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Knocked Up Podcast – Dermatologist Dr Alice Rudd

Posted on May 25, 2020


Dr. Alice Rudd is a dermatologist who has her own clinic, Skindepth in Melbourne. Alice has worked for many years in all areas of dermatology and has a special focus on post adolescent acne and the management of PCOS and other endocrine skin conditions. She is also an expert in anti ageing and cosmetic dermatology.

Find Alice at https://skindepth.com.au and @skindepthdermatology

Q: Tell us a little bit about your background and how you got in to Dermatology.

A: Well, like most medical specialists I’ve had a long journey from many years of medical school, six years, in fact, and then several years out in the wide world of a public hospital system doing general medicine. I actually thought I wanted to be a paediatrician initially, and I started to work in the paediatric training programme before deciding that it was far too distressing for me and I was far too sad. So I decided I wanted to look it something that was a little bit more holistic and where I could treat patients throughout their life. Dermatology struck me is the perfect combination of treating people from the day they’re born to the day they die because it’s really there is really no time in your life where you don’t have a skin condition, and I love that continuity that I get with my patients. I see them for eczema when they’re a baby, then their acne in their teenage years, for their skin checks later in life and anything else that comes up in between. It’s something people are so self conscious about and want to be able to trust someone and seeing their confidence change, I think increasingly now, in the era of social media, people are becoming more and more self conscious. For example, when I grew up, there was no such thing as a mobile phone, let alone instagram or Facebook. And now this such pressure to look good and how you feel very much depends on how you look these days.

Q: Having acne after you turn 30. Is that normal? How common is it because a lot of people seem to have it.

A: We used to think acne was a teenage disease and that you had a few pimples. When you’re a teenager, you grew out of them. We now understand that acne is actually a chronic condition. Part of the reason I think we see so commonly in women in their thirties, late twenties is that they’re often on the contraceptive pill that they have been given for the acne in their teenage years. And then they stop it to become pregnant or because they get some side effect or they don’t want to take it anymore. And then this horrendous cystic acne eventuates and I think it’s probably always being there. I just think that we haven’t actually recognised that were seen it because it’s probably been masked by something else.

Q: How does the pill stops you from getting acne?

A: What happens is that we’ve all got hormones particularly androgynous, which kind of male hormones and the most powerful androgens are related to testosterone, and what happens when you’re on the pill is a couple of things, but firstly and there are different types of pills that work in different ways. Some of the pills themselves actually have androgen blockers in them, But a lot of the way the pill actually works apart from the fact that your hormones a pretty steady state on the pill. I mean, you have a little peek when you take the pill in the little kind of low point when the next pill is due. But the average is pretty steady. It’s not ups and downs and take it every day. Also the pill induces enzymes in your liver, which then makes you make more of a protein called sex hormone binding globulin. And that s Hbg. If you’ve ever seen it on a blood test. And sex hormone binding globulin is really important for mopping up testosterone. So the more sex hormone binding global in you have the less free testosterone you have. And it’s the free testosterone in your bloodstream that really stirs up acne. And that’s why you get it when you’re a teenager because your testosterone and oestrogen as a woman but testosterone as well and in boys same testosterone going up can really flare acne. Would you say I was I totally agree with you, but in terms of coming off the pill, obviously can’t stay on the pill and get pregnant. So, you know, I kind of had patients like you who who come and they’ve come off the pill and had had a flare.

Q: How would you advise patients who are trying to conceive? What other things can they do?

A: If they are having a resurgence of acne, it really depends on how quickly they want to conceive. So I do get some women coming to see me who know that they’re going to get acne coming off the pill. And they say, I would like to get pregnant in the next two years. So if there’s a timeline at around two years or 18 months, then we can probably look at substituting it for a different medication. Coming off the pill and giving something like isotretinoin which is less likely to effect the hormones but actually effects the grease glands in the skin so that you’re not reliant on hormones to control your acne. That’s more likely considered to be a longer term fix. But if you haven’t got that time and you want to get pregnant next month, then there’s multitude of things we can do. Topically we’re probably not looking at giving medication at that point unless it was something like a gentle antibiotic. Although I did read on the weekend that there’s some new research into macrolide antibiotics being dangerous in the first parts of pregnancy. So traditionally we would have given something like that, which we probably won’t be but I like to advise just a simple skincare routine because most people who haven’t had acne when they’ve been on the pill actually don’t know what to do with their skin because actually didn’t have pimples. So their whole skin, millieu and their microbiome et cetera, of their skin completely changes. So it’s about educating what the skin needs at this particular point in time and also what it’s what’s required in terms of safety and pregnancy. So if we were to prescribe topical antibiotics or topical treatments, we would try to stick to Category A medications, and we sort of combine that with skin care and possibly some treatments.

Q: What kind of role does diet play in acne?

A: There’s really only two researched and proven factors in diet and acne, and that’s dairy and that probably relates to insulin like growth factor which is a hormonal emphasis and sugar, which we know that she was obviously very pro inflammatory. Everything else whether it’s gluten in or anything else that people try to tell me, is making their acne worse. It could be but it’s most likely to be the dairy and the sugar, and particularly dairy, in things that you don’t even think about such a way. Protein powders, which I often see people are consuming  as part of smoothies, that’s essentially dairy that you’re consuming. People don’t even realise they’re doing it. So part of our consultation is to actually break down exactly what you eating daily you mentioned

Q: As my friends have been having babies, they’ve been giving me their retinol as they can’t use it while they’re getting pregnant or while they’re pregnant.

A: Well, look its controversial, actually. So it depends on which obstetrician you talk to it. I would always tell patients to take the guidance of their obstetrician on this because I’m not the one that should ultimately decide on that. But there’s a great variability in what the obstetricians allow, and some will say it’s fine to use a little bit of topical tretinoin. It’s not really going to be used in enough of a quantity to be absorbed. And there are some who are real purists who say absolutely don’t use it. In my experience most patients don’t want to because they won’t take any risks and most pregnant women don’t. But I guess we don’t 100% know the risk of topical tretinoin. Now oral Vitamin A. That’s isotretinoin. has been linked with Terata genic problems in Children, so that means that Children can be born abnormally with missing limbs or not formed in a proper manner. And really, the studies came from the very from a long time ago in the eighties, and there were some children that were born without limbs or had some transgenic effects, and women were taking isotretinoin. But they’ve never actually been able to prove that that was the cause. And, of course, with any pregnant population, there’s not going to be any clinical trials that are going to prove or disprove it. So I guess we can’t tell the safety of our oral isotretinoin in pregnancy either. Probably a low doses is OK. If you just think about the vitamin A that you might take in a supplement or within your food. We’re all consuming it every day anyway. This is certainly are higher dose, but doses of five milligrams are probably safe but there’s never going to be a dermatologist or any doctor that would tell you to take them pregnant because we just don’t know. We’re unsure at this point, and if you get pregnant when using topical vitamin A, then you don’t have to worry, it’s going to be fine.

Q: When we say topical Vitamin A that covers isotretinoin and retinoids,  retinol over the counter as well as prescription.

A: Yes, so basically, the generic umbrella term is vitamin A, and it comes in multiple different varieties. So tretinoin as you mentioned, is the prescription form of vitamin A. There are other prescription forms, such as adapalene. They’re many, but the over the counter ones won’t be called that they’ll be. You’ve gotta look on the label. There’ll be names like retinaldehyde or retinol or retinal. These are all the precursors to the active version of the Vitamin A in our skin, which is retinoic acid. So when you give an over the counter vitamin A, you actually just giving the precursor to the active form of vitamin A in your skin. When you give a prescription vitamin A you are actually giving the skin the active form to the skin which doesn’t have to break it down, or body hasn’t got to make it into an active form that the skin can actually use. The problem with prescription vitamin A is it often is very irritating and is usually irritating in people who don’t actually have enough vitamin A in their skin. So they get something that’s called a retinoid dermatitis. If you get a bit flaky when you first started like the skin to feel a bit irritated, basically What that is is that the skin is very deficient in vitamin A receptors, so that happens from when we’re two or even younger, and it’s all related to sun exposure. Probably Australians have lower vitamin A receptors and Europeans or people who don’t experience as much sun exposure. What happens is that the receptors are reduced just from chronic UV and sun exposure. So when you introduce vitamin A into the skin, there aren’t enough receptors in the skin to absorb that vitamin A. So you get flaking irritated because all this vitamin A is sticking around in your skin has got nowhere to go because there were no receptors, if that makes sense, so as you use more you build up your receptors and then the vitamin A can actually do its thing and that dermatitis that you get usually settles with continued use.

Q: The warnings over pregnancy and conception and vitamin A. Is that the same for the over the counter? When I when I say over the counter, I mean beauty put, actually buy in a department store.

A: We apply the same rule to all of them because we don’t know yet.

Q: You mentioned sun exposure briefly just then. It’s something Raelia talks often about is the important of protecting yourself from the sun.

A: Well, it’s a balance, isn’t it? Because everyone’s vitamin D deficient as well. Apparently, but you’re talking to the dermatologist so when my patients say I need to get some sun I say yes, but you could take a tablet. I tell my patients just put it next to your toothbrush because if I do the blood test, you’re going to be deficient. Just take it. Yeah, and I guess the story with vitamin D and this is what the Cancer Council of Australia their, statement and policy is that we don’t actually know what the safe level of sun exposure is that you need to get your vitamin days. So, for example, you Jordi,  you would need two minutes of sun to get your dose of vitamin D because you’re so fair while somebody who’s a little bit more of a tan will take much longer to get their vitamin D up. So you can’t just say go out for 10 minutes because that’s not going to work for everybody.

Q: What kind of sunscreen should you use? I think we’re learning a bit more round like zinc or mineral block or chemical block? Is there anything we should be careful with with?

A: Well, we know that some of the chemicals in sunscreens that aren’t a barrier have been shown to have some detrimental effects on sperm in studies. There’s all these chemicals in sunscreen that we’re a little bit not sure if they might have some unwanted effects.

Q: What’s your take on sunscreens during pregnancy?

A: I would always recommend a physical blocking sunscreen for the reason that you’ve just said in that. Well, you do absorb the chemicals in a chemical sunscreen, and that’s how they work. The skin absorbs that chemicals. It absorbs the UV light and the chemicals break up the UV light and re emit it out of your skin. Kind of like a lower frequency if you like, so you’re always going to absorb some of the chemicals. So my policy’s always if you can use a physical blocking sunscreen such as a zinc or titanium. Traditionally, those kind of sunscreens that sort of Shane Warne’s zinc look, but they are making getting much better at formulation. There’s no excuse not to wear a physical blocker.

Q: Is there anything else you should be doing differently when you’re trying to conceive or are pregnant? People complain about pigmentation.

A: Absolutely. Pigmentation is one of the huge things in pregnancy. Isn’t mill asthma? It can be mill asthma, but it could be any type of pigmentation. You know, women often get that little little bit of pigmentation on there beneath their belly button. So called linear negra which probably should be renamed. But these pigmentation of any cause can come up. The melasma is the most common one and the most debilitating one, because once it’s been set off very, very difficult to get back under control. And obviously the most important thing is you’re some protection in that situation.

Q: Another topic that patients asked me about all the time because especially demographic, that I treat also the demographic that I’m in, you know, late thirties, early forties, very addicted to certain things that make us look a little bit younger. What do you do in pregnancy when you want to help somebody but we’ve told them you shouldn’t do botox, shouldn’t do filler. What can you do to maintain in that nine months of pregnancy?

A: It’ a real problem because a lot of people are addicted and they are used to their three monthly treatments. And then they’re sort of in the face of 18 months, potentially of no treatments, pregnancy and breast feeding. I guess I think to say specifically about injectables like you referred to earlier is that botulinum toxin doesn’t actually cross the placenta. So again, like the vitamin A thing, I think is probably safe. But again, we wouldn’t be recommending that we would ordinarily recommend two women in that phase the use of treatments. So lasers and skin peels and facials are all very safe in pregnancy if they performed from the neck up so you wouldn’t be doing laser hair removal on someone’s bellybutton while they’re pregnant but you certainly can do laser on the face, or you can do things like LED light. So most of the time the skin does improve a bit in pregnancies, or even if you do have acne, always tell patients that you’re probably going to see an improvement once you’re in the pregnancy, some people get worse, which is really awful, but more commonly they get better. So actually, their skin does improves and that is a big advantage. We would always recommend skincare and the use of some treatments and particularly LED lights have been shown to be pretty safe.

Q: With Botox and fillers as we know them. Could you maybe talk us through exactly what they are a bit on? What the risks might be?

A: Well, as the name suggests, Botox is a toxin. So Botox is just short for botulinum toxin, and there’s a whole bunch of different companies that make it. Botox is the one that first with a brand that was discovered, actually, by some ophthalmologists who were treating  someone with a twitch and all these women came in and said, Oh, doctor to their ophthalmologist, What have you done to me? So they had no wrinkles around their eyes, and it was actually Jean Carruthers, who’s an American? And they discovered, but botulinum toxin for cosmetic use. And so that was how was first discovered. I have no idea how it works in eyes, but we know that what the toxin does is actually blocks the message from your nerve fibres to your muscle from acting on from the fight. The message from the nerve to the muscle acting and there’s a little molecule called acetylcholine, and basically, what it does is it blocks that little message from your nervous system to your muscle to move your muscle. So when that is blocked, there’s no message getting through to the muscle to move. So this is really useful for muscles that overwork, it doesn’t mean that they completely stop working but it’s really good for those muscles. And overworked muscles are the ones that create lines in the skin, such as your frown line and your crow’s feet. So it works out on a neurological way, and it’s now why we using botulinum toxin in spasticity and bladder disorders.  People have this whole new quality of life. I know I could grind for Australia and New Zealand I had so much pain in my face and someone injected my masseters,  you know, the clenching muscles and it was truly life changing. So again, it’s just like that neurological sort of chemical pathway that gets blocked. So I guess that’s the mechanism. The risks are really very few. It’s actually really, really safe. There’s really very few risks when you’re injecting in the face for cosmetic reasons. The main things are a little bruising, a little pain, and you’ve had it for the first time we often get a really bad headache because it doesn’t matter where you’re injecting there is  tension in the face, and it releases that tension much like it helps migraines, which often are related to tension. So in terms of risk there are probably very few, except that when we do do it in the face, you have to have someone who knows their anatomy because sometimes you can end up with a dropped eyebrow or an asymmetry on one side if one side is more treated than the other. So, really, those things are very flexible, and it’s very, very safe because it’s relatively new that we don’t know the long term effects. And that’s why, with pregnancy we take precaution. I totally agree with what Alice said. I can’t see how giving a little bit of local botox is going to do anything bad to a baby. It’s not going to travel in your bloodstream. It’s not going to to be an overdose that can do anything terrible. But what botox actually is technically, is a toxin from a bacteria. And that’s why when you make jam, you have to sterilise the jars because otherwise, you can grow this bacteria that makes Botox. That’s where the word botulism comes from. You can get a locked jaw, It’s like tetanus, but you can get from from having this botulinum toxin. You can get kind of like paralysed and you can stop breathing and you can die. So in terms of injecting a toxin into a pregnant woman, it’s just like a bit of a no no, We’re so careful these days with introducing anything in pregnancy, and you’d never on a clinical trial to see if it was safe. Like let’s take this group of pregnant women, inject them with the toxin and see what happens. Like that’s not going to get through an ethics committee. So that’s why we don’t do it. That comes back from thalidomide. You know, they’ve been drugs that have been introduced without due to caution, and they’ve caused birth defects and s. So there’s really strict criteria before introducing any drugs to pregnant women. Just to make sure that it’s safe, you have to be 99.99999% sure that nothing bad will happen. And also the treatment has to tick the box of being necessary. And you know Botox doesn’t tick that box because the reason to give it is cosmetic, which is important and meaningful. But you don’t die from not having Botox while you’re pregnant. So you know, you just wouldn’t get the ethics committee up to run that trial We’ve got a very strict policy about asking a patient every single time that they’re ever injected about whether they’re pregnant or breastfeeding. I don’t know what your thoughts are about breastfeeding. But we have a policy where we don’t inject people who are breastfeeding either. But again, for the same reasons. You know, no one’s going to test that population either. Sorry, it’s a little different. Not it’s not different, but, you know, the other injectable that we use is dermal fillers, and that isn’t a toxin. So that’s just hyaluronic acid. So basically, it’s a natural moisturisers so it’s very interesting, which in a topical application is a complete waste of time and money because hyaluronic acid, even though it occurs naturally in our skin. It’s a very big molecule, so if you put it onto the skin, it doesn’t actually get into your skin. So it feels great because it glides on. But it doesn’t do anything for your skin in the long term, might make it feel temporary for the day. Temporarily great, really, really hydrated. And, you know, the so many people who’ve tried different smaller molecules and but the molecule itself cannot penetrate the skin. So that’s why we inject it in the form of dermal fillers, which just contain pure hyaluronic acid. Now that’s just a sugar that is a synthetic sugar that gets injected into the skin where it needs to be. So, that’s not a toxin, but equally, we wouldn’t inject dermal fillers into pregnant women. Yeah, you know what we actually use hyaluronic acid in IVF, we use it a way that is called embryo glue. It’s like we use a little bit of hyaluronic acid around the embryo in the petri dish and it basically increases the likelihood that when we place an embryo under ultrasound guidance, it will stay where we put it. So that like the best, the ultimate place to place an embryo in the top third of the endometrial cavity in the lining of the uterus. So when we place it there under ultrasound, you know it may move and you can get ectopic pregnancies from doing a beautiful embryo transfer in the right place because the naughty little embryos snuck up the tube. The embryo glue. It’s not actually a glue. It’s a good name but it just encourages thie embryo to stay in that area where it can implant and be safe.

Q: We sort of talked about melasma and pigmentation. But I wanted to ask you about scarring, often when someone’s trying to conceive. If they’re seeking fertility treatment at some stage, they might need to have keyhole surgery or some sort of procedure. Do you have any advice on scarring.

A: The most common type of scarring I see would be from post caesarean section. I don’t know about laparoscopic procedures in pregnancy, but certainly I see a lot of women who’ve had a Caesarean section, and they get variable scars. So if you have a tendency to keloid scarring or hypertrophic scarring, for example, it’s going so that’s an abnormal scar response.

Q: What is keloid scarring?

A: So most people who get an injury their skin will heal and it will heal, like with a nice, flat white scar. There are some people, and we think it’s probably genetically programmed who will heal with a lumpy scar or raised scar that’s often quite itchy and often very unsightly. So women who are prone to that kind of scarring and they would know that because they would have had a procedure before that had done that, or acne can lead to that kind of scarring without actual procedure, they would usually know that. And so there are things you can do at the time off the surgery or immediately after the surgery toe lesson that scarring. And that would be things like injecting corticosteroid into the scar to stop it from actually producing itself. Then, if it’s different type of scarring, where it’s flat scarring and its unsightly scarring, we would laser those type of scars. So if they’re red, which they often are for up to 12 to 18 months after the surgery, we would use a readiness laser or a Vascular laser, as we call it, and then often reduces down the readiness. And sometimes it’s the redness that’s so visible. That’s the problem. And most people see redness as the problem and you know traditionally that’s from the fight or flight response we see red is danger. And so it was very noticeable when there’s red, so removing the red often makes people much happier. But then there are other kinds of treatment that we can do, they are a little bit more invasive that can break up scare tissue that should improve the appearance, but in terms of prevention, there’s not a lot. There’s there’s studies that have been done with topical silicone, such a strata derm and Bio Oil but the results really aren’t that impressive, and probably not that necessarily reproduced about the skin in the first place. It’s all genetic, I think.

Q: What about stretch marks? Is there anything that women can do to prevent stretch marks?

A: Absolutely nothing. And that’s another thing that I get sold all the time with these companies with new creams. it’s just a stretching of your elastin and your collagen, and there’s absolutely nothing you can do to stop them, and they do improve with time, post pregnancy, but you can’t do anything to prevent them. Not that I’m aware of unless you know anything?

Q: We talk a lot about polycystic ovarian syndrome, we’ve certainly covered it on the podcast in many episode and Raelia has it on her blog and it’s a big part of her practise, its very common and what comes up often in the conversation is what it could do to skin.

A: If got PCOS, it’s a bit of a misnomer, in a way, because technically, you don’t have to have polycystic ovaries to have polycystic ovarian syndrome, however most people do, and it’s a whole group and a spectrum of women who have irregular periods, often a big, powerful, ovary with lots of eggs. And that’s all the cysts are, they’re not actually a bad cysts. People ask, well, can we get rid of the cysts and I say no, the cysts are your eggs and you don’t want to get rid of the cysts. Its pretty much a hormonal imbalance so that they don’t have a regular period, and they don’t necessarily know when they’re releasing an egg. Many women with polycystic ovarian syndrome still do release an egg and still do ovulating, but they might. instead of ovulating every 28 days in the middle of their cycle. They might ovulate every 50 days or every 70 days or one month every 30 days, and then the next month after, you know, 55 days. And it’s really hard, given the fact that, and looking back past at episodes, we’ve done a few on the old fashioned way, which is what to do to get pregnant when you’re trying. naturally, if you’re not releasing an egg, you are out of the game. So if you’re not having any periods at all and you’re not ovulating, there’s no way you’re going to get pregnant. If you’re releasing an egg irregularly, you have no way of knowing when the right time is to have sex so that there’s sperm waiting for that egg. And so it’s frustrating. And while many women with policies to go ovarian syndrome have conceived naturally, that’s one of the barriers that they don’t know when to try and that the eggs are not released nearly as regularly, is you or I might have, because most women will have 12 ovulations in a year and 12 opportunities to conceive. And someone who doesn’t release an egg every month isn’t going to have those same number of opportunities. So it’s a syndrome that has a big spectrum of effects in some women. It’s very dominated by the ovary, so that that’s the main problem, that they’ve got this very big over. It’s just a little bit too enthusiastic. The hormone said It produces are a little bit out of balance, and that’s the main issue. Other women might have a less polycystic ovary, but they might have a lot of insulin resistance, and that might be because they’re carrying extra weight. Or it might be because they’ve got diabetes in the family. And we can’t choose our genes. So there’s a real cross over in terms of how important lifestyle is and how it will be beneficial by making lifestyle changes to really reduce your symptoms. One of the things that can happen with polycystic ovaries is high androgen levels, which is the hormone that we spoke about earlier that can have unwanted effects so it can cause acne, but it can also cause excessive hair growth on the skin, often on the face, on the tummy, on the breasts, places that women don’t want to be hairy and also it can cause hair loss on the scalp. So it’s pretty much a trifecta of symptoms that no woman wants.

We do also also see a lot of patients who are not actively trying to conceive, because that stage of your life is quite often a short stage in relationship to the rest of your life. So I often do treat women with things like that are a contraceptive pill. But then, you know, I would refer to someone like Alice to have a more holistic kind of intervention on those fronts of excess hair growth, skin control that’s not achieved by hormonal methods and hair loss of the scalp such an important area for women. Alice, do you want to talk about what you do, and I think thank you.

It a really interesting one PCOS. They are the most recalcitrant patients, so they’re often the patients that you can’t get better consistently. You know, I really like to get patients better, and you know, you really like to get patients pregnant. I really like to cure their acne if I possibly can. But it’s one population of my patients that we find really difficult and I tell them that from the outset.  I say you’ve got these this genetic predisposition, and that you produce these hormones and I can’t really change that. But we can try to help what they’re manifesting as in the skin and they are usually the people that require repeated treatments and courses of treatment. So, like you said, we sort of just attack it from what bothers them the most and you’re right it the hair really bothers women, particularly having facial hair, and we’re pretty lucky these days with lasers now, we didn’t really used to have them, so women had to wax and shave and you know that’s quite brutal to your skin and time consuming, lasers are fantastic, except that in this population, we always say that unlike someone who doesn’t have an underlying hormonal issue, you might do a course of laser, and then maybe you need a little top up every couple of years. These patients need them consistently. You need a laser treatment, probably every couple of months or every six weeks in some women. So it’s something that they need to look at in the long term. And as long as they’re aware of that, then often that’s very manageable and laser is pretty cheap these days, particularly laser hair removal so that our sort of first go to. There are other ways of removing hair but if laser is if they were a suitable candidate for laser, they’ve got the right colour hair in the right skin tone that I would always just that as a first line. If they don’t, then there are other options we discuss. There are other ways of reducing the hair that isn’t just laser and Raelia’s alluded to that, the contraceptive pill, which blocks the effects of the hormone that can often reduce the hair growth. But if they can’t take the contraceptive pill for some reason or they’re still getting hairy despite the contraceptive pill, then we would add in further androgen blocking drugs. And so there’s medications like spironolactone, androcur and flutamide. Multiple different medications that we can use that will reduce growth of hair on the face and the body and the beauty of these drugs, and I still don’t understand on a hormonal basis how it works is that they will reduce hair on the face and body yet they will thicken hair on the scalp. And as Raelia alluded to women with polycystic ovarian syndrome often get hair thinning, and we know that as androgenetic alopecia, so they usually get it not just because of their PCOS, but also because it’s a family history. But they get very debilitated by hair thinning, and by that I mean your scalp becomes more visible. Your part widens, you put your hair in a pony tail and it feels really thin, and women really find that distressing because for females, hair is such a part of their identity and their personality, and men are a bit more accustomed to it. They just know they’re going to have to shave their head, and it’s sort of a bit more acceptable. For women it’s really tough, so these anti androgen medications do tend to block the effect of the thinning on the scalp, and then they tend to reduce the hair on the body, and it sort of seems like the two opposite things but it seems to work extremely well. Similarly, these medications also work for acne. So if they’re not wanting to conceive, then these anti androgen medications are usually a very good option. The reason you can’t use them when you are trying to conceive is, especially if you’re carrying a boy baby, you don’t want to block those androgens or a boy baby will be born looking like a girl baby, and it’s not very good, life’s tough enough. I love those kinds of medication in hair issues, as we mentioned before and a lot of most of my PCOS patients require something like oral isotretinoin which gives them a better chance off curing their acne again. Often they need multiple courses of isotretinoin in a lifetime, perhaps more than your average person who doesn’t have an online hormonal issue but that seems to be the best thing, and they often do use that in combination with an anti androgen blocking medication for the hair as well.

Q: What’s the washout, period? So let’s just say you’re on oral isotretinoin. When what’s wash out period before you can try and have a baby?

A: One month. It’s so short. I get patients coming saying its ‘no its six months’. I say ‘Is it?’ ‘I read that!’ It’s not six months. It’s actually out of your system, probably within seven days, but we like to give a bit of a buffer and the product information’s is one month.

Q: I’m obviously not a doctor, but when I think of it – as Roaccutane and is apparently a whole other side effects to that that aren’t great in general.

A: I spend half my day  unpicking the bad side effects of people read up online because that’s the first place they go to, and before we had online no one asked those questions. So you know, people read a lot about fertility. Yeah, No, you’re right. And it’s got a bad rap for medication has an incredibly bad rap, but it is the most incredible life changing medication, and I say this every single day of my patients and they come back and they said to me, what was I worried about? I was worried about all these things I read online. None of them happened, and I’m now dating. I’ve now got a better job and I feel so confident in myself because my skin is so much better. And that makes my day when I hear that. But the bad rap came from probably the early eighties, when we first had isotretinoin and we used very high doses, extremely high doses. So, for example, in today’s day would probably use a 10 milligrams dosing each day. In the eighties, we probably dosed 80 milligrams, sometimes more and in fact, in the US and the UK that’s still what they do. And of course, everybody got side effects and then we gave it to teenagers. You know, people decided that isotretinoin changed your mood because all these teenagers got moody and such a difficult population to make that assessment. How do you adjust for the bias of a moody teenager when you’re giving a medication to a really moody population. So there was a lot of bad press around at that time. And, of course, when you’re darling, teenager is on a medication and gets moody or does something, nor do you want to blame on the medication not the teenager. So there’s been multiple multiple multiple studies done, and no one has ever been able to prove the link between isotretinoin and mood change. So if I just say that to my patients and no one’s been able to prove it, if you notice that something changes, then let me know. And often people do notice a change and we have a conversation, and then they stop it and things don’t get better. And they realised it was something else in their life that was actually causing the mood change. I have to have to say that it’s very rare that I would stop it for a mood change. The other side effects, the traditional side effects of dry skin and dry lips, are just absolutely expected. I mean, the medication works by acting on our sebaceous glands, which are the glands in our skin that produce moisture and oil. And we want to dry it up because we don’t want you to have oily skin so that you get pimples. So, of course, if we’re drying up the oil, which is one of the moisturising factors in our skin, our skin is going to get dry and everybody gets dry lips. Absolutely everybody. If you’re not getting dry lips you’re not taking the medication. You know, if you’re a bit prone to eczema, you might get a little bit of dryness on the skin elsewhere. It makes a little more sensitive in the sunlight, but then so does antibiotics such as doxycycline. There’s so many things that make us sensitive to the sunlight and we all should be keeping up with this on anyway. So you know, those are very expected side effects, and then, you know, people talk about how it’s going to effect my liver, and it doesn’t effect that. Leave it really, unless you consume huge amounts of alcohol or you’re taking another medication that infects the liver. Then maybe there’s maybe some competing a believer to break down these medications. But that’s a very rare side effect. But don’t think I’ve ever really seen it. So I think a lot of the bad rap comes from the olden days when we used to give people in high doses. And now we just get people very low doses now and they manage it very well.

 


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