Ep 33: Midlife Skincare with Dr. Sarah Stierman

In this episode of Reset Recharge, host Dr. Komal Patil-Sisodia invites Dr. Sarah Stierman, a board certified dermatologist, to discuss essential skincare strategies for women navigating perimenopause, menopause, and beyond. The conversation covers a range of topics including the importance of SPF and retinoids, the benefits of growth factors and antioxidants, and the role of cleansers in maintaining skin health. Dr. Stierman also provides insights into the efficacy and safety of topical estrogens and supplements like collagen powders and biotin for skin and hair health. Listeners will gain valuable tips on creating an effective skincare regimen tailored to aging skin, complete with practical recommendations and brand-specific advice.

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Eastside Menopause & Metabolism

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Dermatology Associates Ohio

Audio Stamps:

00:00 Introduction to Reset Recharge

00:58 Meet Dr. Sarah Stierman

02:59 Understanding Skin Changes During Menopause

04:31 The Importance of Sunscreen

06:50 Retinoids: The Anti-Aging Powerhouse

10:04 Managing Retinoid Irritation

21:48 Advanced Skincare: Growth Factors and Antioxidants

30:11 The Reality of Skincare Routines

30:50 The Best Way to Cleanse Your Skin

33:34 The Truth About Toners

35:43 Oil-Based Cleansers and Makeup Removal

36:37 Collagen Supplements: Skip or Buy?

39:50 The Biotin Debate

43:40 Top Supplements for Hair Health

47:57 Topical Estrogen for Skin: Benefits and Risks

53:37 Conclusion and Where to Find More Information

Thanks for listening. Find more info about Reset Recharge on the website or Instagram.

Transcript

Dr. Komal Patil-Sisodia 0:02

Welcome to Reset Recharge, the podcast where women's health takes center stage. I'm your host, Dr. Komal Patil-Sisodia, a triple board certified endocrinologist and women's health expert. This show is all about empowering you with the knowledge to understand your metabolic health, navigate hormonal changes, and feel confident in the conversations you're having with your healthcare provider. Whether you're managing symptoms, exploring treatment options, or just want to feel more in tune with your body, you're in the right place. As a physician, my goal is to educate on this podcast. The content shared here is for informational purposes only and should not replace personalized medical advice. If something we discuss resonates with you, please talk to your healthcare provider at your next visit. Now let's dive in and help you reset, recharge, and take control of your health. Hi everyone. Welcome back to Reset Recharge. I am excited to introduce our guest for today's episode to Sarah Stierman. She is a board certified dermatologist, dermatopathologist, and president of her busy northwest Ohio independent private practice. She's originally from Ohio, and attended University of Toledo College of Medicine. And graduated from there with her doctorate in medicine, did her residency at Riverside Methodist, and then did her dermatology training at Wayne State University in Detroit. She then did a fellowship in Dermatopathology and she's board certified in both dermatology and dermatopathology. We met in a physician moms group Style MD where it was focused on fashion and fun things. And, Sarah made this amazing post about, skincare and how we should layer it. And I think everybody was just like, oh my gosh, who is this woman? It kind of shot you to a little bit of notoriety in our group, which was great. She has a special interest in clinical pathologic correlation of disease, the microbiome and medical grade skincare. So I invited her on the podcast to talk about all the skincare things that we want to know as we're navigating perimenopause and menopause, because we do actually go through quite a bit of change in terms of our skin texture and things like that. Welcome Dr. Stierman, and, thank you for being here today. I'm so excited.

Dr. Sarah Stierman 2:23

Thanks.

Dr. Komal Patil-Sisodia 2:26

Did I miss anything in your background that you wanna talk about?

Dr. Sarah Stierman 2:30

The past is always the past it's so interesting to be practicing medicine in this timeline and especially practicing dermatology. It's phenomenal and I am so incredibly fortunate and grateful to have the job that I do.

Dr. Komal Patil-Sisodia 2:46

There's so much technology and innovation that's happened, over the last several years, and I love hearing from you what we need to be doing and how the recommendations have changed over time. So let's dive right in. For skincare as we mature, one of the big issues I, hear from my. Patients is the elasticity and my skin doesn't look the same, I'm not glowing the same or it's drier. What are the changes happening during this timeline in our life? Let's talk a little bit through that so we understand, the hormonal connection between skin.

Dr. Sarah Stierman 3:17

So estrogen is, incredibly important for skin health elasticity, barrier, function. As women transition through perimenopause menopause and post menopause, the falling estrogen levels directly affect the skin. You develop more dryness, you're more likely to develop, barrier dysfunction, which means that you're more likely to have sensitive skin even if you've never had sensitive skin before the skin will thin over time as well, as we start losing collagen and elastin. Your fibroblasts, which are your collagen factory cells, start getting lazy around age 26. I know. It's so not fair. Even a decade before many women start to experience other symptoms of perimenopause, your collagen factory is already slowing down combine hormonal changes with UV radiation. And a lot of the aging changes, like hyperpigmentation and elastic damage to the face, we see compounded by decades of cumulative UV exposure. By the time, you hit your forties, you're looking at decades of direct sun exposure that have snuck up on you,

Dr. Komal Patil-Sisodia 4:30

Yeah. And we kind of grew up at a time where tanning beds were definitely a thing.

Dr. Sarah Stierman 4:35

for prom, for spring break for the beginning of the summer where I'm just gonna get that quote unquote base tan so that I don't burn on vacation or if I'm gonna be outside. Well, I am here to confirm that there is no such thing as a healthy tan. A tan actually denotes DNA damage externally. People are like, well, I just get a little bit of color. And I'm like, well, that's DNA damage. And can, can your immune system and your body and your repairative cells do a reasonable job of repairing DNA damage? But if you continue to allow it to be inundated by DNA damage through direct sun or UV exposure daily, then you're really doing yourself an incredible disservice. I have a lot of women who do come to see me who have concerns about facial, especially facial aging, but then face, neck, chest, hands, often areas that are constantly sun exposed. They're like, what can I do? And in my head I'm like, short of a time machine. Well, I think we would all love a time machine, but short of that, where you could go back in time and tell teenage you to start wearing sunscreen every single day, it's the best thing we can do for our skin.

Dr. Komal Patil-Sisodia 5:49

Absolutely. I remember when I first saw your posts about the skincare regimens you thought were optimal, and I realized that I had no SPF in any of my skincare regimen. I'll tell you I have been so dialed in on my sunscreen I live in Seattle, so if I'm doing it, everybody should be doing it I can tell you that. Same, same, oh, that's right.'cause you guys don't get a whole lot of, sunny days either, comparatively. so now that you've nicely explained what those skin changes are, let's talk about what you think are good things that we can start doing for our skin as it starts aging, right? Because we know that the collagen factories have long shutdown, sadly, I think it's been like 20 years for mine. So, collagen factories are shutting down. We have all this photo damage, we're seeing the changes as our hormones change, what are the things that we need to, let's talk about what a good baseline skincare regimen is. Just for any woman, we can even go back to twenties or thirties, what you would recommend there. And then let's talk about how we need to shift that as we hit our forties, fifties. Absolutely.

Dr. Sarah Stierman 6:50

I think the key components of any healthy skin regimen. Includes spf and so SPFI, I know I'm gonna harp on s SPF so much during this episode, but it's really that critical. Yes. Sunscreen, SPF 30 or higher is the bare minimum recommended by the American Academy of Dermatology for daily UV radiation protection. It used to be 15, but now we know there is a clinically appreciable difference in the level of protection you get between SPF 15 and SPF 30. There also is a statistically significant difference between SPF 30 and SPF 50, but when you get above 50, there doesn't really have as much of a statistical difference the FDA has changed the labeling of sunscreens or has approved it differently. Where now you'll often see s pf 50 plus. Because the difference, right? So the difference between an SPF of a hundred and an SPF of 80 is not incredibly high. So it you could, SPF 50 plus is fantastic. So 30 or higher we recommend every single day with reapplication, which is the key component most people are missing. If you are going to be outside during peak sun hours in Seattle and Ohio, yeah, that's probably about 10 to two during the winter and 10 to four during the summer. Maybe even nine to four during the summer. If your shadow is shorter than you are, you really should be seeking shade.

Dr. Komal Patil-Sisodia 8:16

Ooh, I never heard the shadow rule, yeah, tell me more about that.

Dr. Sarah Stierman 8:19

It's the way that the direct rays of the sun hit the surface of the earth, and so if your shadow is shorter than you are, you can pretty much guarantee you're outside during peak sun. So, SPF is clearly the cornerstone of any sort of healthy skin regimen as we start to get into those. Eras of our life where our collagen factory has started to slow down. After the age of 26, when we're talking about thirties, forties, fifties and beyond, the next most important component of a healthy skin anti-aging regimen is a topical retinoid. Topical retinoids go by many different names. Tretinoin is the gold standard retinoid for improvement of facial skin and reduction arid disease, which is the fancy medical word for wrinkles. So Tretinoin was actually FDA approved for wrinkles, cosmetically in 1969, I believe, was the sentinel paper. And so it has decades of data behind it being the most critical and important prescription grade, ingredient for skin health. Retinoids help with skin turnover. They change the way that your skin matures, and they also stimulate collagen. You can wake some of those lazy fibroblasts back up by using a retinoid. Retinoids are to be used at bedtime only. They are not a daytime sort of treatment, for two reasons. Number one, they can make you more photos sensitive. And number two, the vast majority of topical retinoids actually are not photos stable. And so if you go outside in the sun, it'll break down and you'll get side effects, but you won't get results.

Dr. Komal Patil-Sisodia 10:00

That's unfortunate. I did not know that actually. It's like completely useless then and maybe a little harmful.

Dr. Sarah Stierman 10:04

Yeah. Now for people who do not tolerate, retinoids because they help with skin turnover very frequently. They can cause initial irritation until you get used to the product. They can also cause peeling redness and irritation, and so there are definitely different ways that we can help people begin to tolerate a topical retinoid, or there are also now some new retinoid alternatives that are non retinoid, but similar mechanism of action that are available on the market which are incredible.

Dr. Komal Patil-Sisodia 10:36

Okay. That's fantastic. And with the retinol, so they're stimulating the collagen and then creating that turnover. I was one of those people when I first started. I had a little bit of irritation. What do you recommend for people who are getting irritated from the retinoid, like doing it once or twice a week? I've also heard you can mix it in with your moisturizer or you can layer it in a different way so it's not. Irritating your skin as much, what are your recommendations?

Dr. Sarah Stierman 10:59

Lot of recommendations that are out there floating out there, and some of them I find to be very utilitarian, and some of them I find to either not help or be untrue. So let us dispel some of this. When we're talking about active ingredients in skincare, whether they are prescription or over the counter, it doesn't matter. When we talk about an active, we really don't like to mix things. We like to layer. The reason that we like to layer rather than mix is mixing, dilutes the active, right? If you're mixing your tretinoin, cream with a moisturizer to make it more tolerable, you could be cutting its strength by who knows how much. Because it's not regulated. It's not like a dosed compound when you do that. So I like to layer, the first thing I tell patients, whether they're teenagers, because of the cell turnover thing, we prescribe topical retinoids for acne as well. This is the same advice I give to a lot of my teenage patients, let alone my mature female patients. So I definitely would be gentle with your choice of cleanser prior to a retinoid. We're talking about an evening routine at this point, because we know topical retinoids are applied at bedtime only. So gentle cleanser, rinse really well, but then wait until your skin is dry before you apply any of your products in the evening. You don't wanna apply active products to a wet face simply because your barrier isn't completely pH balanced yet if you've just washed your face. And so you do need to allow it to settle a little bit so that it's not irritating. Putting actives on a wet face tends to be very irritating. So waiting until your skin is dry and then. Yeah, moisturizer is a retinoids friend. When we talk about moisturizers, there are many different ingredients. From glycerin and cholesterol to ceramides because if you think of your skin as a brick wall and your skin cells are the bricks and there's mortar between those bricks, the mortar that holds your skin barrier together is actually vastly composed of lipid or fat. The most frequent concentration of fat in the skin lipid barrier is ceramide. That's why ceramide is such a powerful ingredient in moisturizers because not only does it hydrate, it helps with barrier dysfunction, which happens to all of us as we age, especially those of us who are estrogen deficient.

Dr. Komal Patil-Sisodia 13:22

Yeah. And with barrier dysfunction, can you break that down a little bit? Or like what does that exactly mean for, the average person that comes into your office? How do you describe what barrier dysfunction is?

Dr. Sarah Stierman 13:32

Can be genetic as in the case of atopic dermatitis or eczema. Those people have a genetic deficiency in a molecule called rin. That's another component of the skin barrier. But those of us who start having barrier dysfunction with age, it is that lipid loss due to falling estrogen levels in the skin. And when your barrier is not completely intact, you can think of it like cracks in your wall, right? Cracks in your brick wall. Right. And then moisture gets in and out we call that TEWL or trans epidermal Water loss. And that is a key component of barrier dysfunction because the human body is made up of so much water and the skin is a big part of that too. Yeah. So moisturizer is a retinoids French for sure. I definitely encourage people to moisturize, but layer not mix when they're trying to get used to a retinoid. Pea-sized amount of a topical retinoid. Only more is not more with these get a pea-sized amount on your finger and make little polka dots on your face with just that pea-sized amount, avoiding really close to the eye. And mouth. Some people do get a little irritated in their nasal labial folds as well. So those are areas where we tend to not slather on a topical retinoid. Another popular buzz term over the last, five to 10 years is slugging. I'm sure you've heard this.

Dr. Komal Patil-Sisodia 14:52

About that. Yes. Because I was like, that just looks like a ton of Vaseline on your face.

Dr. Sarah Stierman 14:56

when it comes to tolerating retinoids very frequently we'll put a thick moisturizer, if not Vaseline or Aquaphor around the canthi of the eyes. So around the lateral aspects of the eye, where the skin is really thin and delicate, and then your lips as well. You can even put it right here in the corners of your nose to create a barrier between you and a retinoid. That is my slugging advice. I don't like to slather the entire face in occlusive Vaseline unless we're talking post procedure. That's a different conversation. But yeah. Protecting those little areas before you put a topical retinoid on can make it a lot more tolerable. Moisturizer after, protect the delicate areas and then if you're still not tolerating it. So just making sure that you can moisturize and then protect the areas that are likely to get irritated, and not applying too much because you wouldn't believe how many people come in having used, like I know that I've given them a month's supply and it's two weeks later, their face is on fire and more than half of the tube is gone. And I'm like, how much are you putting on your face? Beyond that, after those basic steps, if you still can't tolerate a topical retinoid, we can do my favorite trick, which is called a retinoid sandwich. You can apply a layer of moisturizer, wait a minute, and then apply your retinoid polka dots, wait a little bit, and then another layer of moisturizer. So you are bolstering your barrier, and occluding the retinoid as well, so it works better,

Dr. Komal Patil-Sisodia 16:24

yes, it works

Dr. Sarah Stierman 16:25

a little bit better when we seal it in like that, but it also, creates less irritation when we can use something emollient like a moisturizer. So the retinoid sandwich is my favorite trick. My second favorite trick is actually backing off on the frequency of use. So I let people start nightly Now, I used to, when I was in training, we would train people to start maybe a couple nights a week and work up to nightly. I like to hit it hard to start. If you can push through the worst of it, then you'll be able to tolerate the medication long term usually. So I recommend, nightly to start and if you don't tolerate it, backing it off to three times a week, and then slowly working back up to nightly as tolerated. Now that can get tricky I am a creature of habit and routine, and if I don't do the same thing every single night, I'm not necessarily gonna remember to do it. So I'm gonna be like, wait, did I put that on Monday or Tuesday? And what day is today? Who am I? Where am I, you know. Which gets worse than perimenopause, right? For those who do better with the same routine every night, instead of backing off the frequency, we can back off the amount of contact you give. Rather than wearing it overnight as a topical, what we can do instead is I kind of do the after dinner party. So after dinner, but before bed, you can apply, you can wash your face and apply your retinoid, but then before you go to bed, wash it off and repair your barrier. Oh, and so that's the other thing you can do. We call that short contact therapy. And for stronger retinoids, sometimes short contact therapy is the way to go. With frequency of retinoid, the one to two nights a week that you talked about is not sufficient, unfortunately. Three is the magic number. If you are not able to tolerate a topical retinoid at least three nights a week, you are getting all of the side effects and none of the benefit.

Dr. Komal Patil-Sisodia 18:27

Okay. That's really good to know. And does that hold true for, I know there are people who use over the counter retinols, which I know are not as strong as the retinoids. Is it the same rule of three applies there? Yes. Absolutely.

Dr. Sarah Stierman 18:38

Frequency is the same. So over the counter drug store, topical retinoids, the vast majority of those are retinal alcohol. Retinal alcohol has a concentration roughly a hundred times less than rettino and 0.05% cream. And then the next strongest version of over the counter non prescription retinoids is retinol. Retin aldehyde is just one decimal point. So a 10% change from rettino into that, usually physician dispensed, but sometimes pharmacy dispensed, grade of retinoid. I find that Retin Aldehydes, if you do not tolerate Tretinoin, which is prescription strength retinoid, then a Retin Aldehyde is usually my next go-to.

Dr. Komal Patil-Sisodia 19:21

That's good. Thank you so much for clarifying that. There's so many labels on bottles and when we don't know what is the gold standard versus everything else, I feel like, I can walk into a Sephora or an Ulta and be duped and buy all sorts of stuff that's not doing a darn thing for my

Dr. Sarah Stierman 19:38

Absolutely. It's so overwhelming. Like you don't even get me started about the skin. I love skincare. Yeah. And I love medical skincare and I love science and I am a physician scientist at heart, but the cosmeceutical industry, very much like the nutrition and fitness industries, in my opinion, really prey on our insecurities, especially as women walking into a Sephora or an Alta or into a department store, and having somebody accost you with like 18 different serums and creams and things you need to try. I'm a keep it simple sort of girl and it better have amazing data behind it.

Dr. Komal Patil-Sisodia 20:13

Yeah, I love that. And it is so hard to do that right. I'm wondering, have you noticed that since the pandemic women are so much more nitpicky with their faces because I feel like I am, you know, like you sit there and you stare at yourself on a screen all day. You're like, oh wait. What's happening here?

Dr. Sarah Stierman 20:32

Advent of the stay at home work from home and then zoom meetings, so many people have come in and are like, oh my God. And honestly, what's hilarious is that some of it is the face, but so much of it is neck, because of, I don't believe that actually of tech neck because we don't pay attention. Well, and because of, I mean like literally forward head position in front of a camera all day long, it's tech neck as we call it, which causes some skin changes.

Dr. Komal Patil-Sisodia 20:59

You know, that's so interesting because I always thought tech neck was like on the back, like mm-hmm. You know, kind of hunched over posture. I never really thought about it.'cause if you're hunched over, yeah, that makes sense. That things are in the front. Right. Well, all right, so retinoids, that's like the next, so what, what comes after? So sunscreen and a retinoid

Dr. Sarah Stierman 21:18

Those are the cornerstones, those are the non-negotiables of any sort of healthy skin, anti-aging regimen, sunscreen and retinoid. If you're not doing those two things, you're doing yourself an incredible disservice. People who come into me for Botox and fillers and laser and neuromodulators and all of these things, if they are not doing sunscreen and a retinoid every single day, I'm like, wait, that's like audible flushing of money down the toilet. Let's just bring it back. So sunscreen and a retinoid. I'm off of my soapbox. Now, the next thing that I would consider adding, would be, and I'm biased, so the vast majority of my dermatology colleagues would probably say the next thing to add would be an antioxidant. So like a vitamin C, product to help with oxidative stress. Yes. I am a growth factor girl. I have been for a very long time. And so my next one, if you wanna best bang for your buck, for just really kind of aggressive collagen production, is either a growth factor a peptide or an exosome. Those are all in the same family of products. The first time I did the skincare post in the group that you and I met in growth factors were at their advent, they were new, the original TNS, tissue Nutrient Solution was patented by Skin Medica back in the very late nineties. But that was still, it didn't have broad distribution really until the 2000 tens probably. And so growth factors were just beginning to take off when I became very interested in medical grade skincare. Growth factors, like TNS or other alternatives now. Growth factors, what they do is they sit on the surface of the skin, and then they actually sell cell signal. And so they send a message to your fiberglass and your dermis from the cells in the epidermis. They signal down to the dermis and try to wake them back up and start collagen production again. There are a lot of growth factors derived from mesenchymal growth factors or, platelet derived growth factors. Those are the two main groups. Peptides are like tiny little emails from your system down to the cells. Just tiny little nudges like, Hey, hey, wake up. Hey, hey. You know? So peptides have very similar function to growth factors, but maybe just slightly less potent. Exosomes are kind of the new. Rage, if you will. So exosomes are usually derived from blood product. And there are a variety of sources. Yeah. And there are a variety of sources, they're like a little bubble or a little FedEx truck that holds all of the growth factors and peptides and signaling messages. And so it can be a more comprehensive message, but the one word to the wise about exosomes is because many of them are blood derived, the sources are sometimes questionable, depending on how much data there is behind a particular brand. Exosomes are not regulated by the FDA as of now. So be careful when we start talking about unregulated things. The jury is still out about whether or not they will be able to be regulated.

Dr. Komal Patil-Sisodia 24:25

But the growth factors you were talking about that have been in development for a long time are not necessarily falling into that

Dr. Sarah Stierman 24:32

No. The questions that I get from patients about safety and efficacy with growth factors usually are like, well, so you're stimulating cells. What if I have a history of skin cancer? Can I put that on my face? And what I will say is that it has never been shown to proliferate a cancer line. You're not gonna get a double-blinded controlled study on growth factors in skin cancer. But we have as close to really good data as we can get to know that it is safe.

Dr. Komal Patil-Sisodia 25:02

That's excellent. And then what about inflammatory skin conditions like psoriasis and eczema? Do you feel like those, are okay to use growth factors with will, growth factors, exacerbate skin conditions like that?

Dr. Sarah Stierman 25:14

I have not seen a topical growth factor cause a flare of psoriasis, a flare of eczema, or stimulate the hair on my face to grow okay. I didn't think about that one. The answer is no. Thank goodness. I don't need any more of that either. Growth factors are my next favorite, ingredient in a healthy skin anti-aging regimen. So we've talked about SPF and retinoid again, cornerstones sunscreen, and a retinoid cornerstones of a healthy anti-aging regimen. Vitamin C for a lot of my colleagues would recommend. I will digress briefly about vitamin C'cause there are a lot of different vitamin C products out there as well. My favorite form of vitamin C, the easiest form of vitamin C topically to get your hands on is L ascorbic acid or L ascorbate while it is relatively effective, it is a very volatile compound. That's why you'll see like the SkinCeutical ce ferulic, which is the gold standard of a topical vitamin C. They kind of had the corner on that a long time ago. You'll notice it's in a brown bottle. The reason it's in a brown bottle is because it isn't photo stable. It needs to be in an opaque container in order to be stable. It also tends to be very irritating and kind of barrier disrupting as well. I find when patients are on a regimen and then add a really potent vitamin C, it can cause purging and breakouts like acne breakouts. But my favorite form of vitamin C by far, and I'm gonna take a second to say it'cause you can stumble over this very long word, but it is tetra heyl Desal asco bait.

Dr. Komal Patil-Sisodia 26:50

Okay. I'm not even gonna try and repeat that. That's okay.

Dr. Sarah Stierman 26:53

It's my favorite. And the reason that it's my favorite is that it is very well tolerated and it's photos stable. And it's photos stable. Yeah. So you can use it anytime of day. No big deal.

Dr. Komal Patil-Sisodia 27:06

Is there a particular, I know like there's so many brands that, put that out there and if you don't wanna give a specific brand, I'm fine with that. But is there, because I will remember a brand more than the very long multi-syllabic word that you just said.

Dr. Sarah Stierman 27:19

So you're right. In general, I will preface any sort of brand related discussion saying I have absolutely zero partnership with any brand out there. I am not brand loyal at all. Yeah. But. I do have two vitamin Cs where the active ingredient is tetra yl des ascorbate, which is my favorite. Number one is the revision c plus 30%. Mm-hmm. That it's so, it's so beautiful. It's such an elegant cream. It's very well tolerated. I've never had anyone come back to me saying, oh, it gave me breakouts. Oh, it made me dry or red. And if you're looking for something that is not usually revision is physician dispensed or dispensed out of like a MediSpa where they have a supervising physician. So sometimes it's a little bit harder to get revision, but I do like revision of the, more accessible brands, like you can get it all to. And Sephora, my favorite version of that vitamin C is from Sunday. Riley. It's in an orange container.

Dr. Komal Patil-Sisodia 28:18

I know. Well I've used that one before. See, learning some new tips here. Thank you for that, Sarah. That was a fully selfish question. Here we are, but here we here. That's real.

Dr. Sarah Stierman 28:28

And I'm here for it.

Dr. Komal Patil-Sisodia 28:29

So we've gone through SPF, retinoids, the growth factors and now an antioxidant. Are there other antioxidants outside of vitamin C that people use or recommend there are numerous,

Dr. Sarah Stierman 28:42

Antioxidants outside of vitamin C. Vitamin C is probably just the most prolific and concentrated of them. But, honestly, green tea is probably another one of my favorite ingredients. It has high antioxidant power, which is fantastic. It's also really well tolerated. You see green tea in a lot of products that are meant to be calming to the skin, which is great.

Dr. Komal Patil-Sisodia 29:03

Okay. That's fantastic. All right, so we do that for, retinoids for evenings. I'm assuming the antioxidants during the day. And then the growth factor would be the growth factor.

Dr. Sarah Stierman 29:17

On the indication on the packaging and depends on the dosing that's recommended, but the vast majority of growth factors are twice a day.

Dr. Komal Patil-Sisodia 29:25

That's good to know because, I would be like the person trying to budget and get away with them once a day.

Dr. Sarah Stierman 29:31

Well, when we start

Dr. Komal Patil-Sisodia 29:32

Ease of use and lazy when we start talking about

Dr. Sarah Stierman 29:34

compliance of actually applying topical medications. This is, um, this has to do with psoriasis. There's a very famous dermatology study where they put a microchip in the top of a jar of topical steroid. For their eczema and psoriasis patients. And then monitored'em Yeah. Over a period of time and had them bring their jar back with them into the clinic and they scanned it. And on average, literally when something is prescribed to put on your skin twice a day on average, people were applying it like twice a week.

Dr. Komal Patil-Sisodia 30:06

Yeah.

Dr. Sarah Stierman 30:07

Mm-hmm.

Dr. Komal Patil-Sisodia 30:08

Wow. Okay. So even daily is a stretch sometimes.

Dr. Sarah Stierman 30:11

Sometimes. There are days that I get home and I'm exhausted and I'm lucky that I get my contacts out of my eyes before my head hits the pillow, let alone doing an 18 step regimen. Not that my regimen is even close to 18 steps.

Dr. Komal Patil-Sisodia 30:24

No, yeah, I know. We see all these things that, you know, like 10 step regimen. Seven step regimen, and I'm like, I just wanna wash my face, put some stuff on and then like you, I need my head to hit the pillow. Especially. Yeah, keep, keep it simple.

Dr. Sarah Stierman 30:40

Because there are more steps does not mean it is better. TikTok, we're talking to you. Yes, we're talking to the ticking to, and it has nothing to do with a 13 step skin regimen.

Dr. Komal Patil-Sisodia 30:50

So let's talk a little bit about cleansing the skin, right? Because a lot of times people will be like, oh my gosh, I need something to get everything off. We are of the era of the, Saint Ives apricot scrub and all of the stuff that was like, you know, basically taking like a group cheese grater to your face, right? Yeah. For how rough it was on our skin. What is the best way to wash your face and still protect that skin barrier? Because it sounds like as we age, it's all about the barrier and making sure that we're keeping it protected and then also doing these other things to stimulate collagen. Correct. So,

Dr. Sarah Stierman 31:23

Do not over exfoliate. I'm saying it again, do not over exfoliate. If you're on a retinoid, you're already getting a chemical exfoliant because it's helping with cell turnover. You shouldn't need to scrub your face with walnut shells, which is what stine's is. It's ground up walnut shells. Who knows what it is now, but that's what it used to be. You don't need little tiny pieces of fiberglass on your face'cause that's what it feels like. But yes, we all grew up doing that. I would've taken a Brillo pad to my face if it meant that I wouldn't have had acne when I was 16. But here I am and I survived. Yes.

Dr. Komal Patil-Sisodia 31:56

Right?

Dr. Sarah Stierman 31:57

Yes.

Dr. Komal Patil-Sisodia 31:58

Yes. We made it to midlife.

Dr. Sarah Stierman 32:00

Yes. So a gentle soap pre cleanser is my preference I don't think. You should spend insane amounts of money on a cleanser. There are a lot of fancy cleansers that are very pricey. I find that your money is best spent on Levon products, not something that you're going to wash off of your face. There are a lot of lovely, elegant, drugstore based cleansers by, you know, CeraVe and Cetaphil and Laroche Poe and Neutrogena that I absolutely love. And you don't need to spend, la mere prices to get your face dewy and cleansed. A soap free cleanser, the reason I say soap free is not, necessarily because there's something wrong with soap, but the pH of traditional soap tends to be very alkaline your skin is ever so slightly acidic. You're going to unbalance the pH of your skin if you are using soap, like the soap that you might use on your body. Mind you, I use soap free cleanser everywhere. If you're used to using Irish Spring in the shower and then you're just like, I'm just gonna wash my face real quick, and you use that on your face, you'll pay for it later, I promise. So a gentle soap free cleanser that we're careful about the pH. Nothing scrubby or abrasive. If you're a washcloth girl, fine. I'm a fingers girl just because I can control the amount of pressure and I know that my fingers are clean when I'm washing my face. And so I'm not inoculating my face with bacteria like from a loofah that's been sitting in your bathtub or shower for a week, you know? Beyond cleansing. Let's, dispel some myths. Let's talk about the step between cleansing and starting to apply product. You know what I'm gonna talk about? The toner, toner, toner. Oh yes. Oh my God. Okay. So you do not need a toner at all. Why does toner exist? Because a very long time ago when we all had hard water and didn't have any sort of water softening or treatment. And we used lie based soap to wash everything, including our faces and hair and body and whatever. Hard water plus lie would create a precipitant on the surface of the skin. This waxy film on the surface of the skin that then an alcohol based toner was used to break down and strip off the face before you could do anything else. The myth of the toner has been perpetuated beyond its utility.

Dr. Komal Patil-Sisodia 34:32

I didn't even know that it actually had a purpose. I just thought it was a product made up to make money. But it sounds like it was actually useful, but we don't need it anymore.

Dr. Sarah Stierman 34:41

you're right. You're actually right on both counts.

Dr. Komal Patil-Sisodia 34:44

Fair. It's oh gosh, I didn't realize that.'Cause you see all these different things that are out there, like a exfoliating toner, a moisturizing toner, whatever. But it sounds like you can just get that with the baseline skincare if you're using appropriate products for your skin. Correct.

Dr. Sarah Stierman 35:01

And if you are so into wanting to use a toner simply for a sensory experience. Some people just enjoy a sensory experience between cleansing and putting product on. I would just, if you're going to use a toner at all on your face for any reason whatsoever, make sure that it's alcohol free.

Dr. Komal Patil-Sisodia 35:20

That's fair. There's some really lovely ones that are like rose water that for the sensory experience, I never really thought they were doing much for my skin, but now that's confirmed, so I appreciate that. I might save my money now instead of buying all this stuff. Okay, so that's really helpful and interesting. I did have one more question. This part comes up to me from my patients actually.'cause I deal with a lot of PCOS and acne. What are your thoughts on oil-based cleansers and what do you use to remove makeup? Right. Because a lot of times my patients with acne will try covering it with makeup and then getting it off without irritating. The skin is a big thing what is the best way to do it?

Dr. Sarah Stierman 35:56

A fan of an oil-based cleanser. If you tolerate it, it can be relatively occlusive, so around the eyes, sometimes people can get a little bit more breakouts or, I mean, god forbid a ty or something like that along the lash line if you're not careful about rinsing it. But I am a fan of the double cleanse to remove makeup and then to cleanse the skin thereafter. When you double cleanse, you use something either like an oil-based, cleanser to start, or a micella water is another wonderful way to gently kind of double cleanse. That's the first step. And then once that gets rinsed, you move on to a soap free cleanser.

Dr. Komal Patil-Sisodia 36:31

Okay, great. Thank you for that. That's, so helpful to a lot of my patients, so I appreciate that. Now let's, switch gears and talk a little bit about supplements. You talked about how our collagen factories are shutting down collagen supplements, vitamins for hair, skin, and nails. There's a whole bunch of stuff that I think we just need to know, like, is this a skip or a buy?

Dr. Sarah Stierman 36:52

So if you have specific ingredient questions, let me know, but I'm just gonna hit the top five. People ask me about collagen powders all the time. Micronized collagen, is available in capsule form too, but I tend to prefer powder because I generally think it does mix well into beverages like coffee. But capsules, if you take collagen capsules, it's all of that powder stuffed into little capsules. And it ends up being something like six to eight capsules a day, which is a lot of pills. Oh. So I'm a powder girl. Yeah. So hydrolyzed collagen, releases in your digestive tract releases small collagen peptides, and we know that peptides are messengers. If the message is received, it'll stimulate fibroblasts and collagen in the skin. There are almost 30 different types of collagen. Not all collagens are the same. Collagen. One is the most prolific collagen in your entire body. It's about 80% of the collagen in your body, and that's what makes your teeth, firm and makes your, hair, skin, and nails. And then your bones. It plays a really big part in your bone structure as well, but collagen, type one. And collagen type three are the two that we most want to use to, help with skin, hair, and nail health. Other types of collagen. Can have a little bit of a cosmetic benefit. When we talk about multi collagen powders, you're wanting to focus on not just hair and skin, nail health, but also joint health. And so if you're wanting to use something with multiple types of collagen in it, it will help with both skin and joints, which is great. Yeah, that's good to know. The reason I talk about that is that the, I would say the most, the easiest collagen powder to commercially get, I think, is Vital Proteins. I think people will recognize that brand name. And it comes both as a bovine source and as a marine source. Anecdotally, marine based collagen does tend to be a little bit better for skin health. But Vital Proteins doesn't have as many types of collagen in it as some of the other more comprehensive brands. There have been some really large studies that have had very positive results, in favor of collagen use for skin health. The, problems with some of these studies is that they were self-reported. So it's the patient just saying, I think it's better. And so you can't really. Judge whether or not some of that is placebo effect. But I have seen enough people benefit from collagen powder when they start it in my practice. And I personally have had enough benefit that I don't think it's all in my head. The largest study in 2019 on hydrolyzed oral collagen supplementation was a 96% positive predictive rate for increase in the, youthfulness and, just the health overall of your skin. So, so collagen is a definite. Okay, that's great. Let's, I so wanna pick your brain about biotin because you're an endocrinologist. Oh yes. Let's do this. How about we have the endocrinologist talk about biotin first? She's gonna be smarter about it. I'll tell you what I tell all my patients about biotin.

Dr. Komal Patil-Sisodia 40:05

Okay, so I will tell patients that, it may or may not help your hair, skin, or nails, but it's gonna mess up your thyroid blood test by messing with the lab essay. For some people they take it and they're like, oh, I feel like my hair is growing back thicker, or my hairdresser commented on it I'm not sitting there counting the number of follicles per whatever it is, like square centimeter, square inch on the scalp. So I don't actually know. My biggest pet peeve is how it throws off thyroid tests. I tell people you have to be off of it for three days minimum. That creates a lot of anxiety for people because they're like, but it's helping my hair and if I miss it for three days to a week, what's gonna happen? I don't actually know the answer to that. I just know it messes up the thyroid function test. It doesn't actually mess up your thyroid function. It just makes the lab test look a little wonky. So that's why I prefer people to be off of it when they get that trial.

Dr. Sarah Stierman 40:54

Thyroid panel is a biotin lab. Newsflash not just the thyroid panel, but cardiac assays are biotin native as well. If you were having a heart attack and we ran your cardiac enzymes, they would not be normal if you were on high dose biotin.

Dr. Komal Patil-Sisodia 41:10

Holy moly. Yeah, I did not know that.

Dr. Sarah Stierman 41:12

Was a really tragic story where there was a lady who was just postmenopausal, started having some atypical chest pain, like just a little tightness. Didn't really radiate, had unusual symptoms she came into the emergency room and it either wasn't disclosed that she was on high dose biotin or they didn't think it was a big deal. But they ran her troponins, so her cardiac essays to see whether or not there was any heart damage. They were normal. They sent her home. She died. She had a heart attack

Dr. Komal Patil-Sisodia 41:42

home.

Dr. Sarah Stierman 41:42

Yeah.

Dr. Komal Patil-Sisodia 41:45

Oh my gosh. I had not heard that case. I'm gonna have to look that up.

Dr. Sarah Stierman 41:49

So here's the thing, when the standard of care, has been the same. For decades those of us who are currently practicing, forget the sentinel evidence. That made us make that recommendation or standard of care to begin with. The evidence for biotin is actually from the veterinary literature. It's from the veterinary literature and the sentinel paper was in the 1970s and it was subjective thickening of horse hoves because they added biotin to horse speed. So,

Dr. Komal Patil-Sisodia 42:24

There's never been any human data to show that it improved care,

Dr. Sarah Stierman 42:27

data at best and new slash

Dr. Komal Patil-Sisodia 42:29

wow. No, no, no, we're not. Oh my gosh. Okay. Well, I'm gonna have to tell that story to all my patients I think what's really throwing me, especially since, I've been doing so much more work in the midlife women's space, given, my mom's history of heart disease and all of those things, that story is terrifying to me. Right. It's terrifying to me. Right. Thank you for sharing that. So it's

Dr. Sarah Stierman 42:51

It's just that we don't recommend taking higher doses than what the USDA recommendation is.

Dr. Komal Patil-Sisodia 42:57

so what is the USDA recommendation around biotin? Because I'll go to Costco and it'll be like 5,000, 10,000, and then you read like the little thing and it's like thousands of percent of your recommended.

Dr. Sarah Stierman 43:08

My head, don't even remember what the USDA recommended amount is, but, I will say that we no longer recommend doses of biotin in greater than 5,000 micrograms because the risk outweighs the benefit. So I would just stick to the amount that's in your multivitamin or that you can derive from your diet.

Dr. Komal Patil-Sisodia 43:26

That's excellent information. I think that's the biggest tip for me. I was in it for all the skincare stuff and now I'm walking away with this cardiac assay knowledge. Thank you. I feel very well informed,

Dr. Sarah Stierman 43:37

so, here's the good news if we take away your biotin. There are better things to take for your hair, especially because we can talk about supplements for skin health, but I feel like the nutraceutical, market for hair health has exploded. And so there are a lot of supplements for hair health.

Dr. Komal Patil-Sisodia 43:56

I had love to hear about those. What do you think are the best ingredients that are out there on the market? Or if there are supplements? Definitely. So,

Dr. Sarah Stierman 44:03

Certainly, and again, I will preface any sort of brand discussion with the fact that I do not have a relationship with any brand. So this is totally just from my personal practice, not from any sort of kickback. Neutrophil and Viviscal were the first comprehensive, supplements on the scene for, hair health. And they work in a similar way. Neutrophil has a lot of wonderful ingredients in it, including saw Palmetto saw Palmetto is a very frequent ingredient you'll see in any sort of, hair loss or hair preservation nutraceutical supplement. It's been around for a very long time. The reason it works for hair loss is because it's a five alpha reductase inhibitor. What is five alpha reductase? It is the enzyme that converts testosterone to dihydrotestosterone, and dihydrotestosterone is the hormone that makes your hair fall out. So saw palmetto is a natural mimic to that enzyme. It will not allow testosterone to convert into DHT, which is the hormone that makes your hair fall out. The downside to saw Palmetto depending on concentration, is that it can have some interactions with medication. So before you would start anything with saw palmetto in it, I would make sure that you don't have a contraindication with the drugs you're already taking. That's fair. And the other fun thing is that, so we talked about saw palmetto being a five al or reductase inhibitor. So it blocks DHT, well, pumpkin seed oil is a natural phyto sterol that blocks DHT. Pumpkin seed oil is incredibly well tolerated and has no sort of drug interactions. And so when I look for a really good nutraceutical, I'm looking for something that at minimum has pumpkin seed oil in it and has vitamin D in it. Okay. Plus minus salt palmetto, which is a very, very effective ingredient. But again, just careful with cross reactions with drugs. Yeah. Those are honestly my favorite ingredients. My favorite nutraceutical, was formulated by a group of dermatology colleagues of mine who are hair specialists internationally. It's called Stresse. X-T-R-E-S-S-E. What I love about it is that it's biotin free. And, because Nutra fall actually won't be biotin free until 2027. The only version of neutrophil that is biotin free at present is the women's vegan version. So if you're looking at nut nutri fall and you really like it, go for the women's vegan version because it's biotin free. But extra say is all of the wonderful ingredients of neutrophil sans the biotin, but it's into sugar-free strawberry flavored gummies. And I'm perpetually 12 years old and enjoy, taking two strawberry flavored gummies as opposed to giant capsules.

Dr. Komal Patil-Sisodia 46:48

Yes. I think I would agree with that. I tried some of these other, brands that you had said before, and just how did one of my friends describe it as Earth Forward? They were very earthy and I could not get them down the hatch no matter how hard I tried. Some of'em are like four capsules a day and it is a lot. It's a lot.

Dr. Sarah Stierman 47:08

Viviscal. It's usually one in the morning and one at night. Talk about Earth Forward. I would call viviscal fish forward. It has marine based collagen in it. I did not tolerate viviscal simply because I couldn't stand to swallow it. But it is very effective.

Dr. Komal Patil-Sisodia 47:26

It was great and I wished that I could have tolerated it, but it was not gonna go down the hatch for me, okay. I will link all of these things in the show notes so people know what we're talking about and they can, take a look and see what works best for them. This is fascinating. Thank you. So those are our nutraceuticals, correct? Yes, those are,

Dr. Sarah Stierman 47:43

those are my powerhouse nutraceuticals.

Dr. Komal Patil-Sisodia 47:45

Okay. Tho those were your powerhouses? Yes. Okay, perfect. And then, just because I want to be mindful of your time, I'm gonna jump to the hot topic on everybody's mind, which is. Topical estrogen data in your skin, right? We see all of these things that are out there, the Estriol creams, the, different companies that are putting them out there. I believe they're all compounded. And, you know, what does the data actually show us? And would women benefit from this? And is there a systemic uptake of these that we need to be worried?

Dr. Sarah Stierman 48:17

All amazing and very topical questions. So, topical estrogen has really kind of exploded on the scene there's been some very reasonable data for a while, but I feel like the direct to consumer marketing has become very intense over the last, six to 12 months. The two main topical estrogens that have data are both topical estradiol, which I think a lot of people including your podcast listeners are probably very familiar with it's used for a lot of different things, most of which are not dermatologic in nature. Estradiol, is the much more potent version of topical estrogen. And then there's Estriol as well. So it's, you know, E two versus E three and. Estradiol has a much higher affinity for estrogen receptors, both in the skin and in other places of the body. It does have the most amount of robust data when we talk about stimulatory effects on dermal fibroblasts. So again, your collagen factory cells? Yes. Okay. And for collagen synthesis because of that fibroblast signaling, the only issue Yeah. That we do worry about with topical estradiol is that there is evidence it can be systemically absorbed through the skin, hence transdermal estrogen.

Dr. Komal Patil-Sisodia 49:31

Yes, it is a systemic HRT treatment. Right. So putting additional on your face seems like a quick pathway to maybe taking too much. Correct.

Dr. Sarah Stierman 49:40

Certainly we can see clotting risks with patients who are on excessive amounts of topical estradiol depending on their other risk factors. I have not seen firm data to suggest that there's a direct correlation between applying topical estrogen and activating, you know, hormones sensitive breast cancer, but it's out there in the literature enough that it's worth a conversation with your OB, GYN and or on oncologist if you're wanting to consider topical estrogen. Yeah. Now Estriol, a lot of people, think that Estriol is safer because it is less of a potent topical estrogen. It is pharmacologically weaker and doesn't have the same. Possibility of systemic uptake as estradiol. So estriol generally, we know it's a weaker version. So you're not necessarily gonna get the systemic changes. The problem is that I have no head-to-head studies yet on estradiol versus Estriol about effectiveness versus, you know, risk benefit. But I will say that what does topical estrogen do? Well, estrogen, when we lose that, when we take that out of the skin, again, we talked about barrier dysfunction and skin sensitivity and dryness and breakdown of collagen and elastin. By locally putting it back where it belongs, you can regain some of those youthful things, like more, glowing skin. Or less textural changes. Less dryness, more doingness. More, resilience to your skin. What I will say is that the best studies we have on topical estrogen for facial skin at this time are only for the under eye area. And then a little, a little, another study where we have some neck as well. Data.

Dr. Komal Patil-Sisodia 51:32

That was going to be my next question because I also worry like neck proximity to the breasts, like the safety, I think it's a big question mark right now.

Dr. Sarah Stierman 51:40

And again, if there's ever any doubt about your risk in, starting a topical estrogen I would certainly make sure that if you have risk, that you're in communication with your ob GYN, your endocrinologist, your oncologist, to see whether the risk versus benefit is appropriate for you. And then applying it to just more localized areas of skin concern. So the under eye area has the best amount of data we have, and that's a very localized area to use it. The likelihood of you getting really significant systemic uptake, just applying it under eye once or twice a day, it's probably safe. And then we just don't have long-term data yet for applying it to face, neck, chest, hands, that's a much larger surface area. And so we don't know yet. We don't know yet what the systemic uptake would be if we were to use it in a larger area. I use topical estro. So I started using compounded topical Estriol from a compounding pharmacy that one of my dermatology colleagues founded. That is based in New York City. It's called Skin Medicinals, and my compounded Estriol has niacinamide in it as well. It's sort of a proprietary compound. But I apply it to my under eye area every single night, and then every other night I apply it to my neck. I have yet to be so bold as to apply it to larger swaths of skin. Just again, because I'm now on transdermal estrogen, being perimenopausal, do I really wanna double, triple, quadruple down on that? Probably not.

Dr. Komal Patil-Sisodia 53:13

No, and I would agree with that, right? Like, we just don't know. And if you haven't had proper risk assessment to all our listeners out there, please make sure you talk to your doctors, because you cannot be just doing what you're seeing on TikTok or hearing, especially if it's not been vetted and applied specifically to your medical situation at hand. Thank you so much Dr. Stierman. This was such a good conversation. I feel like there's so many gems. I might have to split this up into two episodes because there was just so much gold in there and I don't want people, to miss out on anything. If you could just spend a minute to tell our listeners where they can find you and where they can find your practice. If you're on socials, we'll link all of that information below in the show notes.

Dr. Sarah Stierman 54:00

Absolutely. So I am located in little Old Northwest Ohio in Toledo Metro. So in the middle of nowhere on the way to somewhere, but no, Toledo has my heart and we'll always have my heart. Our website at Dermatology Associates inc. Is DA ohio.com. And there you can find me and you can find my MediSpa division ADA Aesthetics. I am on Instagram and, Twitter my Twitter handle is, Dr. Sarah Derm. Where all my dermatopathology posts go. So if you're more interested in skincare and skin health. I have two Instagram handles that I think are very educational. One of them is at Dr. Grass Derm as in grass, like the grass is green. D-R-G-R-A-S. BERM. And the reason the mnemonic grass exists is because that was the, yeah. That was the special memory tool that I used to help patients remember the ingredients of a healthy skin anti-aging regimen. G-R-A-S-S-G is for growth factors and peptides. R is for topical retinoids. A is for antioxidants. The first S is a placeholder. It's called specialty products. And it's a placeholder for things like your moisturizer or your estrogen cream. And then the last S is the most important S. And what do you think it is? Yeah. S pf Woohoo. So I learned something. There's a fun story behind my Instagram handle. That's Dr. Derm and those are where all of my educational, medical based skincare posts go. And then if you wanna just follow me like a day in the life of my practice, seeing what I do from like freezing wards to reading pathology slides, to doing Botox, to doing skin cancer screenings. That is at Dr. Stierman Derm. So my last name?

Dr. Komal Patil-Sisodia 55:49

Thank you so much for your time. I was so happy that I ran into you at the conference we were both at in the Berkshires. Hopefully I will be able to see you there next year or in person sooner. I hope you have a great evening. Thank you so much for sharing. You're so welcome.

Dr. Sarah Stierman 56:03

Been so fun.

Dr. Komal Patil-Sisodia 56:03

Thank you.