Katrina Canlas-Estrella, MD, FPDS

Diet is frequently associated in various skin disorders. One way in which diet affects skin disorders is the concept of food allergy. Food allergy is defined by the US National Institute of Allergy and Infectious Diseases as: “an adverse health effect arising from an immune response that occurs reproducibly on exposure to a given food”. Simply put, this occurs when there is a breakdown of the body’s tolerance to food ingested^1,2. Typical manifestations of a food allergy are skin reactions such as hives and itchiness, respiratory tract symptoms such as difficulty of breathing, and gastrointestinal tract symptoms such as vomiting and diarrhea. A severe and potentially fatal reaction called anaphylaxis, can also be experienced. While many advances have been made in understanding the mechanism, treatment and prevention of food allergy, the mainstay of treatment remains to be avoidance of the food allergen/s^1-5.

Allergenic foods comprising more than 85% of food allergy are egg, milk, peanut, tree nuts (walnut, cashew, pistachio), fish, shellfish, sesame seed, soy, and wheat. Several studies identify egg allergy as the most prevalent^4,5. In adults, allergies to certain fruits and vegetables are common³. Usually, many people outgrow their food allergies over time, such as hen egg and cow milk allergies. In contrast, peanut and tree nut allergies, along with shellfish allergy, are known to persist throughout life^1-3. In addition, nickel is also a very common allergen and this could be found in certain foods such as oatmeal, beans, peas, soybeans, shellfish, and chocolate^2,4,6.

A hypoallergenic diet is a diet composed of foods low in allergenicity. Specifically, it is free from soy, nuts, egg, dairy, corn, beef, gluten, shellfish, and citrus fruits. That said, patients on a strict hypoallergenic diet should be carefully monitored and properly managed so as to avoid nutritional deficiencies. In children, food allergies to milk, egg, soy, and wheat tend to disappear during late childhood and these specific foods may eventually be tolerated after 1 to 2 years. As mentioned, allergies to peanut, tree nuts, and shellfish typically persist and may be lifelong^1-4.

There are certain skin diseases that can benefit from a hypoallergenic diet. Several studies have shown that certain food allergens can lead to an exacerbation of a patient’s dermatitis. Specifically, food allergy has been shown to be present in 20 to 80 percent of patients with atopic dermatitis (AD). Thus, a hypoallergenic diet may be helpful in patients with AD. Other skin diseases that may benefit from a hypoallergenic diet are systemic contact dermatitis (SCD) and allergic contact dermatitis (ACD). Furthermore, acute vesicular hand dermatitis may benefit from a diet low in nickel-rich foods^2,4,6. 

In order to find out if one has a food allergy and identify the specific food/s one is allergic to, one may consult with an allergologist. A detailed history and thorough physical examination are important, then skin prick testing (SPT) or radioallergosorbent test (RAST) can be done to identify potential food allergens. Once potential allergens have been identified, one must always be vigilant in checking food labels and ingredients in order to prevent the unfortunate manifestations of food allergy. In the event of an allergic reaction, rescue medication should always be available^1-6.

References:

1. Renz, Harald, et al. “Food Allergy.” Nature Reviews, vol. 4, no. 17098, 4 Jan. 2018, pp. 1–20., doi:doi:10.1038/nrdp.2017.98. 
2. Katta, Rajani, and Megan Schlichte. “Diet and Dermatitis: Food Triggers.” The Journal of Clinical and Aesthetic Dermatology, vol. 7, no. 3, 2014, pp. 30–36. 
3. Chapman, Jean, et al., editors. “Food Allergy: A Practice Parameter.” Annals of Allergy, Asthma & Immunology, vol. 96, Mar. 2006, pp. 1–68. 
4. Dhar, Sandipan, and Sahana Srinivas. “Food Allergy in Atopic Dermatitis.” Indian J Dermatol, vol. 61, 2016, pp. 645–648. 
5. Waserman, Susan, and Wade Watson. “Food Allergy.” Allergy, Asthma & Clinical Immunology, vol. 7, no. Suppl 1, 2011, pp. 1–7. 

Kaimal, Sowmya, and Devinder Thappa. “Diet in Dermatology: Revisited.” Indian J Dermatol Venereol Leprol, vol. 76, no. 2, 2010, pp. 103–116.

by: Maria Elinor Grace Q. Sison, MD, FPDS

What is keratosis pilaris?

Keratosis pilaris or “chicken skin” is a common condition due to plugging of the follicles of our skin. It is common in children and can improve by late adolescence but is often persistent. It is strongly associated with several skin conditions such as ichthyosis vulgaris and atopic dermatitis. The cause of keratosis pilaris is not well understood.

How does keratosis pilaris present?

Keratosis pilaris presents with small bumps with varying degrees of redness. It affects lateral cheeks, extensor aspects of the upper arms, thighs, and buttocks. In children the face and arms are mainly involved while in adults the lesions are found in extensor arms and legs.

How is keratosis pilaris diagnosed?

Diagnosis is made through physical examination by the dermatologist based on the appearance of the lesions and their distribution.

What are the treatment options for keratosis pilaris?

• Avoid drying or irritating skincare products
• Use bland moisturizers as often as needed
• Keratolytics such as urea, lactic acid, or salicylic acid may soften and smoothen the bumps
• Retinoids and short courses of low potency topical steroids can be given
• Laser procedures can be done to improve the redness or hyperpigmentation associated with keratosis pilaris
• Treatments may minimize the symptoms but these do not eradicate keratosis pilaris

Reference:Bruckner, AL. Keratosis Pilaris and Other Follicular Keratotic Disorders. In: Fitzpatrick’s Dermatology. 9^th Ed. USA: McGraw-Hill.

By Dr. Coreen Copuyoc-Sampedro

Does wearing make-up ruin your skin? Back in the day, dermatologists were known to be against make-up or any form of cosmetic camouflage since many products then—think 80’s to early nineties —would cause a slew of unwanted effects such as acne, contact dermatitis, and hyperpigmentation. Instead, we would promote healthy natural looking skin sans any cosmetic product. However, the beauty and skincare market has grown exponentially and this preconception no longer applies. This not only means that the variety and number of products increased, but that many formulations have also gotten more sophisticated and safe. Going all-natural with just sunscreen on your face is definitely still a good way to go, but wearing make-up can actually work well with your skin if you know how to choose the right ones for your skin type. Aside from that, cosmetics actually help a lot of people as a confidence booster and as part of self-care. In fact, I am one such dermatologist that loves make-up almost (almost!) as much as skin care.

So how do you choose the right cosmetics for you? This is best figured out on a case to case basis but basically depends, first and foremost, on your skin type and the environment you’re in. If you have normal skin, almost any product may work well on you so just use the weather as your guide. Wearing oilier formulations may not work as well in a hot & humid environment such as in Manila for example, but these may be best for cold, breezy weather such as in Baguio. For those with oily skin, lightly formulated water-based foundations and medium-coverage powders may work best, provided that the skin is still hydrated. And for those with dry skin, oil-based formulas work best to camouflage anything but again, diligent hydration everyday is really the best way to ensure that make-up applies nicely. Combination skin is quite tricky because you will need to mix and match the products you use per area on your face. Creams or oil-based products applied on dry parts while lighter, more water-based products on the oily parts. Then lastly, the most difficult skin type to choose products for, is sensitive skin. The primary concern for sensitive skin would be avoidance of irritating or allergenic ingredients in make-up such as fragrances and parabens, while also choosing formulations that work well with your base skin type between oily, dry, or combination skin. I personally have sensitive, combination skin and have discovered that I like mousse or cream-gel formulations best, with light finishing powder on areas that are a bit oily.

At the end of the day, all of these are simply general guidelines and choosing your cosmetics will still depend on which ones are accessible to you and work well with your lifestyle and environment. Keep in mind though that the best foundation for make-up is still healthy, luminous skin. So I recommend allocating more time and budget for skin care and always remember to remove your make-up right when you get home. So, does wearing make-up ruin your skin? Well, the correct ones shouldn’t, and that’s the tea.

Jarische Frances S. Lao-Ang, MD, FPDS

Skincare is for everyone, but is it different between men and women? We’re all familiar with the saying “skincare is for all ages”, but how about skincare for all gender? 

To find out, let’s first know the structural differences between male and female skin.

1. Oil/sebum production
   • Men have greater oil production. Androgen, known as the “male hormones”, increases the size of oil glands & stimulates oil secretion. 
   • Due to increased oil, the male skin is more prone to impaired barrier function. Excess sebum is also associated with appearance of larger pores. 
   • This also makes men less fond of applying skincare products due to the sticky feeling on the face as compared to women. 

2. Sweat production
   • Men perspire more and have greater sweat production
   • The sweat glands found in the axilla and genital areas are subjected to hormonal influences and become active just before puberty. 
   • Though sweat is odourless, the bacteria microflora in the skin is responsible for odor production
   • In men, the increase in sweat production makes them prone to harbour bacteria. So, they develop body odor more as compared to women

3. Skin thickness
   • Men have thicker skin in general, but a gradual decrease in thickness can be observed starting at 40 years old. 
   • Due to hormonal changes from menopause, women have less hydroxyl-proline content that causes decrease in collagen. With collagen breakdown, the skin becomes thinner in women. 
   • Given men’s thicker skin, a higher strength and a more potent formulation of skincare products may be needed for better penetration

4. Hair growth

• Hair growth on face & axilla (but no on eyebrows and eyelashes) is affected by male hormones. Hence, men have thicker and more hair on these areas. 
• Facial hair removal differs tremendously. Men perform facial hair shaving more often than women. This regular mechanical exfoliation can make their skin prone to skin trauma or irritation. 
• Hence, men must have proper pre- and post-shaving care. 

5. Skin tone
   • Skin tone is influenced mainly by melanin (main pigment responsible for skin color). Though melanocytes (melanin-producing cells) do not differ among gender, the melanin produced is suggested to be higher in men. 
   • Aside from melanin, skin color is also affected by haemoglobin (blood pigment). Based on studies, men have more haemoglobin. Both these factors contribute to men’s darker skin tone 
   • These structural variations also explain why men retain pigmentation after sun exposure longer than women

Now that we know the structural differences between men & women, must there be a difference when it comes to skincare?

• In terms of routine
  • Men and women have the same basic skincare must haves– cleanser, moisturizer and sun protection
• In terms of formulation
  • Lightweight formulation gel-based or foam-based products can be more suited for men given their oilier skin type. 
  • As for female, the type of formulation depends on their skin type (oily vs dry vs combination skin).
  • This applies to choice of cleanser, moisturizer & sunscreen
  • Some but not all men tends to be reluctant to apply skincare due to the sticky feeling, hence, formulation matters.
• In terms of actives
  • The need for actives depend on the skincare concern
  • Acne is a common enemy for both gender due to hormonal influences especially when puberty starts. So, starting on retinoids early can be helpful in controlling and managing zits

Unique skincare need for men: Facial hair

• Shaving facial hair (reference: AAD)
  • Shave regularly to avoid irritation and bacterial growth 
  • Apply shaving cream, oil or gel before shaving 
  • Clean razors right after use
  • Change razor blade every 5-7 shaves
  • Apply moisturizer after shaving 
• Washing facial hair
  • For short facial hair- may stick to facial cleanser 
  • For long and thick beard – use shampoo to wash

by Michelle-Adeline Noche-Apacible M.D, FPDS

What You Need to Know about Moisturizing

by Michelle-Adeline Noche-Apacible M.D, FPDS

Why is it important to moisturize? 

“I don’t need to moisturize because I only have oily skin.” This is just one of the many myths surrounding moisturizing. The most important truth you need to know about moisturizing is simple- it’s extremely important for the skin’s integrity and appearance. Moisturizers come in different types and contain various components but they mainly improve skin hydration and enhance skin barrier repair. They target the stratum corneum, the outermost layer in the epidermis, necessary for retaining hydration. Its structure is the most important contributor in the overall moisturizing level. 

These involve four key processes namely corneocyte, stratum corneum lipid, natural moisturizing factor (NMF), and desquamation. All these processes aim to lead to the formation of an efficient moisture barrier. First, Corneocytes serve as the stratum corneum’s physical barrier by regulating water flux and retention. Next, stratum corneum lipids block external compound invasion and provide a barrier to water movement. Then, the natural moisturizing factor maintains the corneocytes’ hydration. Lastly, in desquamation, stratum corneum with a lack of moisture functions much less efficiently. This is why moisturizers step in to make sure that all these four processes are fulfilled. 

When these processes are successfully carried out, the level of stratum corneum hydration significantly increases. Moisturizers do this by directly providing water to the skin and increasing occlusion to mitigate trans-epidermal water loss. Your skin’s appearance is positively affected because it smoothens the skin’s surface. 

How do you choose the right moisturizer? 

Choosing the right kind of moisturizer is not an easy task. It’s very easy to be overwhelmed with the sea of moisturizers being sold. Here are a few tips to find your skin’s match. 

First, consider the factors that make a reliable moisturizer. These are particularly the natural moisturizing factor, ceramides and aquaporins (AQPs). Ceramides, a class of lipids, are essential building blocks of epidermal barrier structure. They also contribute to epidermal self-renewal and immune regulation. Aquaporins which come in many types contribute to water transport to the epidermis and hydration. For example, moisturizers with APQ3 spread both water and glycerol around the epidermis. It has also been proven to improve lipids’ metabolism which greatly contributes to the skin’s moisture. 

Second, consider what your skin needs. Maybe if your skin is sensitive, you should avoid occlusives which can cause irritation. If your skin is dry, you should try a moisturizer with both an occlusive and humectant. This is because your skin may not have the protein-binding capacity to trap and retain moisture. Watch out for moisturizers with alcohols or fragrances as this may make your skin’s condition worse. 

Lastly, consult with a board-certified dermatologist. Only a board-certified dermatologist will be able to recommend the most suitable moisturizer for your skin. They also have the necessary expertise in the different types of moisturizers and their respective mechanisms of action. 

What are the kinds of moisturizers? 

These usually come in three main kinds- emollients, occlusives, and humectants. Each has their own unique function that benefits your skin. Emollients, commonly used in topical pharmaceuticals, seal water into the skin. These provide a stronger skin barrier and appearance. Humectants on the other hand increase water absorption from the dermis into the epidermis where evaporation is easily possible. Occlusives have the most important effect when applied to wet skin since they prevent water from escaping the skin. These come in mineral oils, petroleum jelly and much more. 

All of us have different skin types. Some people’s skin has a stronger ability to maintain moisture while others lack it. It is necessary for your skin’s health no matter the type. Moisturizers do this for you. Don’t let them sit in your vanity cabinets. Know what they do and integrate it into your skin care routine today. 

Sources: 

Visscher, M. O. (2003). Effect of soaking and natural moisturizing factor on stratum corneum water-handling properties. PubMed. https://pubmed.ncbi.nlm.nih.gov/12858228/

Coderch, L. (2003). Ceramides and skin function. PubMed. https://pubmed.ncbi.nlm.nih.gov/12553851/

Purnamawati, S., Indrastuti, N., Danarti, R., & Saefudin, T. (2017). The Role of Moisturizers in Addressing Various Kinds of Dermatitis: A Review. Clinical Medicine & Research, 15(3-4), 75–87. https://doi.org/10.3121/cmr.2017.1363 

Draelos, Z. D. (2013, June 19). Modern moisturizer myths, misconceptions, and truths. PubMed. https://pubmed.ncbi.nlm.nih.gov/23837155/

Li, Q. (2019, December 5). The role of ceramides in skin homeostasis and inflammatory skin diseases. PubMed. https://pubmed.ncbi.nlm.nih.gov/31866207/

Boury-Jamot, M. (2009). Skin aquaporins: function in hydration, wound healing, and skin epidermis homeostasis. PubMed. https://pubmed.ncbi.nlm.nih.gov/19096779/

Smeden, J. (2016). Stratum Corneum Lipids: Their Role for the Skin Barrier Function in Healthy Subjects and Atopic Dermatitis Patients. PubMed. https://pubmed.ncbi.nlm.nih.gov/26844894/

Rawlings, A. V. (2004). Moisturization and skin barrier function. PubMed. https://pubmed.ncbi.nlm.nih.gov/14728698/

Jarische Frances S. Lao-Ang

What is a dermatologist?

A dermatologist is a medical doctor who specializes in managing skin, hair and nail conditions. 

Dermatologists undergo several years of training to be able to help people. They take care of both adults and children. They manage not only eczemas and skin infections, but also cosmetic concerns. 

What training does a dermatologist undergo?

• 4 years of medical school
• 1 year of medical internship
• 3 years of residency training
• Fellowship (for subspecialty training) 

What is a board-certified dermatologist?

After accomplishing the residency training, dermatologists take the diplomate board exam under the Philippine Dermatological Society (PDS). Once they pass the exam, they are board-certified dermatologists and are considered diplomate of PDS. They can now practice and hold clinics. 

A person will be able to know if a practitioner is a board-certified dermatologist of PDS by looking at the attached DPDS or FPDS after their name. Aside from checking the names, one may verify by checking at the PDS website. 

Subspecialty under dermatology

• Dermatopathology

A dermatopathologist has one more year of training in pathology in which he or she is trained to identify biopsied skin samples under a microscope and make differential diagnosis of the skin concern involving the biopsied area. 

• Immunodermatology 

An immunodermatogist is an expert in diagnosis and treatment of skin disorders characterized by defective responses of the body’s immune system. The most common immunologic skin condition are bullous diseases. They are also experts in evaluating immunofluoresnce readings for the correct diagnosis and treatment. 

• Photodermatology

A photodermatologist has further training in UV-induced skin conditions and phototherapy (the use of UV light in managing skin conditions such as psoriasis, atopic dermatitis). 

• Dermatologic surgery

A dermatologic surgeon has expertise in doing surgical medical and cosmetic procedures. 

Mohs surgery is a further subspecialty in dermatologic surgery where the expert performs surgery to manage skin cancer. It is a method wherein thin layers of skin are removed sequentially after examining in the microscope until the area is cancer-free. It aims to lessen the removal of normal healthy skin. 

• Laser 

A laser specialist is an expert in using energy-based devices for managing skin conditions. They evaluate people and determine the recommended laser and wavelength to manage the particular skin concern. 

• Pediatric dermatology

A pediatric dermatologist is an expert in managing infants and children. Some conditions are encountered more in children such as a unique birthmark, vascular anomalies or neurocutaneous disease among others. 

• Contact dermatitis and Environmental dermatology

An environmental dermatologist specializes in the external triggers for skin irritation and allergy. They are experts in occupational and recreational related skin conditions and are also trained in performing clinic-based patch testing. 

• Leprosy 

A leprosy subspecialty is an expert in handling and managing this mycobacterial infection. 

• Sexually transmitted infection (STI) dermatology

STI experts are keen in diagnosing and managing sexually-transmitted condition. They handle cases such as syphilis, herpes, and HIV. 

Why choose a board-certified dermatologist?

A board-certified dermatologist is a well-trained medical professional who gives evidence-based management to any skin, hair or nail concerns. It is best to seek consult with them for any skin concern for timely and proper treatment. 

Dr. Carla Perlas, FPDS

What is Psoriasis?

A disease that is characterized by inflammation caused by dysfunction of the immune system also called immune-mediated disease which causes inflammation in the body. A raised plaques and scales on the skin are mostly the visible signs of the inflammation.

The World Health Organization (2014) classified psoriasis as a chronic non-communicable disease, emphasizing the distress caused by misdiagnosis, inadequate treatment, and stigmatization of this disease.

What causes Psoriasis?

Although the exact cause of psoriasis is unknown, several factors such as genetics, environmental triggers, and your immune system can all play a role. As a result, psoriasis is not contagious and cannot spread from person to person.

Because of the overactive immune system that speeds up skin cell growth, the immune system and inflammation play a role in psoriasis. Normal skin cells grow and shed in a month, but in psoriasis, skin cells grow and shed in only (3) three or (4) four days, and instead of shedding, the skin cells pile up on the skin’s surface whereas, the genetics of psoriasis are complex, and it is possible to develop psoriasis even if you have no family history of the disease, as well as a triggering event may cause a change in the immune system, resulting in the onset of psoriasis symptoms, this may vary from person to person, and what may worsen your psoriasis may have no impact on someone else.

Common psoriasis triggers include;

• Stress
• Skin Injuries
• Illness
• Weather 
• Infections (e.g. strep throat, skin infection)
• Some medications/drug reactions including lithium, prednisone and hydroxychloroquine
• Smoking
• Alcohol (heavy drinking)
• Changes in hormone
• Weight

A great way to learn about your unique set of triggers is to track them over time. Keeping records of your symptoms and triggers can help you anticipate and treat your flares. 

Locations and Types of Psoriasis

Psoriasis can appear anywhere on the body even on the scalp,face ,skin folds, hands, feet and nails. Plaques can be a few small patches or can affect large areas and it’s also possible to have psoriasis plaques and scales in more than one location on the body at a time.

There are five types of Psoriasis

• Guttate Psoriasis affects approximately 8% of people with psoriasis. This type usually begins in childhood or early adolescence, but it can begin at any age. It manifests as small, round spots called papules, which are caused by skin inflammation and commonly appear on the arms, legs, and torso. It may, however, develop papules on your face, ears, and scalp. Guttate psoriasis often appears suddenly and may be triggered by an infection such as strep throat, a streptococcal bacterial infection.
• Pustular Psoriasis, about 3% of people with psoriasis develop pustular psoriasis. Although it can begin at any age, it is most commonly seen in older adults. Pustules, white, pus-filled, painful bumps surrounded by inflamed or reddened/discolored skin, are symptoms of pustular psoriasis. The ‘pus’ in pustules is caused by inflammation and is not contagious.
• Plaque Psoriasis as the most common type of psoriasis, affecting approximately 80 to 90% of people with psoriasis. This manifests as raised, inflamed, scaly patches of skin that are itchy and painful. Plaques typically appear as raised, red patches covered with a silvery white buildup of dead skin cells or scale on Light skinned skin. On darker skin, the plaques may appear darker and thicker as well as more purple, grayish, or darker brown. It can appear anywhere on the body, but they are most commonly found on the scalp, knees, elbows, and torso. 

Plaques typically appear symmetrically on the body, affecting the same areas on the right and left sides of the body. Plaque psoriasis frequently coexists with nail psoriasis, which manifests as discoloration, pitting, or separation of the nail from the foreskin.

• Inverse Psoriasis occurs in 21-30% of people with psoriasis. This manifests itself in body folds of people of color as lesions that are purple-ish, brown, or darker than the surrounding skin. On Caucasian skin, it appears as bright red lesions in body folds. It may appear smooth and shiny. Many people who have inverse psoriasis also have another type of psoriasis somewhere else on their body. Inverse psoriasis appears in the armpits, groin, under the breasts, and other skin folds on the body. Because inverse psoriasis is found in skin folds and tender areas, rubbing and sweating can complicate it further.
• Erythrodermic Psoriasis is a very rare type of psoriasis that affects only about 2% of people who have psoriasis. It disrupts the body’s normal temperature and fluid balance, which can result in shivering episodes and edema (swelling from fluid retention) in areas such as the feet or ankles, as well as an increased risk of infection, pneumonia, and heart failure.

What are the treatment used for Psoriasis?

The type and number of treatments involve are determined by the severity of your psoriasis that is determined by how much of your body it covers.

Finding the right psoriasis treatment and understanding the severity of your psoriasis and different treatment options can help you and your dermatologist work toward meeting your treatment goals. This includes the following;

• Topical Treatments, which come in the form of gels, ointments, or creams, are usually the first-line option for treating psoriasis. Topical treatments, when applied directly to the skin, can effectively treat psoriasis by slowing the growth of skin cells and, in some cases, decreasing inflammation and plaque buildup.
• Light Therapy/ Phototherapy Treatment, which involves applying ultraviolet phototherapy directly to plaques and scales which can support in slowing the skin cell turnover of skin
• Oral Systemic Treatment is another treatment option for moderate to severe psoriasis. Oral systemic work by acting on part or all of the immune system to reduce inflammation
• Biologic Treatments, a systemic treatment option typically reserved for patients with moderate to severe psoriasis. They are frequently administered by injection or infusion. Biologics target specific proteins that are overproduced in the immune system, thereby reducing inflammation.

Last June 24, 2021, the Food and Drug Authority issued a public health warning on three cosmetic products: 

1. The Ordinary Niacinamide 10% + Zinc 1% High-Strength Vitamin and Mineral Blemish Essence

2. The Ordinary AHA 30% + BHA 2% Peeling Solution

3. The Ordinary Hyaluronic Acid 2% + B5

The FDA issued Advisory No.2021-1543 warning the public to avoid purchasing the said skincare products because of failure to undergo through the agency’s registration process. Without undergoing proper registration and validation, FDA cannot assure the public on the products quality and safety.

The Food and Drug Administration (FDA) warns the public from purchasing and using the unauthorized cosmetic products.

Read more:-> https://bit.ly/3eDHjj1

By Aznaida L. Tawagon-Pandapatan, MD, DPDS

What are Retinoids?

Retinoids are Vitamin A derivatives. Use of retinoids results to the most sought-after reversal of skin aging. 

How? By organized differentiation and proliferation of skin cells. Think of it as like an organic fertilizer for plants—once applied to the soil, the leaves and fruits will grow faster and with a better quality. 

When applying retinoids, skin cells will grow faster and better (like how your skin used to be when you were younger) and collagen will start to form in your skin dermis, so you can get back that youthful smooth, firm, and glowing skin. 

Currently there are four generations of retinoids:

• First Generation: 

Naturally-occurring: Retinol & Retinaldehyde 

Synthetic: Tretinoin, Isotretinoin, and Alitretinoin

• Second Generation: Etretinate and Acitretin
• Third Generation: Adapalene, Bexarotene and Tazarotene
• Fourth Generation: Trifarotene

What are their uses?

Retinoids are most famous as anti-acne and anti-aging, but amazingly in the medical field, they are also used for other diseases such as in psoriasis, hyperkeratotic conditions and even for cancers. Here we discuss their anti-acne, anti-aging, and anti-melasma actions.

• Anti-Acne

Retinoids have been used for acne vulgaris (pimples) since 1971. Topical Tretinoin & Adapalene are the preferred retinoids for acne. 

These retinoids do their superhero work by normalizing the follicular epithelial differentiation, thus treating the existing pimples and also preventing future pimples to form. New studies also showed that topical retinoids have an anti-inflammatory activity thus further decreasing pimple occurrence.

Adapalene causes less irritation compared to tretinoin, thus it is commonly prescribed for those with sensitive skin and those who cannot tolerate Tretinoin. 

Retinols are milder forms of retinoids. Examples are retinaldehyde & retinyl palmitate. These may be advised for those who cannot tolerate the use of Adapalene & Tretinoin. Studies showed satisfactory results with these retinols, although effects can be slower and milder compared to adapalene and tretinoin.

Oral Isoretinoin (tablet form) is prescription-only and is used for moderate to severe acne that cannot be successfully controlled by creams. Therapy usually lasts for 6 months, and when acne has been controlled, this is shifted by your Dermatologist to topical retinoids as maintenance. 

• Anti-Photoaging (Anti-Aging)

As anti-aging, Tretinoin has been shown to give superior results overall. Fine wrinkles and brown spots are the two targets of retinoids as anti-aging. 

Brown spots or Dyspigmentation], which happens in photoaging, can be treated by retinoids, partially or fully, depending on how severe it is. This is through enhancement of proper cell turn-over of the epidermis, thus shedding off of the darkened/damaged skin cells on top.

Wrinkles can be improved by retinoids by enhancing cell regeneration of the topmost skin layers and by production of new collagen in the dermal layer (lower layer of the skin). This effect on collagen can usually be observed after 6-12 months of regular use.

• Melasma

Melasma has 3 types: EPIDERMAL (affecting the topmost skin layers), DERMAL (affecting lower skin layer), and MIXED epidermal+dermal (affecting both the top and lower layers).

Epidermal type of melasma can be improved by retinoids by enhancing regeneration of new skin cells, thus effectively removing the topmost pigmented cells. Improvement can be 80-100%.

In Mixed type of melasma, the epidermal component can be treated by retinoids by the same mechanism mentioned above, but the lower dermal component does not usually respond to this. Thus the patient can only see a partial improvement of their melasma, about 50-60% improvement.

Dermal type of melasma is difficult to manage with just topical retinoids, it is managed with multiple approaches using lasers and other topicals. 

Retinoids can be combined with other treatment modalities to optimize melasma treatment.

What are the possible side effects of retinoids?

Like many medications, retinoids may have side effects, some are mild and some are severe especially for the first-time users. Here are some of them:

• Dryness
• Peeling, flaky skin
• Irritation: swelling, crusting, blistering when severe
• Skin color changes
• Sensitivity to sunlight
• Redness
• Itchiness
• Burning sensation

Do not let these side effects turn you off from using retinoids. Most of these effects

will usually resolve on their own once the skin adjusts. But for those with severe side effects, your dermatologist will prescribe medications to lessen the effects and guide you when and how to re-introduce it to your regimen.

Tips on proper use of retinoids and how avoid undesirable effects.

• Follow the instructions given by your Dermatologist.
• Do a Patch Test or ROAT (Repeat Open Application Test) before you apply on your face. How? Apply a small amount of the product on the inner forearm or back of the ears, every other day for 3 consecutive instances (example: Mon-Wed-Fri). If there are no allergic reactions, you may start using it on the face twice a week.
• A pea-sized amount is adequate for the whole face.
• Dry your skin first before application, this will lessen irritation.
• Apply thinly. 
• Avoid application on sensitive areas around the eyes such as the eyelids and eyebag areas, and the neck. These areas are very sensitive. There are milder retinol formulations that are better suited for these areas.
• As a beginner, use it twice a week for a month; then every other day for another month, and if there are no bad reactions, you may use it daily.
• Make sure to use it at night only—this is to avoid inactivation by UV light and to avoid UV sensitivity effects in daytime (sunburns & irritation).
• Wear a broad-spectrum sunscreen SPF 30 (or higher) during daytime, and don’t forget to reapply the sunscreen (lunch breaks are great time for reapplication; and every 2 hours when swimming). This is again, to avoid the UV inactivation and UV sensitivity effects of retinoids.
• When on retinoids, avoid the sun in general. If you have to be outdoors, limit the time & avoid the extreme sun from 10am to 2pm. Wear protective gear too, such as wide-brimmed hats, sunglasses and UV-blocking masks and umbrella.
• In general, while your skin is still adapting to retinoids, it is best not to try new products yet. Once your skin has stabilized with retinoid use (could take 2-6 months), then you may start using other products. 
• If starting new products, use one product at a time. Example, a new niacinamide toner, try just this (after proper ROAT/Patch test) for 2-4 weeks before adding another product to your routine. This is to avoidirritation and losing what you have gained from retinoids.
• The following are active ingredients that should not be applied together with retinoids: alpha-hydoxy acids (glycolic, lactic, mandelic), beta hydroxy acids (salicylic, vitamin C, and benzoyl peroxide.
• It takes 3-6 months of regular use (at least every other day) before initial improvements are seen, remarkable results are observable after 6-12 months.
• Avoid retinoids if you have severe eczema, and those with broken, and sunburned skin.
• Purging is not common, but it can happen for a few people, this is noted as worsening of acne on the first 2-4 weeks of retinoid use. If this happens, you may contact your dermatologists so she can advise you on what to do.
• If allergic reactions such as redness, stinging, blistering and inflammation become persistent (lasts for more than a day, or worse enough to disturb your daily activities), stop using retinoids and contact your Dermatologist for advice on what to do.

Myths about retinoids in skincare:

• Retinoids will make the skin thin. 
• No, it will not thin the skin out, it will do the opposite. It will ensure proper, continuous skin cell growth, to maintain normal skin thickness so your get younger-looking skin.
• Retinoids are only for mature skin.
• Retinoids can be used as early as teenage years, mostly for acne especially if indicated and prescribed by a Board-Certified Dermatologist.
• The more product you apply, the faster and better the results.
• Nope. Doing so will not increase its effectiveness, it will only increase chances of side effects such as redness, flaking, dryness and stinging. A pea-sized amount is enough for the whole face.

Facts about retinoids in skincare:

• Major desired effects on the skin as anti-acne can be observed in 2-4 months, so you have to have patience.
• Major desired effects on skin as anti-aging (fine lines, dyspigmentation) and anti-melasma can be observed in 6-12 month.
• Avoid the use of oral retinoids, establish first a proper effective contraception and get guidance from a board-certified dermatologist. These have high tendency to cause fetal death and malformations.
• Avoid the use of topical retinoids when pregnant or breast-feeding. According to a large population-based study done by Jick et. al., there was no risk of birth defects in offspring born to mothers who were exposed to topical tretinoin during pregnancy. Despite this, use of topical retinoids in pregnancy and breast-feeding is still discouraged to avoid even the smallest possible risk of fetal death and malformations. No risk is worth taking, when dealing with new life.
• If in doubt, always communicate with a board-certified Dermatologist, we always have your best interests at heart!

References

1. Bolognia, Jean, et. al. Dermatology 3^rd ed. New York. Elsevier Saunders. 2012.
2. Kang, Sewon, et. al. Fitzpatrick’s Dermatology 9^th ed. New York. McGraw Hill Education. 2019.
3. Kiser, Philip D.; Golczak, Marcin; Palczewski, Krzysztof (11 July 2013). “Chemistry of the Retinoid (Visual) Cycle”. Chemical Reviews. 114 (1): 194–232. doi:10.1021/cr400107q. PMC 3858459. PMID 23905688.
4. Stefanaki C, Stratigos A, Katsambas A (June 2005). “Topical retinoids in the treatment of photoaging”. J Cosmet Dermatol. 4(2): 130–4.
5. Orfanos CE, Zouboulis CC, Almond-Roesler B, Geilen CC. Current use and future potential role of retinoids in dermatology. Drugs. 1997 Mar;53(3):358-88. doi: 10.2165/00003495-199753030-00003. PMID: 9074840.
6. Jick SS, Terris BZ, Jick H. First trimester topical tretinoin and congenital disorders. Lancet. 1993;341(8854): 1181-1182. 

Danielle Nicolle Dionisio Mejia, MD, DPDS

Martha Joy Bruan-Tapales, RPh, MD, FPDS

The science of prescribing medication is second nature to physicians. The therapeutic relationship between a patient and a doctor is founded in mutual trust that the patient will follow the regimen prescribed by the doctor. However, in therapeutics, there are unintended events that may occur anytime during treatment.  

The World Health Organization (WHO) defines adverse drug reaction (ADR) or effect as an individual’s response to a drug which is noxious or unintended occurring at doses normally used in man for the prophylaxis, diagnosis, or therapy of disease, or for modifications of physiological function. In addition, the US FDA describes it as an undesirable effect associated with the use of a drug that may or may not be related to its intended pharmacological action. In short, ADR is harm caused by the drug at normal dose during normal use.

The classification of ADRs can be divided according to the following:

1. Onset: acute, subacute, latent
2. Types: augmented (A), bizarre (b), chronic (c), delayed (d), end of use or withdrawal (e) and failure (f)
3. Severity: mild, moderate, severe
4. WHO/UMC causality: certain, probable/likely, possible, unlikely, conditional/unclassified, unassessable/unclassified 
5. Others: side effect, idiosyncrasies, toxic effect etc

Side effect, a type of ADR that is most commonly discussed with patients, is defined as the unintended and sometimes unavoidable effect occurring at normal dose related to the pharmacological properties. The drug’s side effects are usually listed down by the drug manufacturers for the physicians to know and relay to the patient. Examples of drug side effects would be hair loss and oral ulcers with the use of cancer medication; burning or stinging sensation with the use of topical retinoids or topical calcineurin inhibitors; nausea and vomiting with the intake of doxycycline. Since side effect is a response related to the pharmacological properties of a drug, some would include in the definition effects that are beneficial to the patient even though it is not the main aim of therapy.

Adverse drug reaction or adverse drug effect, therefore, is the umbrella term for all undesirable effects of a medication, whether it is expected or not and to some whether it is good or bad.

The long term safety of a drug can only be determined once it is being widely used by the public. Monitoring adverse drug reactions from medications is important to safeguard the public from these effects. Timely reporting of ADRs is vital and healthcare workers can not do this without the help of the public. Proper health education and efficient communication between the healthcare workers and patients is important to allow prompt monitoring of these unwanted drug related events.

References:

1. CFR – Code of Federal Regulations Title21 https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=312.32#:~:text=Adverse%20event%20means%20any%20untoward,life%2Dthreatening%20suspected%20adverse%20reaction.
2. Adverse Drug Event Monitoring at the Food and Drug Administration 
   Ahmad S. R. (2003). Adverse drug event monitoring at the Food and Drug Administration. Journal of general internal medicine, 18(1), 57–60. https://doi.org/10.1046/j.1525-1497.2003.20130.x

3. FDA circular No. 2020-003 on Guidelines for the pharmaceutical industry on pharmacovigilance
   https://www.fda.gov.ph/wp-content/uploads/2020/02/FDA-Circular-No.2020-003.pdf

4. Edwards IR, Aronson JK. Adverse drug reactions: definitions, diagnosis, and management. Lancet. 2000 Oct 7;356(9237):1255-9. doi: 10.1016/S0140-6736(00)02799-9. PMID: 11072960.
5. Coleman JJ, Pontefract SK. Adverse drug reactions. Clin Med (Lond). 2016 Oct;16(5):481-485. doi: 10.7861/clinmedicine.16-5-481. PMID: 27697815; PMCID: PMC6297296.
6. Herndon J. (2019). ‘Adverse Reaction Information in the Prescribing Information.’ [PowerPoint presentation]. Regulatory Education for Industry: CDER Prescription Drug Labeling Conference. https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.fda.gov/media/133940/download&ved=2ahUKEwijko_M397wAhWJzIsBHRqgCk8QFjAAegQIAxAC&usg=AOvVaw2PfjDIrlBrFUDNmcFiLeRZ&cshid=1621737035399
7. https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.who.int/medicines/areas/quality_safety/safety_efficacy/trainingcourses/definitions.pdf&ved=2ahUKEwigjcPS4d7wAhURCqYKHaM_DMsQFjALegQIDRAC&usg=AOvVaw1l1fBgT5gv87Pj_fP9FjCF
8. Sundaran S, Udayan A, Hareendranath K, Eliyas B, Ganesan B, Hassan A, Subash R, Palakkal V, Salahudeen MS. Study on the Classification, Causality, Preventability and Severity of Adverse Drug Reaction Using Spontaneous Reporting System in Hospitalized Patients. Pharmacy. 2018; 6(4):108. https://doi.org/10.3390/ppharmacy6040108m
9. Medical Definition of Side Effects by Dr. Melissa Conrad Stopler
   https://www.medicinenet.com/side_effects/definition.htm