Behind The Business Woman
About your career and your passion for Photography:
I became interested in dermatology when I was at NYU Medical school, which had a very strong dermatology department. It was the medical side of dermatology that attracted me to the field. I had bad acne as a teenager, and developed an interest as a patient because the products that I was given to treat my skin 40, 50 years ago were all very drying. They caused my skin to be red, raw, and dry, which made me feel so uncomfortable. It was hard to be a compliant patient when the products were so irritating, and made me look so terrible. These experiences really motivated my interest to become a dermatologist.
Back when I trained at Bellevue, there was not a field called “cosmetic dermatology”. Cosmetic dermatology was essentially acne; therefore, my passion became acne. I trained with Dr. Alan Shalita, a pioneer in the treatment of acne, at Downstate Medical Centre where I nurtured this interest. My passion came from my love of making patients feel better, and because I had suffered with this condition.
INDUSTRY ZOOM: Menopausal Skin
What is the role of Menopause in the manifestation of Skin Aging?
There are three main things that contribute to what we see in an aged skin. First is chronological age1. The second is chronic photodamage, which is principally caused by exposure to the sun (and to a certain extent, other elements and pollution in the environment2). The third are hormonal changes. Therefore, aging is a combination of various components, and many things contribute to the way your skin looks.
With chronological aging, we do lose a little collagen and some of the epidermal barrier4, and the skin becomes somewhat dryer, and therefore slightly rougher. As it gets dry and rough, it gets itchy, and it can get a little wrinkly. However, we know that sunlight and the environment are the main factors that contribute to premature aging of the skin and photodamage. So, if you’ve had a lot of exposure to the sun, you will likely have issues with pigmentation, dryness and wrinkles. For women who are post-menopausal, there are now some additional factors contributing to some of the skin changes.
Tell me more about how Menopause affects the skin ?
After menopause, the estrogen levels drop. There is less estrogen to interact with your estrogen receptors. Subsequently, you lose a lot of these receptors, because if there’s no estrogen to interact with them, the receptors become dormant5,6. Estrogen receptors are usually found on fibroblasts, epidermal keratinocytes, and on hair follicle cells, all important cells of the skin.
As a result, your fibroblasts will make less collagen, less elastin, and less ground substance (the substance of the dermis that allows it to be thicker)7. You’re also going to have less glycosaminoglycans (GAG’s) in the dermis8, which usually function to retain water and keep the skin hydrated. This means your skin will become drier. Additionally, you lose some epidermal thickness because of the loss of estrogen receptors on epidermal keratinocytes9.
So, we have less collagen, less elastin, reduced epithermal thickness, and drier skin. The end result is that your skin is dry, itchy, dull-looking and wrinkled. This is happening on top of the photodamage and chronological aging. Because the skin becomes thin and fragile, it’s more likely that the blood vessels will leak blood, manifesting as purpura under the surface of the skin10. This is also something that happens post-menopausally and with age.
You’ve been talking about postmenopausal skin. Why don’t you say menopausal skin?
It starts with menopause, but it is after the menopause that these receptors decrease and the effects of menopause on the skin become more noticeable.
Basically, this usually begins around perimenopause. During perimenopause your estrogen levels gradually decrease, and this slow reduction can continue over even 10 years6,11. Perimenopause can start in the 40s and you can have menopause anywhere from the mid-40s to the mid-50s, with a gradual decline of estrogen. Then you refer to the skin as post-menopausal because you no longer have periods, and you have lost most of your estrogen.
The statistic that we’ve been told is that you lose about 30% of your collagen in the first five years after menopause, and then you lose another 1% to 2% per year thereafter. The loss in collagen is significant7. A lot of women don’t think about that, they think just about sun damage and age. But there is a significant loss of collagen with menopause.
You can do everything correctly, use sunscreen, hydrators and moisturizers, antioxidants, eat a good diet, sleep well and exercise: you’re still going to look wrinkled because you’ve lost your estrogen.
Are women/ your female patients aware of the impact of Menopause on their skin?
They tend not to have such an awareness of the signs of menopausal skin. If they’re menopausal and they’re seeing me, they’re also dealing with chronic photodamage and aging. So, they may complain about their skin, but they don’t necessarily say “This happened to my skin after menopause”. They may say, “My hair’s gotten thinner since menopause”, “I’m not healing as well as I used to”, or “I’m not as oily as I used to be.” But they don’t necessarily associate the skin changes with menopause.
Today, women are living longer and longer, and while the age of menopause has remained essentially the same, the lifespan for women has increased significantly. That means that women are going to be spending a larger and larger percentage of their lives as post menopausal women12,13.These skin changes can become an issue for menopausal women. They associate their insomnia, night sweats, hot flashes and vaginal dryness with menopause, but they don’t usually make the connection with skin changes. When they see their wrinkles and their dry skin, they think of it as old age, but they don’t consider the menopausal effects.
Obviously, as dermatologists, the other important thing that happens post-menopausally is hair thinning14. So really, all the appendages are affected by decreased estrogen.
Some skincare brands are claiming to offer solutions to Estrogen Deficient Skin, is this a new medical term to describe post-menopausal skin?
This is just a term. It’s not an official diagnosis, but it’s a term we’re now referring to describe the skin in women who are menopausal and post-menopausal where they’ve lost their estrogen and therefore their estrogen receptors13. The keratinocytes and fibroblasts are less active in thickening the epidermis or plumping and thickening the dermis the way they used to since there is less estrogen and fewer receptors with which to interact4,7,13.
What are the Skincare Solutions to keep the skin at its best through the stages of Menopause?
Obviously, you can use moisturizers that contain epidermal lipids such as ceramides, which will strengthen the skin barrier and hydrate the skin. You can use moisturizers that contain a humectant (a substance that retains water), such as glycerin and hyaluronic acid, to maintain moisture and further hydrate the skin.
Are there any promising new products or technologies on the Horizon for Estrogen Deficient Skin?
We do have a new addition to the armamentarium now, which is the estrogen receptor agonist that is present in a US based skincare brand. It’s a non-hormonal, synthetic agent that mimics estrogen and interacts with estrogen receptors on skin cells. However, it is not an estrogen. Once it interacts with the receptors, it’s degraded into an inactive metabolite. Its presence near the receptors can potentially stimulate some of the estrogen receptors into coming out of their dormancy and reawakening. Therefore, there may be a benefit to adding that to a skincare protocol.
Is there anything else that you recommend women to do from a more holistic standpoint, besides the skin care regimen?
Eating a healthy diet, consuming foods high in alpha three omega fatty acids, such as fish, nuts, healthy oils like olive oil, and avocados. Drinking plenty of water, getting plenty of sleep, and exercising. All of the things that are good for the body, are good for the skin because the skin is the largest organ in the body. From a holistic standpoint, anything you can do to better your health will reflect as better skin too. Of course, we don’t want to forget sun protection, broad-spectrum, preferably mineral sun protection.
What I’ve been talking about so far is just what we can recommend to our patients to use at home, but patients can also get anti-aging procedures performed by their board-certified dermatologist in the office. This includes injectables such as toxins or fillers, resurfacing such as with lasers or peels, or surgical procedures. Whatever the patient procedures the patients have performed they will have more of an enhanced result and an improved benefit if they are also using a regimen at home.
Do you think that all women are equal when it comes to getting into menopausal skin? What they have done in the past is it catching up, or is it making the case worse?
They’re not all equal. Estrogen is only one factor. If you have menopause at an earlier age, then your skin may look more wrinkled than someone who’s having menopause at a later age. But also, if you’re someone who’s spent tons of time out in the sun, you’re going to look aged much younger than someone who’s avoided the sun and worn sun protection every day of their life.
There are many a lot of factors at play, but estrogen is a big one. Whatever your genetics are, whether you sat in the sun or not, you’re going to have menopause. And if you’re going to be living long, you’re going to be living a larger and larger portion of your life as a postmenopausal woman.
Do you think that there is any science or scientific advances in trying to better understand menopausal skin?
I think that the field is growing more since approximately 6,000 women enter menopause a day, and the number of post-menopausal women will increase12,13. I think there is more interest in this for both skin and hair health. I think that the study of hormonal receptors for both the skin and for hair is increasingly a topic of interest and research14. We will see the development of topical antiandrogens for both acne and hair. That will be a whole new category.
What is your definition of healthy skin?
I think when we define healthy skin it’s radiant, glowing, smooth, flawless, wrinkle-free, and it’s blemish-free. It’s not discolored with respect to hypo or hyperpigmentation or redness, and it’s poreless. But healthy skin is probably what skin looks like between age two and seven, before all the hormones of puberty have kicked in and after the mom’s maternal hormones are gone. After that, a combination of genetics, lifestyle and hormones will influence how healthy that skin remains.
1. Trojahn, C.; Dobos, G.; Lichterfeld, A.; Blume-Peytavi, U.; Kottner, J. Characterizing Facial Skin Ageing in Humans: Disentangling Extrinsic from Intrinsic Biological Phenomena. Biomed Res. Int. 2015, 2015. https://doi.org/10.1155/2015/318586.
2. Gonzaga, E. R. Role of UV Light in Photodamage, Skin Aging, and Skin Cancer: Importance of Photoprotection. American Journal of Clinical Dermatology. 2009, pp 19–24. https://doi.org/10.2165/0128071-200910001-00004.
3. Blume-Peytavi, U.; Atkin, S.; Gieler, U.; Grimalt, R. Skin Academy: Hair, Skin, Hormones and Menopause – Current Status/Knowledge on the Management of Hair Disorders in Menopausal Women. European Journal of Dermatology. May 2012, pp 310–318. https://doi.org/10.1684/ejd.2012.1692.
4. Kruglikov, I. L.; Scherer, P. E. Skin Aging as a Mechanical Phenomenon: The Main Weak Links. Nutr. Heal. Aging 2018, 4 (4), 291–307. https://doi.org/10.3233/NHA-170037.
5. Park, Y.-M.; Pereira, R. I.; Erickson, C. B.; Swibas, T. A.; Kang, C.; Van Pelt, R. E. Time since Menopause and Skeletal Muscle Estrogen Receptors, PGC-1α, and AMPK. Menopause 2017, 24 (7), 815–823. https://doi.org/10.1097/GME.0000000000000829.
6. Iqbal, J.; Zaidi, M. Understanding Estrogen Action during Menopause. Endocrinology. August 2009, pp 3443–3445. https://doi.org/10.1210/en.2009-0449.
7. Thornton, M. J. Estrogens and Aging Skin. Dermato-Endocrinology. April 2013, pp 264–270. https://doi.org/10.4161/derm.23872.
8. Ganceviciene, R.; Liakou, A. I.; Theodoridis, A.; Makrantonaki, E.; Zouboulis, C. C. Skin Anti-Aging Strategies. Dermato-Endocrinology. July 2012. https://doi.org/10.4161/derm.22804.
9. Nelson, L. R.; Bulun, S. E. Estrogen Production and Action. J. Am. Acad. Dermatol. 2001, 45 (3), S116–S124. https://doi.org/10.1067/mjd.2001.117432.
10. Nair, P. Dermatosis Associated with Menopause. J. Midlife. Health 2014, 5 (4), 166. https://doi.org/10.4103/0976-7800.145152.
11. Su, H. I.; Freeman, E. W. Hormone Changes Associated with the Menopausal Transition. Minerva Ginecologica. December 2009, pp 483–489.
12. Hunter, P. The Cost of Living Longer. Fertility Trades with Immunity and Life Expectancy. EMBO Rep. 2011, 12 (10), 1000–1002. https://doi.org/10.1038/embor.2011.183.
13. Rzepecki, A. K.; Murase, J. E.; Juran, R.; Fabi, S. G.; McLellan, B. N. Estrogen-Deficient Skin: The Role of Topical Therapy. International Journal of Women’s Dermatology. Elsevier Inc June 1, 2019, pp 85–90. https://doi.org/10.1016/j.ijwd.2019.01.001.
14. Wend, K.; Wend, P.; Krum, S. A. Tissue-Specific Effects of Loss of Estrogen during Menopause and Aging. Frontiers in Endocrinology. 2012. https://doi.org/10.3389/fendo.2012.00019.
15. Poljšak, B.; Dahmane, R. Free Radicals and Extrinsic Skin Aging. Dermatology Research and Practice. 2012. https://doi.org/10.1155/2012/135206.