recent videos I saw you do, you were talking about exosomes and peptides and to save your money. Is this the new, the new way to get cash from people?
- [37:51]
C
It is a new way to get cash from people. Now I'm not saying that exosomes won't turn out to be something wonderful. They're just not there yet. You never know exactly where they're coming from. There are some companies that have a lot of science behind them and they are well respected. They're vetted. You know, you're not getting prions in your exosomes, but most companies that are out out there are not. And exosomes that come from reliable companies. We still don't have any evidence in my opinion and I've read all the studies that using these on a regular basis is actually going to slow down the aging process. And that's what people claim that they do. So I need proof, I need time, I need to see real studies used over 10 years when they study these things for two weeks, three months. That doesn't impress me. I don't care. I could care less. Less. You know, I look good when I cut my hair for three months. It doesn't, that doesn't impress me. I want to see somebody who looks better 10 years after they started using these than they did when they started. I haven't seen that. And it's illegal to inject them. So now you see med spas and you do see some physicians injecting exosomes into patients. And you should run. If your provider, you know, which, I hate that word. If your provider says they're going to inject you with exoskeleton, get out, get out of Dodge because that's a very bad sign, really. So don't allow that. But I wouldn't, you know, I don't think we're ready for prime time with this. I'm not saying they won't be great. And maybe I will have missed the boat. Maybe in 10 years I'll say, damn, I wish I were using them. But you know, they're not life saving. So you're not going to die if you don't use exosomes and if you, if you use other things that help your skin look young and be healthy. Healthy, you will not have missed out on mush and at least you'll be doing something that's tried and true.
- [39:40]
B
I love it. What did I miss? In absolute must for skin and hair versus don't waste your money on this. Anything else you would add?
- [39:49]
C
Most things I would say don't waste your money. Most things, I think that if you have skincare that you like to use, you will use it and if it's good, it'll be effective. But most people never stay loyal to anything. So if you had to pick something that you should stay loyal to, the two things I would be, I would choose would be retinoids and sunscreen. Those would be my two things. And you should start when you're in your 20s. Sunscreen before, but when you're in your 20s, late 20s, early 30s, with retinoids and just use them for the rest of your life. And people say, how can I do this the rest of my life? Well, think about all the things you do. Don't you brush your teeth every day? You did it when you were four and you do it when you're 84. Well, why can't you do it? Don't you use soap? Okay, just think of retinoids the same way. There's nothing magic about them. There's no, it's not a lot of effort. It takes three seconds to do it. So those are, those are things if you like, you want to try snail mucin, you want to try peptides, you want to try this or that, Try them if you like the way they feel, they're hurting anybody. What I call my non negotiables are the things you have to do when you get dressed in the morning. You put on a shirt, you put on pants. If you want to wear a scarf, okay, I don't care. But you have everything else on. So just do the things that are important and then add on whatever the heck you want to add on. If you like doing it, you will do it. Don't you think that that's true with everything, isn't that it's the way we function?
- [41:10]
B
I love it. I have been so looking forward to this hour with you. Literally. People are going to need to listen to this episode twice at least. Take it all.
- [41:19]
C
Meet you. I can't wait to meet you. You could do an overhaul on me, I'll do one on you and we can see how we turn out. Wait, let me say one other thing. Okay, One other thing I want to. And to, I want, want to remark on and I neglected to say, but I will now. The other thing that I'm pretty attuned to, and it's going to sound crazy, but in young, youngish women, teeth are a really important part of our aging face. And it's important to know that many young people wear braces. They're given these retainers. And no teenager in the history of the universe has ever worn the retainer. And as we get older, what happens is, particularly with the lower teeth, the lower jaw, it starts to retrude and the teet teeth start to crowd. And if you've ever heard the expression, you know, she's long in the tooth, you know what that means. It means as you get older, the distance between your nose and your upper lip lengthens. And so as you're, as you get older, you don't even see someone's upper teeth when they talk. You just see the bottom teeth. And I have women come in, they want to get injected. And I'll say, you know, money's an issue. Honestly, I think you should see a dentist and figure out how to keep your jaw structure intact. It may makes a big difference in this part of the face, in the chin, in the marionette lines. Because as your jaw goes back and you lose bone, the skin has to fold to Cover it. So I know it's not skin related, but to me, I think about the face as a whole and every part of it, and that's why that's important to me.
- [42:51]
B
Well, we know systemic estrogen is important in bone structure, bone health, bone integrity. I wonder the role of systemic estrogen on recession of the jaw.
- [43:04]
C
You know what? I haven't really, I haven't thought about that. But it's gotta play a role because we know that that is something that happens to everyone. It does happen to men too, but less acutely than it does to women. But, you know, there's so many reasons to do systemic estrogen, and many of us were deprived of that because of, obviously because of misinformation. But nowadays, why are more doctors, doctors, gynecologists, internists, why do they not understand this? Why don't they read the studies and just get with the program? Why? I mean, dermatologists, Why?
- [43:37]
B
I don't know. I don't know. I like, I, it's. I think it's hard for me to admit how many doctors stop learning when school's done.
- [43:46]
C
That is true. But learning on social media can be dangerous, as we all know. You know, you need to pick and choose.
- [43:51]
B
Yeah, most patients get their, get their medical info from social media. So, you know, you being on it, me being on it, us trying to do. But it takes an intellectual curiosity for us, because you have to stay on top of stuff, right?
- [44:05]
C
Yes, but in my field, you know, my other problem is, and you've probably seen this, you know, once companies start paying you to talk about their products, in my opinion, there's no credibility whatsoever. So I never take a penny from any company. I buy my own stuff. If somebody wants to send me something, I'll try it. But I'm not getting paid by them to talk about anything. And I, 99% of the time, I spend a fortune on products. I buy everything. I try everything. But when young dermatologists are being sponsored by CeraVe and they're holding up signs and they're being taken to the US Open by La Roche Posay, I mean, what's the point? How does anyone believe this? I don't. It's worthless information to me. So I feel like being a voice of reason and trying to be honest. And I don't always say nice things about products, and I feel bad when I don't, but I've got to be honest about it. And when things don't work, I have no interest in them.
- [44:58]
B
Just like all vibrators can't be good. All lubes are not good. Like you can't all be good for all people.
- [45:05]
C
That's true.
- [45:06]
B
It's okay. And I think that that gives you more credibility because people know you're gonna say what you think.
- [45:12]
C
Yeah, well, people comment on my looks all the time. Think, why would you listen to her? Look at she lies on her face. Face like, are you kidding me? But yeah, totally.
- [45:22]
B
And we can't let social media tell us how we feel about ourselves. Life's too. Life's too short.
- [45:27]
C
Life's too short for that, right? I have enough people who love me. So yeah, totally. They're so nice to talk to you.
- [45:34]
B
Oh, I really appreciate you coming on
- [45:37]
C
and I hope I get to meet you in person, maybe at the next NAMS meeting or wherever. Are you coming to an New York?
- [45:44]
B
Yeah, I think I'm going to be at NAMS in September. It'll be my first nams, so I'm excited. But I, I go to New York like twice a year now, so I'll look, I'll look you up.
- [45:53]
C
It was so nice to speak to you and I'm so glad we met and I love following you and I love listening to your podcast and listen to everything. So thank you.
- [46:00]
B
Thank you for coming on so much.
- [46:03]
C
It was really great.
- [46:04]
A
Thank you for listening to this week's episode of youf Are Not Broken. If you want to dig deeper with me, sign up for my Adult Sex Education Master, where you learn adult things like communication skills, anatomy lessons and desire types, and how to talk to your doctor about sexual health concerns. If you want the Adult Sex Education Masterclass for free, join my monthly membership for more in depth, exclusive content, more time with yours truly, a private podcast, coaching and educational empowerment and you can watch my interviews live and get them immediately without advertising help. Head over to www.kellycaspersonmd.com for the membership and Adult Sex Ed Masterclass members get the Masterclass for free. This podcast is presented solely for educational, entertainment and informational purposes only. I am a doctor, but not your doctor in this format and all of my platforms and guests, including on this podcast are not giving individual medical advice or practicing medicine. See it in consult with your own care team for your individual needs and concerns. This podcast is not intended as a substitute for the care and advice of a physician, therapist or other qualified professional. This podcast does not constitute the practice of medicine, in case you were curious about that and no doctor patient relationship is formed. But I still love you using the information on this podcast or any of my platforms is at your own right risk. Until next time. Remember, you are not broken.