October 7, 2025 • 27 mins
A rough, sandpaper patch on your temple or ear isn’t just “dry skin”—it’s your skin whispering about years of sun you barely noticed. Board-certified dermatologist Dr. Neal Bhatia joins us to unpack actinic keratoses (AKs): how to spot them, why they appear earlier than expected, and what truly reduces their risk of progressing to skin cancer.
From freezing visible spots to treating hidden sun damage, Dr. Bhatia explains what really works—field therapy, photodynamic therapy, and daily prevention that fits real life. Learn how to protect smarter with sunscreen, supplements, and simple habits that keep your skin healthier for years to come.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:00):
Again, just feels like a pimple that doesn't heal,
starts off as a red spot, thatstarts off as dry skin.
SPEAKER_02 (00:05):
What is really the likelihood that they're gonna
turn into skin cancer and whattype or types of skin cancer do
they tend to turn into?
SPEAKER_01 (00:12):
Targets that whole zone of sun damaged skin and
again gets at the precursors inthe early stages and tell them,
look, take this half an hourbefore you go out, and you'll be
protected for about two hours toabout 80% of the the need you
have uh for reducing yoursunburn risk.
SPEAKER_00 (00:28):
Welcome to Dermot Trotter, Don't Swear About Skin
Care, where host Dr.
Shannon C.
Trotter, a board-certifieddermatologist, sits down with
fellow dermatologists andskincare experts to separate
fact from fiction and simplifyskincare.
Let's get started.
SPEAKER_02 (00:46):
Welcome to the Dermot Trotter, Don't Swear
About Skin Care podcast.
I've got Dr.
Neil Batia on with me heretoday, a board-certified
dermatologist in San Diego,California.
He serves as director ofclinical dermatology at
Therapeutics Clinical Researchand as chief medical editor for
practical dermatology.
He's widely published, has abackground in immunology, as
(01:06):
well as interests and mechanismsof therapy, skin cancer, and
medical dermatology.
So it's a joy and a pleasure tohave him here on the podcast.
So welcome to you, Dr.
Bhatia.
SPEAKER_01 (01:15):
Oh, Jenny, you're too kind and thank you.
Thank you.
Thanks for having me.
It's a fun time to actually bepart of it instead of just
listening to it.
SPEAKER_02 (01:22):
So Yeah, and sometime hopefully one day we'll
be able to get it together inperson.
But you're enjoying California.
I'm stuck here in Ohio, ofcourse.
But one day, maybe.
But I'm excited to have you withus because we're going to talk a
bit about actinic keratoses.
This is something that patientsask a lot of questions about.
And even as physicians, we'retreating these on a regular
basis or people are comingthrough the door.
And I think people just don'teven know what they are.
(01:44):
And you know, we're obviouslydoing audio, so we don't really
have a picture to describe them.
But I was hoping you get an ideaof just, you know, what do these
look like?
What are these on the skin?
So maybe somebody out therelistening might get to their
dermatologist to have theseevaluated.
SPEAKER_01 (01:56):
Yeah.
Well, actinogeratoses are asearly as a reflection of sun
damage as you could probably getthat could be of concern that
should bring it to the attentionof the dermatologists.
These are spots that we feelmore that we can see.
They usually start off as vague,dry spots.
These aren't healing.
They look a little red, uh,usually in photo exposed areas,
(02:18):
uh, but often you know in areaslike on the chest and shoulders,
backs of the hands, areas thatdon't often see enough
sunscreen, for example.
Um, these are spots again, youknow, in the dermatology world,
we often refer to them asprecancerous, but they're
actually part of a spectrum.
I I like to refer to them as thetermites of the skin.
You know, you see one and tenmore are coming, and a hundred
(02:38):
more are doing some damage.
Uh so you really don't want tojust treat one.
You want to treat the processthat makes all of them as well.
That being said, again, patientsshould be aware of anything
that, again, just feels like apimple that doesn't heal, starts
off as a red spot, that startsoff as dry skin.
These are the most commonlymistaken, if you will, uh
patient perceptions of whatactinokeratosis really are.
(03:01):
What's also important is thatthese are not just for old
people anymore.
It's not a Medicare disease uhlike it used to be.
We're seeing actinokeratosis in30-year-olds and 40-year-olds.
And again, it's all a functionof cumulative solar exposure
from age 18 and up, if you will.
Uh, what's also important isagain, I always get a kick, even
in San Diego and Wisconsin,where I'm from, Ohio, where you
(03:23):
are, patients are always saying,Well, I don't go out in the sun.
I didn't get this uh when I gotout in the sun.
And I remind them, this is kindof like smoking, right?
You smoke two packs a day untilyou're 20 and you're coughing
when you're 50.
So this is old sun exposurecatching up to you.
Uh the other part of theequation, again, is it's never
too late to use sunscreen.
And just because you have one AKnow doesn't mean you shouldn't
(03:46):
start thinking about 10 yearsfrom now.
So these are patients that weshould be seeing regularly for
screening, and they should beaware of anything that, again,
not only doesn't heal, but also,you know, should be coming to
attention of something a littlesuspicious.
SPEAKER_02 (04:02):
One of the more important things I think you
mentioned is that kind of thatfeel test, like that textural
change you mentioned where itfeels kind of rough or scaly.
Because I know when people comein, I always tell them, you
know, I'm gonna kind of pet yourface a little bit or the rims of
your ears, because you often canfeel them before you see them.
I had a patient even today, hesaid, yeah, I've got this like
sandpaper spot on my skin.
I thought that's like theperfect way to describe it
(04:22):
because it can be confusing,right?
People think it's just dry skin,or maybe it's a rash, not
realizing that this is somethingpotentially serious that could
turn into skin cancer.
So I think that's probably thebig question for you.
People always ask, okay, so yousay I've got this sun damage, I
did it years ago, I'm gonna begood with my sunscreen, but
clearly some of these precancerospots or actinic keratoses are
(04:43):
popping out now.
What is really the likelihoodthat they're gonna turn into
skin cancer?
And what type or types of skincancer do they tend to turn
into?
Do I have to worry aboutmelanoma?
You know, that's a question.
SPEAKER_01 (04:54):
Yeah, those are very important because there's a lot
of misconceptions out there.
And you know, you're in the sameboat as me.
You know, patients are on Googlebefore they come to see me, and
they're all looking at thespots.
And when you tell them what itis by feeling them, they they're
the first to say, Well, are yousure?
And I remind them that you knowtheir two-hour Google search
isn't as effective as my 28years of doing this for a
(05:14):
living.
So that being said, we remindthem also that these are spots
that we feel because there'searly precancerous change to
them that leads to the texturechange, and that's what gives a
precursor to squamous cellcarcinoma.
So actinic keratoses arebasically linked to squamous
cell carcinoma under themicroscope as well as
clinically.
But the good news is it'sanywhere from 0.5% to 16% in the
(05:38):
literature articles that are outthere can show progression to
actinokeratosis.
There's also a subset that mayregress on their own.
So we definitely want to makesure we treat them aggressively
and make sure those aren't theones that get by the goalie and
turn into cancer.
That being said, there'sfortunately no link to melanoma
with an actinokeratosis, butagain, in a heavily sun-damaged
(06:01):
area, there could be a you knowsomething else brewing, which is
why we do the regular skinchecks.
Uh, the other more common uhcancer, basal cell carcinoma,
there's a very rare linkage ofactinokeratosis to basal cell
carcinoma, but the vast majorityof AKs will have a precursor
relationship with squamous cellcarcinoma.
So that's really uh what we wantto talk about.
(06:21):
And again, with patients, youknow, we have to remind them
these are spots that you don'tjust see, they're spots that you
feel.
It's just like going to thedentist, you know, they take
that little probe and we'rewherever they feel it catch in
your teeth, they say, Well,that's a cavity on the way.
We do the same, like you justmentioned.
We rub our fingers over theirforehead, their ears, their
nose, and say, Ah, we can feelthat catch.
That's an early sign of whereactino keratosis may be starting
(06:45):
from.
SPEAKER_02 (06:45):
Now, I just had a patient we mentioned, kind of
feeling nice, touching them andyou know, mentioning there were
several spots there.
And they said, Oh, aren't yougonna biopsy?
You know, to confirm that's whatit is.
And it is important tohighlight, you know, we know how
to diagnose these from aclinical perspective.
It wouldn't be fun to biopsy,nor is it really necessary when
we can go after them.
But an interesting question theyasked, and and I know you know
(07:06):
the answer to this, but I wantto highlight it for our
listeners out there, is that,okay, well, well, which ones
will turn into something?
You know, so they're trying topick and choose maybe what we
treat.
How do you respond to that whenpeople kind of judge maybe which
one would do something kind ofmischievous?
SPEAKER_01 (07:22):
Well, I and that's a real important caveat to the
discussion of treating the wholezone.
Because I remind them about uhhockey, for example, I tell
them, you know, one gets by thegoalie, but you never know which
uh player is going to shoot thepuck.
And from that same example, Isay, well, you don't know which
one of these is actually alreadyin motion of turning into a skin
(07:43):
cancer.
So we need to treat the wholeprocess that makes the actino
keratosis, not just treat whatwe see in front of us.
And that kind of gives into thediscussion of, okay, we may
freeze these today, but we wantto think about what are we going
to do topically to maybe makeyour immune system survey for
these spots more or add to thedestruction of the earlier spots
(08:03):
in motion.
We also think about photodynamictherapy, which is the blue light
or red light treatment,depending on which device is in
the office, that targets thatwhole zone of sun damaged skin
and again gets at the precursorsand the early stages, not just
the ones that are alreadyclinically visible.
So we tend to use the wordsubclinical quite a bit with
these patients.
(08:23):
We say, well, these are the oneswe see today in the office.
There are 10 more that are ontheir way that we're not seeing
yet, and that's all in this zoneof sun damage, whether it be the
backs of their hands, theirforehead, the H zone, or
anything else on their trunk.
So from that standpoint, too, weremind them again, this isn't
from the sun you got fromwalking from your car to the
(08:44):
office.
This is from decades ofunprotected sun exposure or
cumulative sun damage.
And even more so, and I'm sureyou'll you'll say the same thing
to your patients, anywhere whereyou got a sunburn, it's like
having a big cigarette burn inyour in your carpet, right?
It never goes away, and it'salways going to be a precursor
of higher potential that we haveto pay a little bit more
(09:06):
appearance to.
SPEAKER_02 (09:09):
I like what you talk about, you know, the cumulative
exposure.
You know, we we miss thatsometimes, I think, for just
highlighting for patients howimportant it is because they
always talk about, oh, I wentand I had this many burns, which
obviously we know the rolethere, but just how things add
up, right?
Just day-to-day, runningerrands, being in the car,
driving to work, you know, andthe immediate there and now,
right?
They're not seeing the sunburnand thinking damage, but you
(09:30):
know, just how that adds up overtime, what that can do to your
skin when it's not protected,that that's something I think
that is sort of misunderstood ornot really appreciated, how
important it can be fordevelopment of actinic keratoses
and potentially even skin canceras well.
You've you've highlighted againand talked about more about the
ultraviolet light.
What other risk factors, arethere other things people have
(09:50):
to think about besides their sunexposure, sunburns, if they've
used a tanning bat?
Is there other things that theyneed to think about that might
put them at risk for developmentof actinic keratosis?
SPEAKER_01 (09:58):
I mean, genetic tendency and a little bit more
fair skin types, of course, arereally the keys to observation.
I mean, there obviously there'sa setup for patients who are
going to have more, probably atan early age.
Um, but the photoprotection, youknow, behaviors that they
probably learned early on, youknow, not just sunscreen on
their face, but again, Imentioned the back of their
(10:18):
hands, like when they'redriving, for example, or back of
their neck, or even like tops oftheir feet, you know, when
they're wearing sandals.
I mean, these are areas that areall getting the same ultraviolet
exposure.
But then you think about someonewho may have had a transplant,
for example, or who isdefinitely at higher risk
because their immune system isnot able to survey, or if
(10:39):
they've had exposures toionizing radiation, or if
they've had any exposures toarsenic or some other chemicals,
these are things that canactually create another level of
exposure that uh will again helphave these actinokeratoses roll
downhill.
The other part of the equation,too, is again, we we may see
more patients of darker skintypes, and they may not develop
(11:01):
as many actinokeratoses, butthey're still at risk for skin
cancer and as well aspigmentation change and all the
other reasons to have them wearsunscreen.
So, you know, the phobias ofsunscreen and you know the risks
of you know not complying withphotoprotective clothing, we
have to put together the risk ofskin cancer in that same
context.
(11:21):
And you know, unfortunately, youknow, I I have patients who come
in, they say, Well, I just wantI just want to be natural.
I don't want to wear sunscreen.
I said, Well, you know, skincancer is natural.
I I hope you're prepared forthat.
SPEAKER_02 (11:34):
Well, that's a good segue into okay, how do we go
after these, you know, withtreatment?
You mentioned also, you know,freezing or cryotherapy, and
then talking a little bit aboutlight and creams.
Can you kind of an overview oflike the different options that
are there and sort of when youmight choose one option over the
other for a patient?
Yeah.
SPEAKER_01 (11:52):
Well, the main key to the equation, I I often use
it like dating.
The pain, the first thing you'regonna do is you're gonna get to
know somebody, you're gonnaexamine them, and you're gonna
talk to them about not only whatthey have, but also their risks.
The easiest thing to do on thefirst date, which is often the
most uncomfortable, is freezingthe spots initially.
(12:13):
And I hate to uh think about itin many ways like a patient
would, but it it actually givesthem the fang the sense that
something was done when theyleave the office, even though
it's uncomfortable.
But within that same algorithm,we have to remind them that
freezing only gets the treat, itonly treats the spot that we're
seeing.
There may be five otheractinogatosis in development
around it, and more so it's notundoing the damage that the sun
(12:37):
had caused over the years.
So I tell them this is whatwe're gonna do as a bandage, but
then we need something that's alittle bit better remedy, which
is more treating topically withdifferent uh agents that'll
either turn over the skin orcreate an immune response
against the pre the the precastspots, or some combination of
protecting against sundam.
(12:58):
So drugs like retinoids, forexample, are very important for
photodamage and correcting theirdefect.
There are some uh old schooltreatments like topical five or
uracil, which turns over theskin and creates a very
aggressive sloughing response,which can be a bit uncomfortable
and a little bit uh difficult tomanage sometimes.
Humiclamide is another treatmentthat makes your immune response
(13:20):
kind of work harder againstsurveying for those precanterous
spots, which is again going tocreate a little bit of redness.
And then there's a few othersthat have been taken off the
market.
Uh, and then one newer agent,which is called turbinivulin,
which comes in an ointment form,which I think is now the
standard of treatments on themarket.
Um, it's five days of treatment,very little local skin reactions
(13:41):
that could be limiting, and yetis still very effective.
So I think we've we've reachedan era where that's going to be
very important for us.
Um, the other part of thatequation, again, goes with
compatible sunscreen andmoisturizer, things that are
gonna feel good on the skin, getrid of some of the sloughing and
the dead skin.
And then more importantly, is uhtaking some supplements that'll
have some antioxidant effects,uh, ingredients like polypodium
(14:05):
leucotomas, for example, uhnicotinamide.
These are all importantsupplements that are available
on the market that actually canhelp over time reduce some of
that impact of photodamage andreduce the risk of sunburns and
eventually reduce the risk ofskin cancer, hopefully.
And then the other part of thatequation is again scheduling
photodynamic therapy at a timewhen they can be available for
(14:28):
the skin reactions that follow.
Because photodynamic therapy isbased on sensitizing the skin,
exposing it to a light devicethat is going to create a
reaction to destroy those spotsand destroy the spots that are
coming.
The downside for many patientsis that they're gonna be a
little bit red and they have tostay indoors for a day or two.
So it is a little bit ofinvestment in time.
(14:48):
So that takes a little bit ofscheduling.
It's probably not something wewould do on the first day
because they have to stay in theoffice for about two hours to
incubate their uh sensitizer,they have to stay in the light
for about 16 minutes, 40seconds, or 10 minutes,
depending on if it's red lightor blue light.
And then for the next two days,they really need to plan to be
indoors away from light.
And I one thing I think youmentioned too about UV light,
(15:11):
we're we're learning a lot aboutblue light from devices, blue
light from the computer screen.
We're learning a lot aboutvisible light.
All of these now are creatingsome of the same interactions
with the skin that UV light hasbeen.
And the newer sunscreen agents,uh, whether they be mineral or
chemical, whether they haveshield, whether they have tint,
they're they're actually meantto help us focus on you know the
(15:33):
blue light and visible light.
So, you know, many of us havepatients who work from home.
You know, we learned a lotduring the pandemic about you
know how much time people arespending in front of the
screens.
And they they have to be wearingsunscreen actually indoors,
which for many of them iscounterintuitive.
It's an extra step.
But we know that if they dothat, it's gonna help reduce
their risk of uh developing alot of these spots as well.
(15:55):
So that's kind of the algorithmof incorporating those three
devices.
Now, many will turn to othertreatments such as chemical
peels, uh laser resurfacing witha CO2 laser or a fractional
laser.
Those are typicallyout-of-pocket treatments that
are not covered by insurance,although, again, there are
others who can use similardevices that might have some
(16:16):
insurance coverage, buttypically those are considered a
off-label or out-of-pockettreatment.
That being said, they do help itto resurface and give a new
layer to the skin, but they'renot really doing anything to the
process.
They're more just treating whatwe see in front of us and
improving the texture of skin aswell as the photo damage.
Uh, but you know, patients arestill at a setup for
actinokeratosis, even with thosetreatments.
SPEAKER_02 (16:39):
So someone came into you and had, you know, maybe
this was, you know, because thisis what you said we're seeing a
lot more of, and I agree withyou, a woman who's 40 years old,
maybe has one or two spotsyou've noticed on her face,
maybe a history of using atanning bed or has had a lot of
sun exposure early on in life.
You know, would you approach herwith maybe the option of
freezing, or would you addresskind of the zone or field
(17:00):
therapy that people call itwhere you'd be a little bit more
proactive versus reactive, justmaybe based on age?
Because I think a lot of peoplethink, oh, you got to be
covered, right, to do theselight treatments or creams that
you have to have multipleprecancers.
But do you feel like there's youknow validity and like a room
for it, you know, to actuallyhave purpose where we could go
after this a lot you know moreaggressively than what we do?
Because a lot of people do.
SPEAKER_01 (17:20):
Oh, absolutely.
I mean, someone like that whomay be you know public facing,
you know, they may be on TV, forexample, they may be in sales,
they may have a reason to be outin public, they may not be ready
to have the treatment on thatsame day.
So we probably would have toschedule it and say, all right,
look, we'll freeze you on aFriday afternoon when you can
take the weekend off, you canrecover a little bit.
(17:40):
But we talk to them a lot aboutphotodynamic therapy because of
the benefits that it's doing toreverse some of the elements of
photoaging.
And there's there's very gooddata in research as well as
clinical practice on what bluelight and red light can do to
help resurface and improve thetexture of the skin, improve the
sallow color, improve some ofthe uh wrinkling and some of the
(18:02):
dyschromia from from uh old sundamage.
And a lot of patients like thatwho are in with one or two
spots, you know, we have toremind them that you might have
10 uh in a year from now if wedon't do something more
aggressive.
So they're a little bit more intune to saying, yeah, maybe
let's do something like thatnow, and they'll get the
benefits of the impact ofphotoaging as well.
(18:22):
So a lot of differentconversation topics to have.
And you just have to really putthings into every individual's
context.
You know, a 70-year-old man whoyou know doesn't spend a lot of
time in front of people may notfeel the need to worry as much
about appearance as, again, a40-year-old female who's out in
the public.
So definitely want to take, youknow, take your audience and
(18:42):
talk to them about thoseoptions.
And then the other part of thatequation is incorporating a
timeline of you know, lettingthe skin rest before you do the
next treatment, whether it beyou know liquid nitrogen, then
two weeks later, incorporate atopical, do the topical for a
month, you know, give anothertwo-week holiday, then do the
photodynamic therapy, and justkind of rinsing and repeating
(19:04):
that cycle so that you'restaying on top of those patients
who are not only high risk, butalso the ones who come in with
early spots and then you knowtry to mitigate those and
prevent those from turning intoskin cancer too.
SPEAKER_02 (19:16):
And for some of the tobaccos, I know we talked a
little bit about five floweryour cell.
Have you been using it incombination with calcipitrine or
a vitamin D cream where theycombine it?
Do you feel like that's beenuseful as a treatment option as
well?
SPEAKER_01 (19:28):
I inherit a lot of those patients from the VA, from
Kaiser, uh, and they they havesome very uh uh they have some
very vigorous skin reactions.
They're they're they can burnand stain, they they're not sure
of what the protocol is thatthey should do, which when.
Uh so a lot of patients come ina little bit confused.
Uh they also get irritated quitea bit and they may not have the
(19:48):
adjuncts to controlling thatirritation, whether it be
emollients or anything else.
Uh the one thing that you wantto tell patients not to use are
topical steroids because thatundoes the inflammation that
we're actually trying to recruitto treat the process.
Um, so I I more often am usingterbenibulin ointment just
because, again, I I think thereaction patterns are are more
(20:10):
effective and more manageable.
But you know, patients on 5 FUand calcifitriine, they they
tend to do very well.
It's just the burning andstinging can be a little bit of
an issue for them.
SPEAKER_02 (20:20):
Yeah, I think that's obviously the downside with the
the creams, the the tolerabilityis really the driving force, I
feel like, for a lot ofpatients, you know.
Yeah.
SPEAKER_01 (20:29):
If they're not on something they can stick with,
they're not gonna they're notgonna get the outcomes.
SPEAKER_02 (20:32):
Yeah, we used to we used to teach, you know, when
you had you know Tom Cruise, youknow, you can you remember back
in the day the movie said, Canyou handle the truth?
It was like, can you handle theirritation?
We used to all about thatbecause boy is it real.
And you do have to pick, Ithink, like you said,
personality, lifestyle,temperament of the patient.
Definitely sometimes withtopicals, there is uh, and
sometimes obviously with PDT tooor photodynamic therapy that no
(20:54):
pain, no gain can happen.
It's just variable in how mucheveryone experiences.
SPEAKER_01 (20:58):
And and to that same point, you have to time it.
You know, I've I've had patientscome in and say, Well, I'm I'm I
have uh my sister, you know, Ihave my daughter's wedding the
next day.
Can we do it then?
I'm like, no, we're not doingthat.
You know, I have to get out ofright, I to I have to play
around to golf that afternoon.
It's like, well, then we'redefinitely not doing anything
today.
So, you know, again, a lot of itgoes with that.
SPEAKER_02 (21:18):
Yeah, exactly.
And and the trends is you'veseen, I think, across healthcare
too, and and you alluded to thisearlier, is looking for
supplements, natural ways tokind of go after sun damage.
And you talked a little bitabout polypodium and also
nicotinamide.
Do you mind just explaining alittle bit like what we kind of
know about those and how theymight actually be helpful for
correcting sun damage?
SPEAKER_01 (21:37):
Yeah, I I know that um there's a lot of
misconception about when to usesunscreen and when to take these
pills.
And I remind everyone that youknow, sunscreens are like
toothpaste to the skin.
You know, you're not reallytreating anything, you're
preventing problems.
And we do things, you know,again, twice a day to actually
keep a level of maintenanceagainst the process that's gonna
harm us.
(21:58):
Just like we brush our teethtwice a day.
If they use sunscreen atbreakfast and lunch, they're
prevented, they're helping toprevent the exposure from
getting to the skin at the mostuh sunny day times of the day.
So I put it into context likethat so they understand how
sunscreen is actually helpingthem by preventing problems, not
treating problems.
What polypotamine leucotomasdoes is it reduces the
(22:19):
interaction of the skin withultraviolet light by antioxidant
effects.
But it takes a little bit oftime to kick in.
So, like if you have someonewho's going to the beach or want
to play golf or going on a hike,I tell them, look, take this
half an hour before you go out,and you'll be protected for
about two hours to about 80% ofthe need you have for reducing
your sunburn risk.
(22:39):
And then I tell them take itagain two hours later.
You know, for golf, I tell themtake it at the turn.
For a hike, I tell them take itagain on your way back.
You know, just put it intocontext of what their activities
are, and they'll understandthat's like, okay, I'm doing
this to reduce my risk ofsunburn because sunburn is no
fun.
And that also, again, putincreases their risk.
So it'll help kind of put intocontext for them a prevention
(23:02):
strategy as well as a treatmentstrategy with what we're seeing
in front of us.
So some of that is really veryhelpful.
I mean, you can't expectpatients to put themselves in
bubble wrap and you know weargloves all day long or wear a
hat all day long.
It's just unrealistic, eventhough those who do are are
helping themselves out.
But the fact of the matter is ifthey if they can get into some
routine of, okay, this is whatI'm gonna do every day, and I'm
(23:25):
gonna change my outcomes,they'll help reduce their skin
cancer risk for the long run.
SPEAKER_02 (23:30):
And that's what patients want.
They want options, right?
I mean, they're used tosunscreen.
I feel like people are kind oftired on sunscreen.
And for another podcast,obviously there's kind of this
uh attack on sunscreen era thatwe've been, you know, dealing
with, I feel like, on socialmedia and this podcast that
we'll address.
But so I think just givingpeople these other options, it's
a whole, you know, skin cancer,actinic keratosis prevention, if
(23:53):
you will, sort of uh, you know,toolkit that they have lots of
options to go after it.
And the one thing I think Iforgot that I wanted to kind of
bring up is just the chronicityof actinic keratosis.
I'm gonna have you kind of endwith like speaking to that
because I think that's very wellmisunderstood, sometimes even by
uh, you know, providers outthere that are treating it, or
obviously even the patient,because I've had patients come
(24:14):
in like, you just treated these,you know, a year ago, six months
ago.
What's going on?
You know, once you treatedsomething recurred, I've got new
ones.
Do you mind kind of explainingit?
Because I think that is kind ofanother misconception that leads
to a lot of patient frustration.
SPEAKER_01 (24:27):
Yeah, it's it's kind of how I go back to that dating
example.
I tell them, I say, all right,well, look, you're you just met
me today, but we're gonna sticktogether for a while because I'm
gonna be seeing you back atleast every six months, if not
every year, to make sure thatthese don't come back.
I remind them, you know, andagain, at the risk of offending
your listeners, I say, look,this is a lot like losing your
virginity.
Once once it's happening, you'renot going back.
(24:47):
So now that you have these,you're gonna keep getting them
if we don't be careful to screenyou adequately.
Uh the other part, again, isthat we have to stay on top of
regular screenings, not just foryour risk of these, but for
melanoma and anything else thatcould be related to the amount
of sun exposure you have.
So the chronicity for them isI'll be seeing you routinely to
(25:11):
prevent problems and stay aheadof this, so that we don't have
to get into more aggressivetreatments like the topicals or
you know, photodynamic therapyif we can if we can keep them at
bay and try to freeze what wesee.
But more importantly, also isyou know, again, establishing a
routine for them so they have amap of what to look for and they
know that the consequence ofthem not being screened could
(25:32):
actually lead to surgeries andand things that we might have
more risk with.
The other part, again, is indermatology, you know, we do our
best to cure problems, but thereare many things that we end up
maintaining, whether it beeczema, rhizus, severic
dermatitis, actinokeratosis fitsright into that.
You know, once you're in thatclub, we're gonna be following
you for probably for the rest ofyour life.
(25:53):
So we just have to put that intoa context.
But I we also try to do itwithout blame.
We say, well, remember all thoseyears we were at the beach?
Well, you did this to yourself,so you know, suck it up, right?
I mean, we can't really do thateither.
SPEAKER_02 (26:05):
No, no.
Our job is not to judge, but totreat and help people, you know,
that's what that's what comesfirst.
Well, well, thank you so muchfor coming on and going through
that.
I think that gives a clearerpicture.
We've got to understand, youknow, a lot of people even heard
what's an actinic keratosis orwhat's an AK or pre-cancerous
lesion.
So that was a great overview ofeverything.
And we'll we'll be sure to stickwith you too, just like your
patients stick with you andmaybe get you back on here.
SPEAKER_01 (26:26):
Dr.
Trotty, you point out.
SPEAKER_02 (26:28):
Oh, of course, of course.
Well, I do want to let ourlisteners know if they want to
track you down, do you mindsharing with them how they can
find you online or if you havesocial media?
SPEAKER_01 (26:38):
Oh, sure.
Well, I mean, our our place iscalled Therapeutics Clinical
Research.
We're in San Diego, California.
Uh, I'm not much of aninfluencer on social media.
I speak at a lot of conferences,but uh our place is found on uh
social media and we can uh weusually keep a presence there.
I I tend to keep a little bitlower profile on online just
because of uh someconfidentiality things that we
(26:59):
deal with with with clinicalresearch trials.
So that's that's the onlyreason.
SPEAKER_02 (27:03):
Makes sense.
Well, I'm sure people still wantto track you down and they can
listen to you.
I'm sure they can find you ifthey Google you, they'll find
some of your presentations ormore information.
So you know, you can't hide toomuch from them.
That's pretty good.
SPEAKER_01 (27:14):
Well, thank you for having me.
This was fun.
SPEAKER_02 (27:16):
Of course, yes.
We'll have to do it again.
And I want to let everyone knowif you like what you hear,
please click like and subscribe.
And stay tuned for the nextepisode of Dermotrotter.
Don't swear about skincare.
SPEAKER_00 (27:28):
Thanks for listening to Dermot Trotter.
For more about skincare, visitdermittrotter.com.
Don't forget to subscribe, leavea review, and share this podcast
with anyone who needs a littleskincare sanity.
Until next time, stay skinsmart.
Again, just feels like a pimple that doesn't heal,
starts off as a red spot, thatstarts off as dry skin.
SPEAKER_02 (00:05):
What is really the likelihood that they're gonna
turn into skin cancer and whattype or types of skin cancer do
they tend to turn into?
SPEAKER_01 (00:12):
Targets that whole zone of sun damaged skin and
again gets at the precursors inthe early stages and tell them,
look, take this half an hourbefore you go out, and you'll be
protected for about two hours toabout 80% of the the need you
have uh for reducing yoursunburn risk.
SPEAKER_00 (00:28):
Welcome to Dermot Trotter, Don't Swear About Skin
Care, where host Dr.
Shannon C.
Trotter, a board-certifieddermatologist, sits down with
fellow dermatologists andskincare experts to separate
fact from fiction and simplifyskincare.
Let's get started.
SPEAKER_02 (00:46):
Welcome to the Dermot Trotter, Don't Swear
About Skin Care podcast.
I've got Dr.
Neil Batia on with me heretoday, a board-certified
dermatologist in San Diego,California.
He serves as director ofclinical dermatology at
Therapeutics Clinical Researchand as chief medical editor for
practical dermatology.
He's widely published, has abackground in immunology, as
(01:06):
well as interests and mechanismsof therapy, skin cancer, and
medical dermatology.
So it's a joy and a pleasure tohave him here on the podcast.
So welcome to you, Dr.
Bhatia.
SPEAKER_01 (01:15):
Oh, Jenny, you're too kind and thank you.
Thank you.
Thanks for having me.
It's a fun time to actually bepart of it instead of just
listening to it.
SPEAKER_02 (01:22):
So Yeah, and sometime hopefully one day we'll
be able to get it together inperson.
But you're enjoying California.
I'm stuck here in Ohio, ofcourse.
But one day, maybe.
But I'm excited to have you withus because we're going to talk a
bit about actinic keratoses.
This is something that patientsask a lot of questions about.
And even as physicians, we'retreating these on a regular
basis or people are comingthrough the door.
And I think people just don'teven know what they are.
(01:44):
And you know, we're obviouslydoing audio, so we don't really
have a picture to describe them.
But I was hoping you get an ideaof just, you know, what do these
look like?
What are these on the skin?
So maybe somebody out therelistening might get to their
dermatologist to have theseevaluated.
SPEAKER_01 (01:56):
Yeah.
Well, actinogeratoses are asearly as a reflection of sun
damage as you could probably getthat could be of concern that
should bring it to the attentionof the dermatologists.
These are spots that we feelmore that we can see.
They usually start off as vague,dry spots.
These aren't healing.
They look a little red, uh,usually in photo exposed areas,
(02:18):
uh, but often you know in areaslike on the chest and shoulders,
backs of the hands, areas thatdon't often see enough
sunscreen, for example.
Um, these are spots again, youknow, in the dermatology world,
we often refer to them asprecancerous, but they're
actually part of a spectrum.
I I like to refer to them as thetermites of the skin.
You know, you see one and tenmore are coming, and a hundred
(02:38):
more are doing some damage.
Uh so you really don't want tojust treat one.
You want to treat the processthat makes all of them as well.
That being said, again, patientsshould be aware of anything
that, again, just feels like apimple that doesn't heal, starts
off as a red spot, that startsoff as dry skin.
These are the most commonlymistaken, if you will, uh
patient perceptions of whatactinokeratosis really are.
(03:01):
What's also important is thatthese are not just for old
people anymore.
It's not a Medicare disease uhlike it used to be.
We're seeing actinokeratosis in30-year-olds and 40-year-olds.
And again, it's all a functionof cumulative solar exposure
from age 18 and up, if you will.
Uh, what's also important isagain, I always get a kick, even
in San Diego and Wisconsin,where I'm from, Ohio, where you
(03:23):
are, patients are always saying,Well, I don't go out in the sun.
I didn't get this uh when I gotout in the sun.
And I remind them, this is kindof like smoking, right?
You smoke two packs a day untilyou're 20 and you're coughing
when you're 50.
So this is old sun exposurecatching up to you.
Uh the other part of theequation, again, is it's never
too late to use sunscreen.
And just because you have one AKnow doesn't mean you shouldn't
(03:46):
start thinking about 10 yearsfrom now.
So these are patients that weshould be seeing regularly for
screening, and they should beaware of anything that, again,
not only doesn't heal, but also,you know, should be coming to
attention of something a littlesuspicious.
SPEAKER_02 (04:02):
One of the more important things I think you
mentioned is that kind of thatfeel test, like that textural
change you mentioned where itfeels kind of rough or scaly.
Because I know when people comein, I always tell them, you
know, I'm gonna kind of pet yourface a little bit or the rims of
your ears, because you often canfeel them before you see them.
I had a patient even today, hesaid, yeah, I've got this like
sandpaper spot on my skin.
I thought that's like theperfect way to describe it
(04:22):
because it can be confusing,right?
People think it's just dry skin,or maybe it's a rash, not
realizing that this is somethingpotentially serious that could
turn into skin cancer.
So I think that's probably thebig question for you.
People always ask, okay, so yousay I've got this sun damage, I
did it years ago, I'm gonna begood with my sunscreen, but
clearly some of these precancerospots or actinic keratoses are
(04:43):
popping out now.
What is really the likelihoodthat they're gonna turn into
skin cancer?
And what type or types of skincancer do they tend to turn
into?
Do I have to worry aboutmelanoma?
You know, that's a question.
SPEAKER_01 (04:54):
Yeah, those are very important because there's a lot
of misconceptions out there.
And you know, you're in the sameboat as me.
You know, patients are on Googlebefore they come to see me, and
they're all looking at thespots.
And when you tell them what itis by feeling them, they they're
the first to say, Well, are yousure?
And I remind them that you knowtheir two-hour Google search
isn't as effective as my 28years of doing this for a
(05:14):
living.
So that being said, we remindthem also that these are spots
that we feel because there'searly precancerous change to
them that leads to the texturechange, and that's what gives a
precursor to squamous cellcarcinoma.
So actinic keratoses arebasically linked to squamous
cell carcinoma under themicroscope as well as
clinically.
But the good news is it'sanywhere from 0.5% to 16% in the
(05:38):
literature articles that are outthere can show progression to
actinokeratosis.
There's also a subset that mayregress on their own.
So we definitely want to makesure we treat them aggressively
and make sure those aren't theones that get by the goalie and
turn into cancer.
That being said, there'sfortunately no link to melanoma
with an actinokeratosis, butagain, in a heavily sun-damaged
(06:01):
area, there could be a you knowsomething else brewing, which is
why we do the regular skinchecks.
Uh, the other more common uhcancer, basal cell carcinoma,
there's a very rare linkage ofactinokeratosis to basal cell
carcinoma, but the vast majorityof AKs will have a precursor
relationship with squamous cellcarcinoma.
So that's really uh what we wantto talk about.
(06:21):
And again, with patients, youknow, we have to remind them
these are spots that you don'tjust see, they're spots that you
feel.
It's just like going to thedentist, you know, they take
that little probe and we'rewherever they feel it catch in
your teeth, they say, Well,that's a cavity on the way.
We do the same, like you justmentioned.
We rub our fingers over theirforehead, their ears, their
nose, and say, Ah, we can feelthat catch.
That's an early sign of whereactino keratosis may be starting
(06:45):
from.
SPEAKER_02 (06:45):
Now, I just had a patient we mentioned, kind of
feeling nice, touching them andyou know, mentioning there were
several spots there.
And they said, Oh, aren't yougonna biopsy?
You know, to confirm that's whatit is.
And it is important tohighlight, you know, we know how
to diagnose these from aclinical perspective.
It wouldn't be fun to biopsy,nor is it really necessary when
we can go after them.
But an interesting question theyasked, and and I know you know
(07:06):
the answer to this, but I wantto highlight it for our
listeners out there, is that,okay, well, well, which ones
will turn into something?
You know, so they're trying topick and choose maybe what we
treat.
How do you respond to that whenpeople kind of judge maybe which
one would do something kind ofmischievous?
SPEAKER_01 (07:22):
Well, I and that's a real important caveat to the
discussion of treating the wholezone.
Because I remind them about uhhockey, for example, I tell
them, you know, one gets by thegoalie, but you never know which
uh player is going to shoot thepuck.
And from that same example, Isay, well, you don't know which
one of these is actually alreadyin motion of turning into a skin
(07:43):
cancer.
So we need to treat the wholeprocess that makes the actino
keratosis, not just treat whatwe see in front of us.
And that kind of gives into thediscussion of, okay, we may
freeze these today, but we wantto think about what are we going
to do topically to maybe makeyour immune system survey for
these spots more or add to thedestruction of the earlier spots
(08:03):
in motion.
We also think about photodynamictherapy, which is the blue light
or red light treatment,depending on which device is in
the office, that targets thatwhole zone of sun damaged skin
and again gets at the precursorsand the early stages, not just
the ones that are alreadyclinically visible.
So we tend to use the wordsubclinical quite a bit with
these patients.
(08:23):
We say, well, these are the oneswe see today in the office.
There are 10 more that are ontheir way that we're not seeing
yet, and that's all in this zoneof sun damage, whether it be the
backs of their hands, theirforehead, the H zone, or
anything else on their trunk.
So from that standpoint, too, weremind them again, this isn't
from the sun you got fromwalking from your car to the
(08:44):
office.
This is from decades ofunprotected sun exposure or
cumulative sun damage.
And even more so, and I'm sureyou'll you'll say the same thing
to your patients, anywhere whereyou got a sunburn, it's like
having a big cigarette burn inyour in your carpet, right?
It never goes away, and it'salways going to be a precursor
of higher potential that we haveto pay a little bit more
(09:06):
appearance to.
SPEAKER_02 (09:09):
I like what you talk about, you know, the cumulative
exposure.
You know, we we miss thatsometimes, I think, for just
highlighting for patients howimportant it is because they
always talk about, oh, I wentand I had this many burns, which
obviously we know the rolethere, but just how things add
up, right?
Just day-to-day, runningerrands, being in the car,
driving to work, you know, andthe immediate there and now,
right?
They're not seeing the sunburnand thinking damage, but you
(09:30):
know, just how that adds up overtime, what that can do to your
skin when it's not protected,that that's something I think
that is sort of misunderstood ornot really appreciated, how
important it can be fordevelopment of actinic keratoses
and potentially even skin canceras well.
You've you've highlighted againand talked about more about the
ultraviolet light.
What other risk factors, arethere other things people have
(09:50):
to think about besides their sunexposure, sunburns, if they've
used a tanning bat?
Is there other things that theyneed to think about that might
put them at risk for developmentof actinic keratosis?
SPEAKER_01 (09:58):
I mean, genetic tendency and a little bit more
fair skin types, of course, arereally the keys to observation.
I mean, there obviously there'sa setup for patients who are
going to have more, probably atan early age.
Um, but the photoprotection, youknow, behaviors that they
probably learned early on, youknow, not just sunscreen on
their face, but again, Imentioned the back of their
(10:18):
hands, like when they'redriving, for example, or back of
their neck, or even like tops oftheir feet, you know, when
they're wearing sandals.
I mean, these are areas that areall getting the same ultraviolet
exposure.
But then you think about someonewho may have had a transplant,
for example, or who isdefinitely at higher risk
because their immune system isnot able to survey, or if
(10:39):
they've had exposures toionizing radiation, or if
they've had any exposures toarsenic or some other chemicals,
these are things that canactually create another level of
exposure that uh will again helphave these actinokeratoses roll
downhill.
The other part of the equation,too, is again, we we may see
more patients of darker skintypes, and they may not develop
(11:01):
as many actinokeratoses, butthey're still at risk for skin
cancer and as well aspigmentation change and all the
other reasons to have them wearsunscreen.
So, you know, the phobias ofsunscreen and you know the risks
of you know not complying withphotoprotective clothing, we
have to put together the risk ofskin cancer in that same
context.
(11:21):
And you know, unfortunately, youknow, I I have patients who come
in, they say, Well, I just wantI just want to be natural.
I don't want to wear sunscreen.
I said, Well, you know, skincancer is natural.
I I hope you're prepared forthat.
SPEAKER_02 (11:34):
Well, that's a good segue into okay, how do we go
after these, you know, withtreatment?
You mentioned also, you know,freezing or cryotherapy, and
then talking a little bit aboutlight and creams.
Can you kind of an overview oflike the different options that
are there and sort of when youmight choose one option over the
other for a patient?
Yeah.
SPEAKER_01 (11:52):
Well, the main key to the equation, I I often use
it like dating.
The pain, the first thing you'regonna do is you're gonna get to
know somebody, you're gonnaexamine them, and you're gonna
talk to them about not only whatthey have, but also their risks.
The easiest thing to do on thefirst date, which is often the
most uncomfortable, is freezingthe spots initially.
(12:13):
And I hate to uh think about itin many ways like a patient
would, but it it actually givesthem the fang the sense that
something was done when theyleave the office, even though
it's uncomfortable.
But within that same algorithm,we have to remind them that
freezing only gets the treat, itonly treats the spot that we're
seeing.
There may be five otheractinogatosis in development
around it, and more so it's notundoing the damage that the sun
(12:37):
had caused over the years.
So I tell them this is whatwe're gonna do as a bandage, but
then we need something that's alittle bit better remedy, which
is more treating topically withdifferent uh agents that'll
either turn over the skin orcreate an immune response
against the pre the the precastspots, or some combination of
protecting against sundam.
(12:58):
So drugs like retinoids, forexample, are very important for
photodamage and correcting theirdefect.
There are some uh old schooltreatments like topical five or
uracil, which turns over theskin and creates a very
aggressive sloughing response,which can be a bit uncomfortable
and a little bit uh difficult tomanage sometimes.
Humiclamide is another treatmentthat makes your immune response
(13:20):
kind of work harder againstsurveying for those precanterous
spots, which is again going tocreate a little bit of redness.
And then there's a few othersthat have been taken off the
market.
Uh, and then one newer agent,which is called turbinivulin,
which comes in an ointment form,which I think is now the
standard of treatments on themarket.
Um, it's five days of treatment,very little local skin reactions
(13:41):
that could be limiting, and yetis still very effective.
So I think we've we've reachedan era where that's going to be
very important for us.
Um, the other part of thatequation, again, goes with
compatible sunscreen andmoisturizer, things that are
gonna feel good on the skin, getrid of some of the sloughing and
the dead skin.
And then more importantly, is uhtaking some supplements that'll
have some antioxidant effects,uh, ingredients like polypodium
(14:05):
leucotomas, for example, uhnicotinamide.
These are all importantsupplements that are available
on the market that actually canhelp over time reduce some of
that impact of photodamage andreduce the risk of sunburns and
eventually reduce the risk ofskin cancer, hopefully.
And then the other part of thatequation is again scheduling
photodynamic therapy at a timewhen they can be available for
(14:28):
the skin reactions that follow.
Because photodynamic therapy isbased on sensitizing the skin,
exposing it to a light devicethat is going to create a
reaction to destroy those spotsand destroy the spots that are
coming.
The downside for many patientsis that they're gonna be a
little bit red and they have tostay indoors for a day or two.
So it is a little bit ofinvestment in time.
(14:48):
So that takes a little bit ofscheduling.
It's probably not something wewould do on the first day
because they have to stay in theoffice for about two hours to
incubate their uh sensitizer,they have to stay in the light
for about 16 minutes, 40seconds, or 10 minutes,
depending on if it's red lightor blue light.
And then for the next two days,they really need to plan to be
indoors away from light.
And I one thing I think youmentioned too about UV light,
(15:11):
we're we're learning a lot aboutblue light from devices, blue
light from the computer screen.
We're learning a lot aboutvisible light.
All of these now are creatingsome of the same interactions
with the skin that UV light hasbeen.
And the newer sunscreen agents,uh, whether they be mineral or
chemical, whether they haveshield, whether they have tint,
they're they're actually meantto help us focus on you know the
(15:33):
blue light and visible light.
So, you know, many of us havepatients who work from home.
You know, we learned a lotduring the pandemic about you
know how much time people arespending in front of the
screens.
And they they have to be wearingsunscreen actually indoors,
which for many of them iscounterintuitive.
It's an extra step.
But we know that if they dothat, it's gonna help reduce
their risk of uh developing alot of these spots as well.
(15:55):
So that's kind of the algorithmof incorporating those three
devices.
Now, many will turn to othertreatments such as chemical
peels, uh laser resurfacing witha CO2 laser or a fractional
laser.
Those are typicallyout-of-pocket treatments that
are not covered by insurance,although, again, there are
others who can use similardevices that might have some
(16:16):
insurance coverage, buttypically those are considered a
off-label or out-of-pockettreatment.
That being said, they do help itto resurface and give a new
layer to the skin, but they'renot really doing anything to the
process.
They're more just treating whatwe see in front of us and
improving the texture of skin aswell as the photo damage.
Uh, but you know, patients arestill at a setup for
actinokeratosis, even with thosetreatments.
SPEAKER_02 (16:39):
So someone came into you and had, you know, maybe
this was, you know, because thisis what you said we're seeing a
lot more of, and I agree withyou, a woman who's 40 years old,
maybe has one or two spotsyou've noticed on her face,
maybe a history of using atanning bed or has had a lot of
sun exposure early on in life.
You know, would you approach herwith maybe the option of
freezing, or would you addresskind of the zone or field
(17:00):
therapy that people call itwhere you'd be a little bit more
proactive versus reactive, justmaybe based on age?
Because I think a lot of peoplethink, oh, you got to be
covered, right, to do theselight treatments or creams that
you have to have multipleprecancers.
But do you feel like there's youknow validity and like a room
for it, you know, to actuallyhave purpose where we could go
after this a lot you know moreaggressively than what we do?
Because a lot of people do.
SPEAKER_01 (17:20):
Oh, absolutely.
I mean, someone like that whomay be you know public facing,
you know, they may be on TV, forexample, they may be in sales,
they may have a reason to be outin public, they may not be ready
to have the treatment on thatsame day.
So we probably would have toschedule it and say, all right,
look, we'll freeze you on aFriday afternoon when you can
take the weekend off, you canrecover a little bit.
(17:40):
But we talk to them a lot aboutphotodynamic therapy because of
the benefits that it's doing toreverse some of the elements of
photoaging.
And there's there's very gooddata in research as well as
clinical practice on what bluelight and red light can do to
help resurface and improve thetexture of the skin, improve the
sallow color, improve some ofthe uh wrinkling and some of the
(18:02):
dyschromia from from uh old sundamage.
And a lot of patients like thatwho are in with one or two
spots, you know, we have toremind them that you might have
10 uh in a year from now if wedon't do something more
aggressive.
So they're a little bit more intune to saying, yeah, maybe
let's do something like thatnow, and they'll get the
benefits of the impact ofphotoaging as well.
(18:22):
So a lot of differentconversation topics to have.
And you just have to really putthings into every individual's
context.
You know, a 70-year-old man whoyou know doesn't spend a lot of
time in front of people may notfeel the need to worry as much
about appearance as, again, a40-year-old female who's out in
the public.
So definitely want to take, youknow, take your audience and
(18:42):
talk to them about thoseoptions.
And then the other part of thatequation is incorporating a
timeline of you know, lettingthe skin rest before you do the
next treatment, whether it beyou know liquid nitrogen, then
two weeks later, incorporate atopical, do the topical for a
month, you know, give anothertwo-week holiday, then do the
photodynamic therapy, and justkind of rinsing and repeating
(19:04):
that cycle so that you'restaying on top of those patients
who are not only high risk, butalso the ones who come in with
early spots and then you knowtry to mitigate those and
prevent those from turning intoskin cancer too.
SPEAKER_02 (19:16):
And for some of the tobaccos, I know we talked a
little bit about five floweryour cell.
Have you been using it incombination with calcipitrine or
a vitamin D cream where theycombine it?
Do you feel like that's beenuseful as a treatment option as
well?
SPEAKER_01 (19:28):
I inherit a lot of those patients from the VA, from
Kaiser, uh, and they they havesome very uh uh they have some
very vigorous skin reactions.
They're they're they can burnand stain, they they're not sure
of what the protocol is thatthey should do, which when.
Uh so a lot of patients come ina little bit confused.
Uh they also get irritated quitea bit and they may not have the
(19:48):
adjuncts to controlling thatirritation, whether it be
emollients or anything else.
Uh the one thing that you wantto tell patients not to use are
topical steroids because thatundoes the inflammation that
we're actually trying to recruitto treat the process.
Um, so I I more often am usingterbenibulin ointment just
because, again, I I think thereaction patterns are are more
(20:10):
effective and more manageable.
But you know, patients on 5 FUand calcifitriine, they they
tend to do very well.
It's just the burning andstinging can be a little bit of
an issue for them.
SPEAKER_02 (20:20):
Yeah, I think that's obviously the downside with the
the creams, the the tolerabilityis really the driving force, I
feel like, for a lot ofpatients, you know.
Yeah.
SPEAKER_01 (20:29):
If they're not on something they can stick with,
they're not gonna they're notgonna get the outcomes.
SPEAKER_02 (20:32):
Yeah, we used to we used to teach, you know, when
you had you know Tom Cruise, youknow, you can you remember back
in the day the movie said, Canyou handle the truth?
It was like, can you handle theirritation?
We used to all about thatbecause boy is it real.
And you do have to pick, Ithink, like you said,
personality, lifestyle,temperament of the patient.
Definitely sometimes withtopicals, there is uh, and
sometimes obviously with PDT tooor photodynamic therapy that no
(20:54):
pain, no gain can happen.
It's just variable in how mucheveryone experiences.
SPEAKER_01 (20:58):
And and to that same point, you have to time it.
You know, I've I've had patientscome in and say, Well, I'm I'm I
have uh my sister, you know, Ihave my daughter's wedding the
next day.
Can we do it then?
I'm like, no, we're not doingthat.
You know, I have to get out ofright, I to I have to play
around to golf that afternoon.
It's like, well, then we'redefinitely not doing anything
today.
So, you know, again, a lot of itgoes with that.
SPEAKER_02 (21:18):
Yeah, exactly.
And and the trends is you'veseen, I think, across healthcare
too, and and you alluded to thisearlier, is looking for
supplements, natural ways tokind of go after sun damage.
And you talked a little bitabout polypodium and also
nicotinamide.
Do you mind just explaining alittle bit like what we kind of
know about those and how theymight actually be helpful for
correcting sun damage?
SPEAKER_01 (21:37):
Yeah, I I know that um there's a lot of
misconception about when to usesunscreen and when to take these
pills.
And I remind everyone that youknow, sunscreens are like
toothpaste to the skin.
You know, you're not reallytreating anything, you're
preventing problems.
And we do things, you know,again, twice a day to actually
keep a level of maintenanceagainst the process that's gonna
harm us.
(21:58):
Just like we brush our teethtwice a day.
If they use sunscreen atbreakfast and lunch, they're
prevented, they're helping toprevent the exposure from
getting to the skin at the mostuh sunny day times of the day.
So I put it into context likethat so they understand how
sunscreen is actually helpingthem by preventing problems, not
treating problems.
What polypotamine leucotomasdoes is it reduces the
(22:19):
interaction of the skin withultraviolet light by antioxidant
effects.
But it takes a little bit oftime to kick in.
So, like if you have someonewho's going to the beach or want
to play golf or going on a hike,I tell them, look, take this
half an hour before you go out,and you'll be protected for
about two hours to about 80% ofthe need you have for reducing
your sunburn risk.
(22:39):
And then I tell them take itagain two hours later.
You know, for golf, I tell themtake it at the turn.
For a hike, I tell them take itagain on your way back.
You know, just put it intocontext of what their activities
are, and they'll understandthat's like, okay, I'm doing
this to reduce my risk ofsunburn because sunburn is no
fun.
And that also, again, putincreases their risk.
So it'll help kind of put intocontext for them a prevention
(23:02):
strategy as well as a treatmentstrategy with what we're seeing
in front of us.
So some of that is really veryhelpful.
I mean, you can't expectpatients to put themselves in
bubble wrap and you know weargloves all day long or wear a
hat all day long.
It's just unrealistic, eventhough those who do are are
helping themselves out.
But the fact of the matter is ifthey if they can get into some
routine of, okay, this is whatI'm gonna do every day, and I'm
(23:25):
gonna change my outcomes,they'll help reduce their skin
cancer risk for the long run.
SPEAKER_02 (23:30):
And that's what patients want.
They want options, right?
I mean, they're used tosunscreen.
I feel like people are kind oftired on sunscreen.
And for another podcast,obviously there's kind of this
uh attack on sunscreen era thatwe've been, you know, dealing
with, I feel like, on socialmedia and this podcast that
we'll address.
But so I think just givingpeople these other options, it's
a whole, you know, skin cancer,actinic keratosis prevention, if
(23:53):
you will, sort of uh, you know,toolkit that they have lots of
options to go after it.
And the one thing I think Iforgot that I wanted to kind of
bring up is just the chronicityof actinic keratosis.
I'm gonna have you kind of endwith like speaking to that
because I think that's very wellmisunderstood, sometimes even by
uh, you know, providers outthere that are treating it, or
obviously even the patient,because I've had patients come
(24:14):
in like, you just treated these,you know, a year ago, six months
ago.
What's going on?
You know, once you treatedsomething recurred, I've got new
ones.
Do you mind kind of explainingit?
Because I think that is kind ofanother misconception that leads
to a lot of patient frustration.
SPEAKER_01 (24:27):
Yeah, it's it's kind of how I go back to that dating
example.
I tell them, I say, all right,well, look, you're you just met
me today, but we're gonna sticktogether for a while because I'm
gonna be seeing you back atleast every six months, if not
every year, to make sure thatthese don't come back.
I remind them, you know, andagain, at the risk of offending
your listeners, I say, look,this is a lot like losing your
virginity.
Once once it's happening, you'renot going back.
(24:47):
So now that you have these,you're gonna keep getting them
if we don't be careful to screenyou adequately.
Uh the other part, again, isthat we have to stay on top of
regular screenings, not just foryour risk of these, but for
melanoma and anything else thatcould be related to the amount
of sun exposure you have.
So the chronicity for them isI'll be seeing you routinely to
(25:11):
prevent problems and stay aheadof this, so that we don't have
to get into more aggressivetreatments like the topicals or
you know, photodynamic therapyif we can if we can keep them at
bay and try to freeze what wesee.
But more importantly, also isyou know, again, establishing a
routine for them so they have amap of what to look for and they
know that the consequence ofthem not being screened could
(25:32):
actually lead to surgeries andand things that we might have
more risk with.
The other part, again, is indermatology, you know, we do our
best to cure problems, but thereare many things that we end up
maintaining, whether it beeczema, rhizus, severic
dermatitis, actinokeratosis fitsright into that.
You know, once you're in thatclub, we're gonna be following
you for probably for the rest ofyour life.
(25:53):
So we just have to put that intoa context.
But I we also try to do itwithout blame.
We say, well, remember all thoseyears we were at the beach?
Well, you did this to yourself,so you know, suck it up, right?
I mean, we can't really do thateither.
SPEAKER_02 (26:05):
No, no.
Our job is not to judge, but totreat and help people, you know,
that's what that's what comesfirst.
Well, well, thank you so muchfor coming on and going through
that.
I think that gives a clearerpicture.
We've got to understand, youknow, a lot of people even heard
what's an actinic keratosis orwhat's an AK or pre-cancerous
lesion.
So that was a great overview ofeverything.
And we'll we'll be sure to stickwith you too, just like your
patients stick with you andmaybe get you back on here.
SPEAKER_01 (26:26):
Dr.
Trotty, you point out.
SPEAKER_02 (26:28):
Oh, of course, of course.
Well, I do want to let ourlisteners know if they want to
track you down, do you mindsharing with them how they can
find you online or if you havesocial media?
SPEAKER_01 (26:38):
Oh, sure.
Well, I mean, our our place iscalled Therapeutics Clinical
Research.
We're in San Diego, California.
Uh, I'm not much of aninfluencer on social media.
I speak at a lot of conferences,but uh our place is found on uh
social media and we can uh weusually keep a presence there.
I I tend to keep a little bitlower profile on online just
because of uh someconfidentiality things that we
(26:59):
deal with with with clinicalresearch trials.
So that's that's the onlyreason.
SPEAKER_02 (27:03):
Makes sense.
Well, I'm sure people still wantto track you down and they can
listen to you.
I'm sure they can find you ifthey Google you, they'll find
some of your presentations ormore information.
So you know, you can't hide toomuch from them.
That's pretty good.
SPEAKER_01 (27:14):
Well, thank you for having me.
This was fun.
SPEAKER_02 (27:16):
Of course, yes.
We'll have to do it again.
And I want to let everyone knowif you like what you hear,
please click like and subscribe.
And stay tuned for the nextepisode of Dermotrotter.
Don't swear about skincare.
SPEAKER_00 (27:28):
Thanks for listening to Dermot Trotter.
For more about skincare, visitdermittrotter.com.
Don't forget to subscribe, leavea review, and share this podcast
with anyone who needs a littleskincare sanity.
Until next time, stay skinsmart.
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