Tinted, Tested, and...Optional?

[music] Welcome to Derms on Drugs Season 2, a video podcast brought to you by scholars and medicine, the best educational platform in dermatology and provided at no cost to medical providers. Derms on Drugs is where cutting edge Derm meets hitter miscomedy. Now you might be thinking season 2 sounds a little different to me and that's because our fearless leader Matt Zyrus is on vacation. So today I'm just joined by my one residency buddy Tim Patton to use our 40 years of combined experience to discuss debate and dissect the hottest topics in dermatology. It's everything you need to know to be on the cutting edge of dermatology and you'll actually have fun listening. New episodes drop every Friday on scholars and medicine, Apple podcasts, Spotify and other major podcast platforms. Don't forget to check out the video component. It has key figures and tables from the articles that we discuss and you can find that on the scholars and medicine platform. You can also look in our episode description for links that will help you get to articles and other resources that we discuss as well. Well today we are excited to have Dr Heather Woolery Lloyd with us. She is a board certified dermatologist and she's also the founder of Derm friends which is an innovative platform and newsletter that focuses on skin care education. Her career has spanned two decades and she's earned recognition as a sought-after speaker at national and international dermatology conferences. She has over 70 peer-reviewed papers in the literature and you've probably seen her on top media sites including the New York Times Forbes and in the Wall Street Journal. She's an active member of the American Academy of Dermatology and she was honored with the AED's presidential citation for her commitment to education and research in dermatology. Dr Woolery Lloyd, welcome to Derms on Drugs. Hello, thank you so much for having me. Great. Well we are excited to have you and you know we're going to talk about sort of one of our favorite topics on Derms on Drugs which is the Sun and Protection and what can we do for our patients but also some of the controversies around sunscreen and some of the maybe little-known facts about sunscreen. So we're going to start by reviewing three papers and excited to get your input as we go along. All right so the first paper that I have to go over was actually recently published in the Journal of Drugs and Dermatology. It was by Chappulzac and Leo and its sunscreens, mechanisms, and safety in depth. So I picked this because you know it was a nice review. I thought went over some of the important things about sunscreen but also kind of you know taught me a few new things. So you know one went over mechanisms of action. We know that there's chemical sunscreens and physical sunscreens and you know I had always learned that you know chemical sunscreens absorb radiation physical sunscreens reflect it. I learned from here that physical sunscreens zinc oxide and titanium dioxide are actually semi-conductors so they also absorb some UV light as well. So I thought that was interesting. Talked about things like SPF which I think we all know about but also and that's a measure of UVB protection. So basically protection from erythema induced by UVB but I thought that the other interesting measure that I don't really think about is persistent pigment darkening. So that is looking at basically protection from UVA and then the third important you know factor that goes into efficacy measures when sunscreens are being you know evaluated as substanceivity so basically how long does it stay on if you sweat or you go in the water. Other key points there's this the FDA has this rating called graze which is generally recognized as safe and effective and really it's really the titanium dioxide and zinc oxide are the ones that have this graze rating the chemical blockers do not. And then you know they talked a little bit about some other factors like you know coral reefs the Ristam reenlife and that this is you know resulted in actually fans in some places like Hawaii and Mexico but really stated that the data are not necessarily like fully there's not sort of fully developed to really substantiate this. So you know I think this is a great you know opportunity to review sunscreens there's a lot of science in here so I would just recommend checking that out. Patent did you get a chance to look at this article any other take-home points from this one? No I right I'm surprised that you know you counsel patients on sunscreen all the time and then you sit there read this article you know like well I was wrong about that so I now need to start doing things a little bit differently and it just goes back to like you know the the myths of some sunscreens that even as doctors we we tell people about yeah doctor Woolery Lloyd aside from you know like the zinc oxide titanium oxide being actually absorbers they start to reflect at like a higher wavelength maybe 380 they start to become reflective so it's sort of like a hybrid mechanism but yeah that was an interesting one that I just you know not something I told patients anything else any other myths that you can think of that maybe the paper didn't touch on. Well I will say this you know I think we all kind of learn the same thing right that chemical sunscreens absorb and mineral sunscreens reflect and probably the old-fashioned mineral sunscreens that were completely white like that zinc oxide that surfers would put on their nose like maybe in that case it reflected but the modern zinc and titanium that we see in our modern sunscreens are all nanoparticle and they do work basically the same way is chemical sunscreens and they absorb UV light and converted into heat so I I learned that the hard way because I posted on social media very after on social media and I did a video several years ago and someone corrected me online and and you know so that's why I was up to date because I was corrected online but really it's because we didn't I don't think learned incorrectly I just think the modern formulations work differently because now all of the zinc and titanium for me titanium formulas are nanosize and then there's this concept of hybrid sunscreens so I now when I talk about sunscreens I have three categories and I talk about you know the ones that basically absorb which are traditional chemical and also the nanosize minerals that we use and then the hybrid sunscreens which contain a combination of chemical and mineral sunscreens and the reason why companies do that is they're trying to kind of maximize the clear properties of chemical sunscreens but I still adding a little bit of mineral in there so the less mineral sunscreen you have the clearer it is probably one of the biggest challenges I have and my patients work darker skin patients is that those mineral sunscreens leave a white cast even if it says it's clear even if it says design for darker skin types there's always going to be a little bit of a white cast just by definition of it having a mineral in there so there are these hybrid formulas that try to drop that level of zinc as far down as they can and still get the SPF 30 or 50 or whatever they're looking for so that's another relatively new concept that didn't exist 20 years ago but now is pretty much widely available where we see these combination or hybrid sunscreens. What does your take is somebody thinks about this about the the coral bleaching and the environmental impacts of the chemical sunscreens do you think is it real is it just hype how do you what do you tell patients you're in the you're in Florida you probably get asked this question. Yes so I think that we just don't have the data like there is almost all of the studies that looked at this had major flaws and so I personally don't know if there is a true correlation and I don't think anyone really knows I think that the data is very very weak and you know it's kind of like everything in medicine or in science we're gonna see one paper and another paper and another paper and then finally in 5 10 15 years there'll be a meta analysis and we'll figure out really what the real science is but right now what we have is very weak to support that the chemical sunscreens are causing issues the reefs I think a lot of the things that we put on our body probably disrupt the reefs I don't know if it's specifically the chemical sunscreens. That's a good point there's so many things that we're getting into the ocean that are getting into our water supply. Well and I think you know bringing up the topic of you patients with darker skin tones and sunscreens patent you had a article about another component that we can add to sunscreen that maybe we'll be at auction. Die paper was from the July 2025 issue journal of drugs and dermatology titled Photo Protection Epochacy of Sun Protection Factor. Iron oxide formulations in diverse skin with malasmen photo damage and this was by at all, and at all was mostly employees of L'Oreal. So L'Oreal is definitely pitching a product here. But as Durham's when we talk about sun protection, as we were talking about, we primarily focus our attention on UV radiation, but UV radiation only makes up about three to five percent of sun like that reaches us, something I just again learned within the last couple months. Most of the sun's energy that reaches the Earth's surface is infrared or visible light, but there's been some interesting effects of visible light, particularly in skin of color. UVB and UVA blockers don't really absorb visible light. So conventional sunscreens may not be effective at preventing the effects of visible light that may have on the skin. So this was a double blind study, although I don't think it could have been double blinded because half of the patients were told to use an SPF 50, and half of the patients were told to use SPF 50 plus a tinted sunscreen. So I think the patients clearly knew what they were using, but the evaluators, I'm sure, were blinded. All the patients were female, they had facial dyschromia or mild to moderate malasma, it was kind of two groups of patients, they did actually split them when they did the analysis. They applied as we talked about the SPF 50 or SPF followed by iron oxide containing foundation, the concentration of it varied, depending on the shade of the foundation, so they wanted to match the skin color. So the patients actually had a choice of which percentage iron oxide they wanted to use. They were evaluated at various time points during the trial, 21 females were in each group, the SPF 50 versus the SPF and the iron oxide, kind of split evenly between photo damage patients and malasma patients, and at 12 weeks both groups had improvements in multiple clinical evaluations. The SPF 50 and iron oxide showed statistically significant improvement from baseline earlier in the course of the study, so you started to see the benefits at four weeks versus eight weeks, but at weeks, we 12 there weren't a huge difference, statistically significant difference between the two different products, the SPF minus iron oxide or the SPF plus the iron oxide, figures 1A and 1B were just kind of like skin quality, figures 2A and 2B are bar graphs, measuring individual typology angle, it's kind of more of an objective measurement of skin color, higher ITA values, correspond to lighter skin, lower values correspond to darker skin, and again, there wasn't statistically significant differences between the two groups, the iron oxide group had a sooner response, and then table three reviewed quality of life data from the malasma patients, everything was better. I mean, it was questions like, are you not bothered by frustration due to your skin condition, are you not bothered by restricted sense of freedom? All of those questions, the improvements were better in the iron oxide group, but again, it wasn't statistically significant. So yeah, I don't know what to make of this. I mean, everything else that I've read about tinted sunscreens, it seems like there is a definite benefit because of the blocking of the visible light. I expected to see bigger differences in the numbers. 12 weeks is kind of quick for malasma, like malasma takes forever to get better. So I thought 12 weeks was a little bit odd. I thought it was interesting at four weeks, you see the improvement. I think that's probably good for patients. I think malasma, especially, they come back in three months, and they're like, this is no different whatsoever. If they're seeing that improvement at four weeks, maybe that encourages compliance, and they actually would use it for a longer course. Yeah, I don't know what was your two takeaways from this paper? - Well, I think for me, it definitely confirms what I see in my everyday practice. I practice in Miami. I'm in a very sunny climate. So it is really a challenge to treat malasma in Miami. I am working against, you know, the highest, probably one of the highest UV indexes in the country when I'm treating my patients, and we all know the sun is the enemy of patients with malasma. So I do think mineral sunscreens are the iron oxides, and I'm gonna clarify a little bit about iron oxides, because I think maybe some of the listeners might not realize. So iron oxides are red, yellow, and black pigments, and when they're mixed together, they make a brown, just like when you're an elementary school and you mix your paint together, you got brown. And so they're used in foundations, color cosmetics to make foundations brown, and they're also added to sunscreens to give them a tinted color. And one of the huge benefits in our darker skin patients is that masks that white cast. So if we're very well formulated mineral sunscreen that's tinted, that matches the patient skin color. Has to match, you can't just be any tinted sunscreen. It has to match their actual skin color. Really will hide that white cast that we see with mineral sunscreen. So it improves compliance with mineral sunscreens, because the patient wants to put it on, 'cause it looks good, it doesn't make them look like a ghost. And it also improves the efficacy of that sunscreen because it's blocking the visible light. So iron oxides are very, very important when you're treating pigment. You really have to recommend a tinted sunscreen if you're addressing pigment for your darker skin patients. And this is because our darker skin patients react to visible light, and they get pigment darkening from visible light. So my patients will tell me, if they're using a traditional sunscreen, I reapplied every two hours. I put on a thick layer every two hours, and I still got darker. Why is that? That's because a mineral sunscreen has zero protection against visible light, really almost no protection against visible light. So that's when the patient complains that they're getting darker, and they're compliant, and they're really putting on their sunscreen every two hours. And they go out in the sun for the day, like a Miami on the boat or to an outdoor event, and their skin gets significantly darker, is because that mineral sunscreen is not protecting that darker skin patient from the darkening that we get from visible light. So I think this is in a very important study. It does reflect what I show, see in my everyday practice, and the key with iron oxides is to find a tint that matches the person's skin tone so that they're compliant and want to put it on every day. That's really interesting. And I feel like I just recently have started hearing about tinted sunscreens and the importance. And looking at that paper, one of the thoughts that I had is somebody who's not like a big makeup person, I like tinted sunscreen, because it's like, oh, I'm wearing makeup. So it's like it takes a step out of the getting ready in the morning. Do you think that there was any benefit that some of the early benefit could have been? Basically, there's a little camouflageing or blending effect if you have a tinted sunscreen. That was one of the things I wondered if that made a difference. Yeah, I think that obviously when someone put something on, especially in this, this was a good study because they got to use their own foundation or a match of foundation to their skin color. So, like I said, it's not any tinted sunscreen. If I put on a tinted sunscreen, but it's four or five shades lighter than me, I would look a little bit odd. So because in this study, the patients got to use a tinted foundation that matched their skin color. They probably felt better about themselves walking out the door because the ones with the malasma or even the models kind of pigment that we see with photo aging was less obvious. So there could be some impact on that, but there are also really well-controlled design studies that show that adding iron oxides to a sunscreen significantly improves protection against visible light and reduces that delayed pigment darkening. So even though, yes, I think it makes people feel better because their skin looks more even when they're walking out the door, especially because the other product didn't have iron oxides, and the other ones might have looked a little gray, right? Even if it's the best possible mineral sunscreen, they're still gonna have a little bit of a white cast. So especially in your skin type 6. So that could have definitely impacted the quality of life questions, because I do think that when your skin looks more even, you definitely feel more confident. - Yeah, and I can do it. - Great, that's a great segue. I'll go ahead, Pam. - I didn't mention specifically. It was chemical. It was a combination of avobenzone, homosylate, - Oh, okay, good. - Optosalate, noctocrylene. So it actually didn't have any of the, - Oh, so that's good. - The physical block, but yeah. - But you still get that benefit of that lightweight coverage. If for the 10th, the people got to wear their foundation versus the ones who had just the clear product. So I think that even though we didn't see statistical significance in very well controlled trials, they have shown statistical significance when you induce pigment with what I call a sun gun, but a visible light gun basically. And so I definitely think it does make a difference, especially when you're practicing in a sunny climate like I am. - Yeah, I thought that was interesting too. It seemed like the study was kind of based in New Jersey. Like, L'Oreal headquarters were in New Jersey and Dr. Grimes works out of-- - Los Angeles. - Does anyone know that? - Los Angeles. - Los Angeles, so, well, okay. I don't know where they were recruited. - Well, it probably wasn't Los Angeles, that's my guess. But even, like LA has a really high UV index. And then Miami, basically we're in the tropics. So I often see patients when they move here from anywhere in the country with Malasma. They'll say, I didn't have this before I moved to Miami because our UV index-- - Yeah, so that. much of a difference because, right, this was not in a lab where they shown light on their face. It was just go out and do your everyday thing. They filled out a diary and things like that. But yeah, so maybe that's why there wasn't a huge difference that you would expect. Right. A good segue into one more paper that I think kind of rounds out this whole story, which is "Impact of iron oxide containing formulations against visible light induced skin pigmentation and skin of color individuals." And this was in "Journal of Drugs and Dermatology," July 2020, Dumbaya at all. And so this looked at the role of visible light, so 400 to 700 nanometers. So we know that that makes up, and again, I learned this 45% of solar energy. And so this was a study where they took 10, they had 10 women who were Fitzpatrick four skin type or higher. And they exposed them with a solar simulator, which I think is the sun gun you're talking about, to they had different areas. So there was like the untreated, the solar exposed, and then solar exposed without any sunblock, and then three different sunscreens. And they were basically either A was a zinc oxide, titanium dioxide. So this is now that sort of physical blocker, only product B had titanium dioxide and iron oxide at 4.8%. And then product C just had 27% iron oxide. And so what they what they did then was they looked at darkening. And what you can see is that, you know, there was a really significant, like statistically significant, but also just by using like color imagery over a 14 day period, they showed like significant benefit if you had iron oxide in the in the sunscreen. And you did not get that protection, like you said, Heather, at all, when you just had the mineral sunscreen. So I really thought like if you look at this paper, you look at those test spots, I mean, it's really like dramatic, the difference that the iron oxide made. So I thought that really drove that home. The other cool thing I pulled out of this for like Borg's fodder for residents who are listening is that the mechanism for the visible light induced pigment darkening is the opsin 3 photo receptor, which regulates tyrosinase expression. So yeah, that was also interesting with science behind it. Well, I have to comment on opsin 3 because I'm a little bit obsessed with it. So if you're not familiar with opsin's, opsins are G protein receptors. And they're primarily in our eyes. They detect light in our eyes. And these researchers from a different paper found that opsin 3, so this light receptor is in our melanocytes, our melanocytes express opsin 3 and our melanocytes detect blue light, you know, in that visible light spectrum. So specifically the blue light turns on that opsin 3 receptor activates it. And in darker, darkly pigmented patients, this is not in everyone in these studies. It's primarily the darkly pigmented patients that react to this visible light and get this pigment darkening that we see. So in this study, they found that the melanocytes in patients who had darker skin had that receptor, that light receptor activated and it caused increased pigmentation. And I think this is really interesting because I'm also board certified in lifestyle medicine. And one of the things we know is that sleeping in a dark room is really important for good, you know, for better sleep, better quality sleep and better quantity sleep. And they did a study once and they had the patient in a pitch black room, but they put lights on their skin and they found that the light disrupted their sleep. And even though their eyes didn't see the light, their skin saw the light. So I'm just absolutely fascinated with the role of opscens and they really are what causes our darkly pigmented patients to get darker when they're exposed to visible light. But I also think it's interesting that just that our melanocytes can see light. I think it's the coolest, you know, they're like little eyeball skin. Yeah, that's fascinating. Was that sleep study? Was it only done on dark skinned individuals? No, no, it was just really looking to see how light influenced sleep patterns. And they found that even in a blot's out room, if you put light LED like taped an LED light to someone's skin, it would disrupt their sleep. So there's some feedback mechanism that I don't know that mechanism, but you're ready. Maybe circadian rhythm. Yeah, you know, things like that. Fascinating. Now, well, that's great. This has been such an interesting discussion. We had some questions for you. One of the questions I had is in light of all of this. How do you, are there certain sunscreens that you recommend for your darker skinned patients? And are you really as worried about SPF? For say, are you more worried about what's in the content of the sunscreen? And particularly, like blocking visible light, and are there other strategies that you use to block visible light? So for me, personally, the most important thing is that it's at least an SPF 30, but the most important thing is that the patient wants to put it on every day. That is the biggest predictor of compliance and someone using a sunscreen regularly. So I have a list of ones I recommend. If I'm looking at tinted mineral sunscreens, I'll recommend the brands that have the widest range of shades so that the person hopefully can find a shade that matches their skin color. And, you know, there are quite a few. I don't know if I can recommend name brand. Yeah, we have no, we are not CME compared to Dermquant Drugs. You can say anything you want. So for a very kind of lightweight, clear formula that kind of is very sheer. The LTA MD has a light tint and then a darker tint. The darker tint is, so there's two tinted formulas. One is darker, but because it's so sheer, it kind of works with a lot of different skin types. The darker tint is a little bit darker than my skin color. So when I put it on, it looks like a bronzer almost. L'Oreche Passee has four shades. So then you, you know, you're getting into a wider range of shades and then there, you know, some brands out there like Ilya, which is something that you can get in like the Sephora, Ulta type of thing or online or Beauty of Jocen, which is a Korean skincare line that comes in, you know, 10 or more shades. So really, it cosmetics also has a huge range of shades where someone can actually find a shade that exactly matches their skin color. So I recommend all of these to my patients and I'll say these, you know, these are the, these are some that I like, but if you find one that you love and you want to wear every single day as long as it's a tinted sunscreen, I'm okay with it. Laura Mercier also has chemical tinted sunscreens that come in a wide range of colors. So what's more important to me is compliance and that the patient wants to put it on every day. Great. I think having those names and, you know, different, you know, price ranges and everything to recommend to patients is super powerful. Yes. What about like not recommending sunscreen at all? So one of the papers that I had sent was the relatively newer Australian recommendations. And this was the first time I had ever seen like based on your skin pigment. Here is what we would recommend. And for darker skinned individuals, they said you like when the UV index is not going to be above what you don't need sunscreen at all. Don't don't use it. And then they even said even if the UV index is greater than or equal to three, if you're not going to be out in the sun for they said two hours, I think, was the recommendation. You may not need sunscreen. I was blown away that a group which included skin cancer. What do I want to call them advocates that said, hey, you might not need to put sunscreen on at all. What do you, how do you feel about that? So this is a really interesting paper and recommendation. So basically Australia last year, it might be two years ago now, change their recommendations across the board based on skin types. So they change their sunscreen recommendations for skin types one and two. They recommended sunscreen, and they didn't use skin types one and two. They said lighter, medium and dark, but you know, we're thinking of them as one and two. They say sunscreen every day regardless. For skin types in the mid range, three and four, if you have a family history of skin cancer or personal history of skin cancer, we're a sunscreen. If not only we're a sunscreen, if the UV index is greater than three, and I think that one also you have to be outside for more than two hours. And then for skin types five and six, they said basically only we're sunscreen if the UV index is greater than three and you're going to be outside for more than two or three hours, whatever that number was. So I found this really interesting and you know, when it came out, it was all over the news. It was you know, and all of the big newspapers and all of the big online publications and there was a lot of talk. And the reason why the Australians came up with these recommendations is they wanted to look at sunlight from a very holistic point of view. So we're very focused on skin cancer and you know, photo protection from the damaging effects of the sun, but they also wanted to look at from a public health standpoint, the benefits of the sun. And we do know the sun has benefits. So the benefits of the sun is it's known to improve mood, you know, lower risk of depression, early morning sun exposure. exposures associated with better sleep habits. They even mention in the paper that people, as a laddett, as people get closer to the equator, they have lower rates of some autoimmune conditions like multiple sclerosis. So based on this overall very big holistic view of the sun and its benefits and risks, they wanted to come out with a very, I would say detailed or tailored, some protection recommendations based on the risk-benefit ratio. So it included dermatologists, but it also included people from the public health sector and so forth and altogether they published this paper and made these new recommendations. So what do I think is a germ? Well, practicing here in Miami, most of what I see are pigmentary disorders. The UV index is always above three. So it's never above, it's never below three where I live. But when this first came out, I was presenting at the pigmentary disorders exchange in Chicago, which was in June around two years ago. So I was like, let me just check with the UV index on it was like a relatively cloudy day in Chicago. UV index was still above three in Chicago on a somewhat cloudy summer day. So I think for a lot of us who are in North America, the UV index is always above three, like most of the time. Maybe in the dead of winter it might not be, but it's almost like if you could see the sun, it's probably, I don't know, I'm in a place where it's always a-- I haven't done the Pittsburgh. I spent 25 years in Pittsburgh, Tim lives in Pittsburgh. I swear the UV index is below three a lot. Oh, it was. OK, there you go. I'm very biased because I'm down here in Miami where that's like, I don't think that has ever happened. So-- And I'm-- Except one at three. Right. And I'm treating pigmentary disorders, which is the number one complaint for our patients with darker skin. So if you drive to and from work, if you have a one hour commute, you're going to be in the sun for more than two or three hours. If you are just running errands every day, if you sit next to a window, et cetera, you're going to be exposed to sunlight. So for my personal practice, it doesn't-- it hasn't changed my practicing behavior because I'm treating pigmentary disorders in a very sunny climate in a place where people are going to get several hours of sun exposure daily. Now, if you live in Maine or, you know, northern Canada, and you've skin type six, and you don't have any pigmentary disorder complaint, and you're going out to your mailbox to get the mail, do you have to put on sunscreen? Probably not. So I definitely know where they were coming from with this. But for practicing dermatologists who are dealing with medical problems associated with the sun, like melasma, photoaging, for-- I think for practicing germs, this is less relevant because our patients are complaining about sun related illnesses. What if you had a darker skin patient who came in for like tenia-pedus or something and said, I hear stuff about sunscreen and darker skins. Like, do I need to wear sunscreen? They don't have a pigmentary disorder. They don't have melasma. I mean, I kind of want to say, well, I could tell them, no. You don't need to. Yeah, I think that-- so that's a really great question. So if it's a woman, and she's 30 years old, right? And she doesn't have fine lines or wrinkles, but she does not want to get hyperpigmentation, and she lives in Miami, right? Then she really needs to start-- she needs to wear sunscreen because that continuous incidental sun exposure of her 20 or 30 years she'll come in when she's in her 50s or 60s with maturational dyschromia or some sort of uneven skin tone. And that would be her primary complaint. And she would have wanted to be able to prevent that if she could, because when patients ask me, what do you use on your skin? I'm like, the only thing I've been very, very, very compliant with is sunscreen every single day. So because I'm in the sunny climate. Now, what if I practice in Northern Canada? I don't know what it's like in those types of climates, but then maybe for that patient, it might not be important. Or maybe for a patient who has zero interest in preventing the photo aging that we see and darkly pigmented people, which is uneven skin tone, progressive darkening on the cheek, sometimes on the forehead, on the lower face. If they had no interest in that, they didn't bother them at all, then maybe for that patient, they don't need to wear sunscreen. So it really depends on the patient. That's great. That's really helpful. I want our last little bit of time. I want to just switch gears a little bit. You mentioned that you're certified in lifestyle medicine. Can you just tell us a little bit about what that is and what does that mean specifically in dermatology? So lifestyle medicine is a specialty that's relatively new that focuses on the six pillars of lifestyle that influences chronic diseases. So it looks at things like diet. And specifically, it focuses on a plant predominant diet. That doesn't mean you have to be vegan or vegetarian. That just means that the majority of your foods should be plants. So things like meat and things that specifically meat should really just be a side part of your meal and not the focus of the meal. It also, that diet component also recommends to avoid processed meats and processed foods. Then also another one of those six pillars are things like exercise. And that's around 150 minutes of moderate exercise weekly. So a moderate exercise is a type of exercise where you can talk but not sing. So that would be a brisk walk or a bicycle ride, something like that. It focuses on really healthy sleep, managing stress. So doing things that help manage stress. For me personally, I walk outside in nature every single morning. And that's a form of really helps to manage stress. It focuses on avoiding risky substances. So smoking or illicit substances. And finally, social connectedness, which is the one of the things that's most predictive of longevity, because this might sound kind of familiar to you if you're familiar with the blue zones. This concept of these overall overarching lifestyle interventions that are associated with longevity and social connectedness is one of them. So lifestyle medicine looks at these six pillars, these lifestyle interventions and looks at evidence-based approaches to treat and prevent chronic disease. When it comes to dermatology, most of the studies have looked at things like psoriasis, eczema, even acne, because we know stress for sure makes acne worse. I think all of our inflammatory skin diseases get worse with stress. And in the lifestyle medicine literature, the only time they mentioned dermatology is in that stress management area, because they know that stress really does aggravate patients with inflammatory skin diseases. So I do incorporate it into my practice and I talk about lifestyle interventions that have been proven, because this is evidence-based. Everything in lifestyle medicine is based on a study and an outcome. And I do discuss these interventions and how it can help these patients with chronic inflammatory diseases. Is drinking allowed in lifestyle? Because I'm down with all of this, but if I can't drink-- [LAUGHTER] Well, I've done these papers, like, kind of reviewed all of these different lifestyle interventions. Let me think about drinking. The one that I think that was interesting is I thought that smoking-- we were looking at smoking, and I think it was acne. And there was no correlation. But then they looked at cannabis, and it did increase the acne, or it's I thought, well, maybe people are eating more unhealthy foods, I don't know. For drinking, there's less studies on that. Most of the studies focus on diet, exercise, stress. Those are the vast majority of the research. I always have to struggle to find the studies on alcohol and all of the other substances. All right. We could be down to support this. [LAUGHTER] We endorse it at Derms on Drugs. We are Derms on Drugs. There you go. We got it. Thank you. Think about our lifestyle. If you had one dietary intervention for patients who have a topic dermatitis, psoriasis, what do you think is the most important thing? And I'm thinking about this in terms of microbiome is now seeming to be so important. Is there one intervention that you think is probably the most bang for your-- Eat more plant-- from the microbiome or dietary? That's what I always say. Why don't you eat more plants? You know, eat more plants. It's really-- it's not rocket science. It really is exactly what we know it should be, just that well-balanced healthy diet. So I'm trying to get as much fiber, because that's what's good for our microbiome, not surprisingly. What's good for our microbiome is a high fiber diet. And what's bad for a microbiome is sugar. So lower sugar-- so less than 25 grams of sugar a day, lots of fiber, 25 to 45 grams of fiber a day, eating more plants, avoiding processed foods, and avoiding processed meats. Those are the things that I really emphasize to my patients. But it's kind of common sense. The way all of us intuitively know what's healthy, there's no special-- one special vegetable that I think is the best. It's just eat more plants and a variety of plants. Try your best seed plants. Plants for breakfast. Vegetables for breakfast. That's great. All right. It wasn't the magic bullet that we were hoping for. But it's what we probably-- I do as the right way. They recommend seven to nine servings of vegetables a day, which is a very-- it sounds like this. My son always says, "That's impossible." (laughs) Nice. So you should be eating seven to nine servings of Mechel today, but that's really what you should be aiming for. So eat more vegetables. All right, the words to live by. All right, Patten, do you have trivia for us? I do. Sunscreen trivia was the category. All right. I don't know. Three questions. All right. Read, let me read the whole question and then just shout out your answer. All right. The first modern sunscreens was developed by Swiss chemist, Franz Grader, who was inspired after developing a severe sunburn following what outdoor activity? Sailing. No. I'm going to say how do I activity tennis. It was mountain climbing. Oh, yeah. That's a win. He developed, yeah, he was marketed in 1946 under the name. Pooh is, I'm screwing this up, Pooh is Booan, which that was the name of the mountain. And that is actually still a brand sunscreen that's available today. So if you ever see that, that's how that name came to be. All right. Zero zero. Aside from Papa, what was the other sunscreen ingredient that was removed from the market because it was not deemed to be generally regarded as safe and effective? Mm-hmm. I think, yeah, I'm not sure. I feel like it might be one of the cinamates, but I'm not sure. I don't know. It was trullamine solicilate. Solicilate, oh, there you go. Yeah, I think most people make a problem. So I wanted to, maybe. Yeah, you didn't have to make it harder. We would have taken an easter. Yeah, exactly. All right. Well, I think it was interesting. So that, that, that grace or grosser or however you pronounce it, it's weird because for sunscreens, you do have the type one. And that's zinc oxide, titanium dioxide. And then you have this category two grace, which that was Papa and trullamine solicilate, where they said generally regarded not safe and effective or whatever. They didn't deem at that. And then the category three was pretty much every other chemical sunscreen that was out there. And it wasn't that they are saying it's not safe nor are they saying these aren't effective. They're saying we want more data because you do have blood levels of these sunscreens. And we just want more data. So they're still available. They're still on the market. And, but it's just, it's interesting that they kind of had these three different categories of that generally regarded as safe and effective. Well, one thing I do want to bring up that's very timely is that, you know, we all know we're definitely behind the times with the rest of the world when it comes to sunscreen technology because in the US sunscreens are regulated as a drug. That means it has to go through all of the clinical testing that, you know, something that is a prescription drug, which includes animal testing and all of these other tests. Now in the rest of the world, sunscreen is regulated as a cosmetic. And so they have access to many more sunscreen ingredients. So recently last month, there was a bipartisan group that actually went to Congress and suggested that listen, we're really behind the times. The FDA needs to restructure how it views sunscreen because it's almost impossible to get a sunscreen approved in the US because basically you have to go through the entire process that a lot, you know, a pharmaceutical company would go through and that can be cost prohibitive. So we might see some changes and we'll see what happens with this new initiative that there really are lobbying Congress to really ask the FDA to look at these other ingredients and stop the animal testing requirement because that is a big hurdle because some of the companies don't want to do animal testing because a lot of consumers don't buy from brands that do animal testing. So from that cosmetic standpoint, it's very hard for a company to get it approved without the cosmetic, the animal testing. Now there's newer models that look at things like carcinogenicity and so forth. And then there's also newer models that have skin explants or these skin models that are very effective at measuring that the FDA currently doesn't recognize. So hopefully we'll see some changes and some new technologies. If the FDA changes how it categorizes sunscreens and how it approves sunscreens. Yeah, that'd be nice to see. Alright, third and final. What actress first appeared in a 1965 copper tone sun tan lotion commercial? The plan to be iconic copper tone girl with her pig tails and a dog tugging after being sitting. No, it wasn't so. The big tails and a dog. I don't remember her name. That's kind of interesting. She's three years old. It was in 1965. Was it really temple? No, no. She'd be older. She would be probably dead in 1960. It was Jody Foster. Jody Foster was the copper tone girl. Yeah, yeah. You're a copper tone girl. She was the model for the copper tone girl. Okay. Well, we all learned something. I would spend a band of things more important than other. I thought it was. I was thinking of Vendice Ale before you finished because I feel like so feel the rent is in that, but I have no idea. Oh, yes, yes. Yeah, yeah, yeah. We have heard a thank for thinking tanning is beautiful. That's right. That's the story. Yeah. Alright, well, that's great. That was great. Heather, thank you so much for joining us. I feel like like everything that I have thought about sunscreen and sun protection for years as somebody who's been like a melanoma person has like, I really rethought a lot of it. Thank you so much. Learned so much from you. Yeah, thank you. Thank you. Thank you so much. So thank you to our listeners for joining us this week. If you've got questions, comments or ideas for topics we should cover on the show or if you just want to send us a fan mail, shoot us an email at [email protected]. We hope you learned a few things, laughed once or twice and mostly we hope you're planning to join us again next week. So until then, I'm Laura Ferris. I'm Tim Patton. And we are Derms on Drugs.