Skin aging and acne: What you should do

0:00Welcome to Zoe, Science and Nutrition, where world leading scientists explain how their research can improve your health.

0:13Today we discuss why your skin has a huge impact on your overall health and learn how to slow skin aging and reduce acne. We'll give you plenty of practical tips. You'll learn how what you eat impacts your skin health and whether you really need those collagen supplements that so many of you have asked us about. Dr. Sarah Berry joins me as co-host today. Sarah is our chief scientist at ZOE and an associate professor at King's College London. Our guest is Dr. Justine Cluck. Justine is a consultant dermatologist with a specialist interest in acne. She's a member of the British Association of Dermatologists, the Royal Society of Medicine and the Royal College of Physicians.

0:55I'm excited for you to meet Justine, partly because so many of you have sent in questions about your skin health. And secondly, and also why I'm a bit nervous, because Justine is my wife. And I know Sarah is going to ask a lot of questions. I'll probably prefer she didn't.

1:13Wonderful. Well, I'm very excited to do this one and I have to admit a little nervous. So great to see you. Great to be here. I'm even more nervous. So that makes you feel better. And poor Sarah stuck in the middle of us. I'm loving it. Yeah, we can gang up on him, Justine. We always do. I can get him back for like the last year of podcasts. All right, so I'm not feeling any more relaxed now. I'm going to try and take a little bit more of a backseat today. And so Sarah is actually going to start with a quick fire round of questions from our listeners. Yeah, so Justine, we start all of our podcasts with quick fire questions.

1:49The rules are you can say yes, no, or one line, only if you have to say one line. Okay, so there's six questions. First one is, can your skin tell you about the health of your whole body? Yes. Great. Does what I eat matter for my skin? Yes. Wow, that's good news for us at Zoe. Can dairy make acne worse? Yes. And we'll talk more about why and how much. Great. Is it possible to reverse skin ageing? We can't reverse it. We can slow it down. Fabulous. Are collagen supplements a waste of money? it remains to be determined okay that's allowed okay i can simplify possibly okay probably now the last question you're allowed one to two lines and what i want to know is what's the most unexpected thing you've discovered about skin through working with your patients i think the impact the really huge impact that having a skin condition can have on people's psychological and emotional well-being.

2:55I think that is something that really drives me to want to share with you guys and with your audience why it's so important that we pay particular attention to our skin health. Amazing. So as I was preparing for today's podcast, I was thinking two things. So first, I was thinking I have to be really careful what I say today or I'm going to be in trouble for weeks. And the second is I actually thought back to Justine and my very first date. And I asked something really stupid, which for those of you who know me won't be very surprised, like, Justine, why did you decide to specialize in skin rather than all those much more interesting things you could do as a doctor?

3:35And Justine explained to me that I was an idiot and that basically skin was the most interesting thing in the world. And so I thought actually that would be a brilliant place to start. Could you tell us what skin does and why it's so important for us all? And why you went on that second date as well, I think. I sometimes ask myself the same question. Jonathan was sparkling and witty and all the good things even back then. So now just exposed to a bigger audience, which is annoying. But I thought it was just for me. Why do I think skin is the most interesting thing? On a personal note, I had acne myself as a teenager, as Jonathan knows.

4:13In fact, still do, still take treatment for it. So for me, it's been a 30-year journey with a skin condition. So I think having had that experience and found it really difficult at times, I really want to prevent other people from going through the same. So I think one of the reasons why I think skin is so important is it's visible. And that can be a good thing. It also means it's accessible. So if we want to study the skin, we can access it easily. We can take swabs. We can take biopsies. But I think going back to basic principles, why is the skin so interesting and important? I think I can distill it into three points, which is hard for me because I'm quite verbose.

4:49But the first is that there's the skin barrier function, which we'll come and talk about in a moment. But the skin is our outer shield. It's our first point of communication with the environment. And so our skin does provide some vital functions, for example, regulating heat and water loss, protecting us from UV, from infection, from things we're exposed to around us. The second thing is, and you guys will be interested in this, is it's home to our skin microbiome. And we definitely will be talking about that, I hope. And the third thing, which I think is one of the reasons why I was really interested in becoming a dermatologist, is our skin tells us a lot about what's going on inside our bodies and gives us clues about the health of our internal organ systems.

5:36And so one of the cool things about being a dermatologist is basically we're like super detectives. And so, you know, there are, I think, 3 ,000 different dermatological conditions. My colleagues might be listening to this and thinking, you know, there are actually 2 ,000. And so if I'm over-inflating it, it's because I want to really represent dermatology here today. But, you know, 2 ,000 different ways of looking at red spots. So you have to be really good as a dermatologist at looking at patterns and looking for clues. And our skin does give us a sort of window into things that are happening inside.

6:06So that's why I think skin is interesting and why I will say it is the most important part of the body. But of course, it's connected to everything. So we can't think of it in isolation. Yeah, I think it's fascinating that it is like a window because I must say it's something that I had never thought of before. And there was a study that someone had highlighted to me where they had twins and people were asked to age these twins according to their skin. Okay. And the twins that they aged as being older according to their skin actually went on to die and develop disease a lot sooner than the other twin just based on them detecting their age based on their skin.

6:46That really surprised me. That is really fascinating. And I think maybe when we get into what are the factors that influence aging, you'll see that there may be some common things between what influences skin aging and what influences aging of our other organ systems. And so you can't separate these things out. And I think it's something that you guys have talked about on the podcast quite a lot. And I've certainly heard Tim say that we can't think of different parts of our bodies, different compartments separated from each other. It's something I talk about in my clinic quite a lot. All of this is connected.

7:17we haven't always understood how science is starting to plug gaps so we understand now about the microbiome we understand a lot more about hormones but all of these bits are connected and so you can't just think about trying to address one in isolation you have to of course therefore will be factors that influence the health of multiple organ systems so yeah great and you talked about the microbiome which is one of Zoe's real areas of interest and we talk a lot on our podcasts about the gut microbiome so all of the trillions of bacteria that live inside our gut and impact our health but I've recently started hearing about the skin microbiome I know nothing about it Jonathan probably does because he's probably heard you talk about it but I wonder if you could tell listeners a little bit about what the skin microbiome is in the first place what functions it has what we do know and maybe what we still don't know about it.

8:06So I'll start with the last question which is we know a lot less about it than we know about the gut microbiome which might surprise people because I've said that the skin is so much more accessible so you would think it's the obvious place to start investigations on the microbiome but that isn't the case. We know that we have all of these microbes living in our gut we also have millions of microbes living on the surface of our skin. Something that I think is really fascinating is there's an argument always about what is the largest organ in the body and it's often said to be the skin and so dermatologists take a lot of pride in that.

8:37I've actually recently learned that's not exactly true okay okay for anyone who's interested by weight it's the musculoskeletal system and by surface area it's actually the lungs and the airways the sort of gas exchanging surfaces are the largest but what's really cool about the skin is if you were to kind of roll it out flat it's two square meters but there are millions of these appendages so dips and divots in the surface of the skin because of our hair follicles and our sweat glands and our sebaceous glands which are oil producing glands and so actually the real surface area of our skin that our microbes can inhabit is 10 times that at least 10 times that so some some say sort of 25 square meters so it's huge so it's it's pretty big a football pitch don't ask me i'll have someone that's into football maybe like a tennis court or something like it's definitely getting big so there are yeah there are lots of them and there are good and bad ones something that's really interesting is a bit like tim talks about sort of there being these like mini pharmacies that the microbes he compares into mini pharmacies and the gut sending out signals to the rest of our body the same is true of the microbes on our skin and so they interact with our immune system this is really important particularly in early life we should talk about the hygiene hypothesis i think which is the idea that we often think about small children babies in particular being vulnerable to infection and they are because their immune system is yet to mature and develop.

10:09So the theory in the past was that you should keep everything clean around small children so that you don't expose them to this risk of infection. And what we've learned is that unfortunately by not exposing kids to dirt and animals and you know all of this other stuff we actually reduce the diversity of the microbes that live on their skin. And therefore, this affects the development of the immune system and actually increases the risk of people developing allergies and inflammatory skin disorders. And how do you do about letting your own children get really dirty in those first few years of life?

10:49I mean, Jonathan knows this is definitely a sort of do as I say, not as I do. And I think it's something actually that I've thought quite a lot about since having our daughter who's now four because, you know, I've trained in a hospital environment where sterility and cleanliness are king. And so that often gets translated into home life. So, you know, my family, you know, will laugh when they hear this, but like you could eat off the floor in my home. I often say to my daughter, you can eat off the floor here, but nowhere else. but we know that this is not great for kids and actually there have been some recent studies showing that actually exposing children to the natural environment so there is this scheme called play and grow where kids i think there were two to five year olds and they were sent to go and play with leaves and soil outside for a number of weeks and what's amazing is the researchers found that the kids were less stressed and less angry.

11:47They had higher gut serotonin levels. They felt more connected to nature. So by that, they were more prepared to eat vegetables afterwards and were interested in the environment. And they had greater abundance and variety of microbes on their gut samples at the end of the study. And when you were studying dermatology, were you taught anything about the microbiome at that point? No I think the first time I heard the word microbiome was as a dermatology trainee so I was already pretty advanced in in my career so. But it's relatively new even in nutrition it's only the last 10 years that we're talking about it and Justin something we often talk about is how can we change the microbiome in our gut to make us more healthy given the link between the gut microbiome and health.

12:37Can you change your skin microbiome? So you talked about there's different bugs that are associated with different skin conditions can someone change their microbiome on their skin and most importantly does that then alleviate some of the symptoms or conditions that you talked about we're only really starting to get into it Sarah and I think often people would think that there's more real science here than there is because I'm going to be cynical but there's a commercial opportunity to sell skincare products that say they're going to balance your microbiome and and supplements okay so cream that you can put on that will change your microbiome yeah so like a probiotic cream yeah creams containing probiotics and really yeah so i mean this is this is not new it's been you know for the last i don't know five plus years there these products out there they say they can balance your microbiome they contain probiotics etc but if you actually you know i think people might be surprised because if they are into skincare or beauty and have been into a skincare store, looked at the shelves, there are lots of products that have these claims now.

13:42But if you look at the science, actually it's still in its infancy. And it's not nonsense that there are some studies where people have been given oral or topical probiotics. And there have been some favourable changes in reducing some of these pathogenic some of these bad microbes that can take over but I think the sort of magic bullity type things that say you know a probiotic cream is going to balance everything I'd be a bit skeptical about those things still. Okay so I've got a question that I think a lot of listeners might be thinking or maybe I'm just crazy but we know that yogurt for example is a probiotic and it's going to be a lot cheaper than any of these creams.

14:22What about slathering yogurt on your face i mean forget the smell has anyone done that um i'm sure they have i'm sure they have done i'm sure they have done i don't know of any trial where people have put the yogurt on their skin but i think it goes back to you know dermatologists are used to telling people not to put toothpaste on their spots like there are things that are designed for a specific purpose yeah okay you know eat your yogurt and in terms of practical things that you could do to potentially support your skin barrier and reduce dysbiosis on the skin. These are things like, for example, using a gentle cleanser on the skin.

15:00So I like a cream or a gel cleanser for washing the face morning and evening. If we overwash our skin, we might disrupt the microbiome on the skin. If we use very harsh, soapy cleansing products, we might disrupt the microbiome on the skin. Does it strip the microbiome if you use quite a tough, like I like one that really scrubs off everything that's got all grains in it and will that strip it or does it just reduce it? It can do in theory and I think we've got to remember that it is quite individual, right? So, you know, some people might say I use this, you know, exfoliating cleanser and actually that's fine for me.

15:38I have no problems with it. If it's fine for you and it's not disturbing your skin and you have no skin problems, it's probably OK. but the the microbes on our skin like certain conditions so if someone has an inflammatory skin condition and is thinking how can i kind of support the good microbes on my skin i would say think about this soap-free gentle creamy or gel cleanser if your skin is inflamed so in my acne clinic for example i tell people not to use those scrubs or exfoliating cleansers because if you think of an inflamed surface and then you're going to go and scrub something over the top of it, you're going to increase inflammation in the area.

16:16So that wouldn't be a good idea. I love this time of year. Yes, it's busy, but it also means a moment to reconnect with the people you love. And what brings us together more than anything? Food. It's the season for family feasts, long dinners with friends, and hearty home-cooked meals. The good news is social eating isn't just enjoyable. Connecting over food can also to support our mental and physical wellbeing. And that's why we've created the Zoe Holiday Hosting Guide. It's free and full of simple hosting ideas, plant-rich dishes, and shareable gut-friendly meals that will nourish you and your guests from the inside out.

16:58So if you want good food for when you're in good company, this guide is for you. To download your free guide, simply click the link in the show notes or go to zoe.com slash holiday guide. That's Zoe.com slash holiday guide. I'd actually love to take that opportunity to move on to sort of two of the skin topics where we had a huge number of questions from our Zoe listeners, which is acne and skin aging. And I'd actually love to start with acne. Maybe just start by telling us, like, why does acne matter? So it's a big problem. Okay. Acne is the eighth most prevalent disease globally. So not the eighth most prevalent skin disease, the eighth most prevalent disease, you know, full stop.

17:46So big problem. 9.4 % of the population have acne. So just think like almost one in 10 people. Yeah, it is a lot. And it is the most common reason for people to come and see a dermatologist. It's associated with higher rates of depression and suicide. It's associated with scarring, which can become permanent in more people than you think. So maybe this is a kind of something that stays with people even after the inflammatory phase has gone. 90 % of teenagers will have acne of some severity. So if they're lucky, that will be very mild. They may just have a few blackheads and a couple of pimples.

18:28But for some people, it's very much more severe than that. And they have, you know, these deeper red swellings and cysts in the skin, and they're more likely to get the scars. And I think it's, I always think it's quite cruel that the time at which people are most likely to develop acne is in puberty because of the rapid change in the hormones. And this is also where, you know, kids are so vulnerable because they are developing their social identity. They're trying to become more independent. They're navigating personal relationships and they've got exams and all of this pressure that they didn't have when they were younger.

19:03And then they've got to contend with this very visible and painful skin condition. So I could keep going, Jonathan, but those are some of the reasons why I think... Is it just teenagers? Because I know that's actually not most of the people who see you. No. So for sure, it's much more common in the teenage years. And then acne is much more common in males than females in the adolescent years and in the early 20s. But beyond sort of early to mid 20s, it is much more common in females. And so a rough sort of rule of thumb is that half of females in their 20s will have acne, a third of females in their 30s and a quarter of females in their 40s.

19:45Which is huge, isn't it? So half of all women in their 20s, still a third in their 30s. and what about menopause as well we hear lots of people talk about getting spots you know around menopause I'm at that perimenopausal phase and I've never had spots I've been really fortunate but I've started to notice I've got a few of my spots I get on my chest I get a few here and you hear anecdotally a lot of women say during the perimenopause suddenly acne returns and spots return so just to reassure people if we look at age alone you are much less likely to develop acne for the first time or to continue having it in your 40s or 50s so the chances of having acne do decrease with time however at any time of hormonal shifts you may be more vulnerable to having spots so we do see it around the time of of the menopause we also see it around pregnancy and of course the classic time for having acne is is during puberty and is it more common than it used to be.

20:45Yeah, it is. And I think we haven't really always understood why acne has been becoming more common over the last few decades. But I think there are two leading thoughts at the moment. And the first is the adoption of the Western diet. And the second is increased stress levels. And could we talk a little bit about the impact that diet might have on acne? Because I I know lots of my friends who are parents of children that suffer from acne often will say, oh, Sarah, what should they be eating? And I can't tell them what they should be eating. But I know that lots of people will go on elimination diets.

21:23You know, I must avoid all dairy or avoid gluten, etc. And, you know, when I was growing up, acne was blamed on eating sugar and chocolate. I'm pleased you mentioned elimination diets. We should come back to that in a moment because it's one of the most worrying things I see in clinic. is people coming in and having read that various foods can contribute to acne and have taken that further and started excluding all sorts of things from their diet and are frankly malnourished when they turn up in clinic and also have developed I think disordered eating as a result of I think misinterpreting information about food and acne.

22:05And especially for adolescents that's such an important time to make sure that you're eating you know wide variety of nutrients you know the prevalence of iron deficiency anemia in adolescence is huge and so if people are avoiding certain foods that's a real problem correct and i think of you know my steps and so we have a 15 year old at home he'll be absolutely dying that he gets mentioned today but um dying of embarrassment that it's not excited uh excited but you know you they they have to sleep so much right in their teenage years because they need all this you know conserving energy for growing so actually we do need to think about fueling ourselves properly and not restricting things particularly when there isn't sufficient evidence to to suggest it would be helpful so you know what what do we know um we know that diets with high glycemic content are associated with increased severity of acne and so can i just tell people what we mean and actually i'm not a nutritionist so i would rather you explain what it means.

23:04Well we have an entire podcast talking about it but when we talk about high glycemic foods we mean foods are typically high in really refined carbohydrates so white bread, white pasta, potatoes that kind of thing that cause a really rapid increase in blood sugar. So you eat these kind of foods about 15-20 minutes later you've got this big peak in blood sugar and it also stimulates lots of hormones like insulin. And insulin like growth factor and And so a little bit about acne so people understand how the sort of pathway is connected is that what basically underlies acne is an increase in oil production in the skin, blockage of the pores where the oil is supposed to come out onto the surface of the skin by dead skin cells.

23:47And then this creates a delicious feast for this particular bacteria, C acnes, that feeds on this and this triggers inflammation. and underlying this is a particular group of hormones called androgens. Testosterone is the classic one which increases the oil production and the pore clogging and we can connect food to this because these sugary foods and these very refined carbs your blood sugar rises then your insulin rises and insulin like growth factor rises IGF-1 and this increases these androgen hormones so we can connect all the different dots along the pathway. Okay, you also talked about inflammation, which is something Jonathan particularly loves talking about.

24:28And I quite like talking about it with him. We know as well from our own Zoe Predict research that the food that we eat is associated with our gut microbiome that's also associated with lots of inflammatory factors. We also know if we consume really high glycemic index food, it actually initiates an inflammatory response. Now, this is inside our blood. this is inside our gut would any of that be related to the kind of inflammation you're talking about that's going on at the level of the skin the answer is yes because there is a connection between our gut health and our skin health we call this the gut skin axis and so for sure the same sort of principles will apply that sugar is the most important one dairy is one of them people often will see an association with eating dairy and their skin getting worse or certainly will have read about it from an acne perspective and there is some evidence now mainly there aren't any rcts as far as some ways it's mainly observational studies showing that in western populations dairy can aggravate acne particularly milk because this seems to have a greater impact on insulin than other things like cheese potentially because of the whey content so whey supplements can be problematic for acne sufferers as well so the two areas of nutrition where there's been most research and evidence of their impact is dairy and and the sugary stuff so justine what would your practical advice be to help people with acne because there's a lot of people listening to this who would love to know okay what can i do for myself or maybe they're thinking you know about their teenage children what would you say i'd say the first thing is do go and get expert help if it's something that you're not able to manage yourself at home.

26:11I'm going to start with that because I think there is a big spectrum of severity with acne. There is very mild acne, which can be self-managed at home with some of the tips I'll give you in a second. But there are people who have much more severe acne. It may be affecting their mental health. It may be causing scarring. And I think in that circumstance, please go get some support from your family physician, your GP or a dermatologist, and do these other things on top of that but I wouldn't want to delay people getting appropriate treatment. I think there are some skincare tips I would give thinking about supporting the skin barrier and also you know in inverted commas helping to balance the skin microbiome but you know to create a healthy environment for the skin microbes that are beneficial to us.

26:57Moisturizing the skin is important so moisturizing the skin reinforces skin barrier function and it makes the skin a happier, healthier place. If you have acne, people often avoid using moisturiser because they're worried about clogging their pores up more. Look for the words non-comedogenic on a package. That means non-pore blocking. And that is something that you might find helpful. Vitamin A, retinol, retinoids. This group in topical form is really good for reducing pore clogging in the skin and can also reduce inflammation to a degree, more so for the prescription forms and the over-the-counter forms but i think what is really important is choose one and incorporate it in your skin routine so i would say cleanse your skin or tell your teenager if this if you're going to be relaying the information cleanse your skin with a non-stripping product twice a day moisturize the skin with a non-comedogenic product twice a day put a non-comedogenic sunscreen on in the morning and choose one active ingredient or one product with these active ingredients in to incorporate into your routine and introduce it slowly.

28:02Because again, you can sometimes do more harm than good if you're too aggressive and overzealous with these active ingredients. Try to combine too many of them together. Try to use too much too soon. I mean, I remember as a teenager being given a cream for acne and thinking this is the answer to all my problems and like squirting half the tube out and putting it on overnight. And of course, nothing happens immediately. And you think my acne is going to be gone tomorrow. and then you wake up the next morning and you're like you can't smile because your face is red and it's going to crack and it's really sore and so you know I always say to my patients you know I'm glad you're excited about using this but you know you do need to you know you do need to incorporate it gradually into the routine because you can actually end up doing more harm than good if you are you know not slow and steady.

28:47So Justine you've talked us through top tips of what you can apply to your skin and your understanding of nutrition and acne so if I could just summarize back from a practical perspective based on what you said about nutrition you're suggesting that foods at high glycemic index are going to be a problem so this is where this perception that for example sweets chocolate might be bad but also therefore perhaps people should be reducing the amount of these refined carbohydrates so for example the white bread the white rice the pasta the potatoes and any other kind of rapid carbohydrates that increase blood sugar and would you say that that would be a good diet tip that we could also give people yes and i think one of the things you said in this podcast before that i think is like really helpful and practical is even if you do nothing else you can just switch having your white bread white rice or white pasta with whole meal versions of that you don't have to change your lifestyle or any of the other things that you do that's a sort of simple switch that you could make as a starter for 10 or add protein healthy proteins or healthy fibres or fibres healthy you can add healthy proteins fiber or some healthy fats as well which will kind of reduce that blood sugar response yeah exactly and i would also say just life is about balance and it is okay to have treats and i wouldn't want the take-home message for anyone you know to be that you know if they're at a restaurant on their birthday they can't have the pasta as it's served or they can't have a pudding that night like it's okay to do that as long as that's you know that is the treat and not the norm i would say okay so while we're talking about food I'd quite like to quiz you a little bit about Jonathan so Jonathan is obviously incredibly well behaved in everything he does so my perception is is that Jonathan follows the Zoe recommendations to a tea so I'm not even convinced that he would go and have his birthday cake at a restaurant if it didn't score high on the Zoe score have you noticed his diet change since he started the whole Zoe program.

30:49And also I'd be curious to know how yours has changed. So I'd say Jonathan's diet changed before the Zoe program a little bit. And I'm sure this is why he went on to form Zoe. Jonathan's talked a bit about having had issues with his gut in the past, etc. I hope you don't mind me saying that, Jonathan. And so had already started making some changes to the way he ate before we even met. but you know he does live it at home and I think actually after you know a couple of years of being told you know the what was our life like after I did Zoe and before how I say that before you did we actually we have now I want to know what Justine was going to say the fact that she's thinking twice about how to say it I was going to say you know it's a sort of mind field here I think we have a sort of you know there are lots of jobs we share in the house we both work we both have young children and the sort of split is normally I prepare the food during the week and Jonathan does it on the weekends that's how we do it.