Does perfect skin really exist?: Transcript

Dr. Jen Gunter:
My children were born extremely prematurely-- one was one pound 11 ounces and the other was one pound 13 ounces. Right after they were born they were taken to the neonatal intensive care unit, or N.I.C.U. I didn’t get to hold them after birth. They spent a lot of time with a breathing tube and in an incubator. It was really a scary time. Their nervous systems were so underdeveloped that they couldn’t even handle touch. But as soon as they were able to be touched we did what’s called skin to skin care. You take your tiny little naked premature baby--who is still attached to a breathing tube and monitors and wires. And you basically stuffed them down your shirt, against your skin.

And what happens next is incredible: You actually watch their heart rate stabilize and their oxygen levels go up. You can see in real time what touch does to their bodies. I’d never thought about touch that way before, and suddenly I was thinking about it all the time.

I spent several hours a day in the NICU, just sitting there with my babies against my skin because that skin-to-skin contact was sooo good for them. That was seventeen years ago. Their skin went from being smooth and delicate to growing beards and having acne--from not being able to protect them from the outside world to something that can handle everything the world throws at a teenage boy.

It gave me a different perspective on skin. And that’s what i want to share with you in this episode. We’re going to throw out ideas about “good” skin or “perfect” skin and instead we’re going to talk about how to keep this amazing organ healthy. I’m Dr. Jen Gunter. From the TED Audio Collective, this is Body Stuff.

There’s a reason that memory of my sons is so intense. Touch is a very important and formative sense for humans. Our skin is one of the first ways that we experience the world around us-- It’s the only sense that, if you’re deprived of it early in life, will affect development long term. Skin to skin contact can be very emotional. And our skin also reveals our emotions. We shiver and our hair stands on end when we’re afraid. We blush when we’re embarrassed, we sweat when we’re nervous.

Our skin isn’t a fancy saran wrap surrounding our body. It’s not just a container. It’s a complex organ that does a lot for us. Our skin shields us from the elements. It helps us regulate body temperature. It produces hormones like Vitamin D. It heals itself from wounds, bringing fresh new skin to keep out infection.
But our skin--how we look--is also often the first thing people know about us… how they judge us...from our skin color, to wrinkles, to blemishes.
As a result we hear a lot about how our skin looks… and a lot less about what it does. And we’re sold all sorts of products that are supposed to keep our skin LOOKING good. So in this episode we’re gonna talk about skin in a way that goes beyond products and regimens we’re told to use.

Dermatologist Jenna Lester hears about trendy products from patients all the time… .

Dr. Jenna Lester:
I always am wary of like, you know, very grandiose promises from a product.

Dr. Jen Gunter:
Dr. Lester founded the Skin of Color program at the University of California: San Francisco.In her years teaching at medical school and working as a clinician, most of the trendy products her patients ask about aren’t backed up by peer reviewed studies. But that doesn’t mean they can’t serve a purpose:

Dr. Jenna Lester:
I think a lot of people engage in skincare as like an, something they find fun.So maybe that's relaxing benefits

Dr. Jen Gunter:
There are skincare products that have great research behind them, like retinols or retin-a, which people use to decrease the appearance of wrinkles. And hey, if a product isn’t irritating your skin and makes you feel good, you know what? That’s self care. But what about healthy skin? To understand that we have to know basic anatomy and how our skin works. Just like we’ve done with every organ system.

Skin is part of the integumentary system-- That system also includes our hair and nails. Our skin waterproofs our body, contains nerve endings that sense pressure, temperature and pain. And our skin fends off infections.

It’s a physical barrier that prevents microorganisms from getting inside your body. And it has layers. The coating on the skin is called the acid mantle. It’s made up of oils and fatty acids and sweat and bacteria. It’s part of the waterproofing.

It’s also part of the first line of defense, it maintains the PH of the skin which helps keep bad bacteria from growing. The acid mantle sits on top of the epidermis, the first layer of skin. The epidermis is many layers of cells, like a brick wall. But the surface layer is what you see.

Dr. Jenna Lester:
At the base of the epidermis or the melanocytes, and those are the pigment producing cells, the cells that give your skin its color. Those cells make more pigment when you are exposed to sunlight.

Dr. Jen Gunter:
The next layer underneath the epidermis… is the dermis.

Dr. Jenna Lester:
That's where the collagen is that helps give your skin sort of it's full appearance. and then below that is a layer of fat, that helps insulate your body.

Dr. Jen Gunter:
The dermis is where you’ll find hair follicles, oil glands and sweat glands. When your hair grows it emerges from the skin through pores-- openings in the skin that also release sweat and oil. And just so you know-- pores don’t “open” or “close.” They’re not windows! Pore size is largely genetic, but can also be affected by environmental factors, like sun damage.

When the layers of your skin work together --helping you feel the world around you, protecting you from the elements, then your skin is doing its job.

But still, sometimes we only see the “flaws.”

Since I've been doing a lot more video chats, I've been a little bit more aware of my skin also as an aging woman. I'm looking at all day at my face in the zoom window. And do you think--are you hearing that from people at all?

Dr. Jenna Lester:
I have heard from several patients, you know, I'm more bothered by my acne now because I spend all day looking at myself on a video chat platform. I think it's a combination of that. And then more people working from home and just being around mirrors. And then I think also stress has made us focus maybe a little bit more inwardly. My theory is just because things within your body, you feel like you have more control over. So people are just paying attention to their skin a bit more.

Dr. Jen Gunter:
We’re going to talk through some common skin conditions Dr. Lester hears about from her patients: starting with acne. It’s an issue she hears about a lot.

And that makes sense, because it’s a big deal. So many people struggle with acne. Acne has been linked to low self esteem and bullying. And while it’s sometimes thought of as a “teenage thing,” it can affect adult patients too. Acne can really have a negative impact on peoples’ lives… and that can make them vulnerable to so-called miracle cures.

Dr. Jen Gunter:
I want to tell you about something I just wrote about-- people are apparently-- the latest Tik Tok trend is period blood on your face for acne.

Dr. Jenna Lester:
Oh my gosh. Wow.

Dr. Jen Gunter:
I know. I, yeah. Um, so

Dr. Jenna Lester:
I haven't seen any studies on that.

Dr. Jen Gunter:
I think it also explains like how easy it is, like how desperate people are, right?

Dr. Jenna Lester:
Yep and I think access to dermatologic care is a huge issue. So that's why I am, like you, sympathetic to people who are trying anything possible to treat their acne because it's so hard to get in, to see a dermatologist.

Dr. Jen Gunter:
Right so let's, let's debunk some acne myths. So people hear about, Oh, it's like junk food that causes it, or maybe your skin isn't clean. So can you tell us what what actually causes acne?

Dr. Jenna Lester:
Acne is caused by three different things: overproduction of oil, plugging of that pore or follicle and bacterial growth. So, the treatments that work the best are treatments that are aimed at addressing those three things.

Dr. Jen Gunter:
Another thing people hear about online are special diets or foods to avoid.

Dr. Jenna Lester:
So, you know, food that you eat, some people do notice a change when they eat certain foods. There are studies that sort of, describe certain foods as being implicated with acne. And then there are studies that refute those same things.
So what I tell people is that if you notice that a certain food triggers your acne, and then when you avoid that food, your acne is much better. Um, I just invite people to pay attention to that and make those adjustments, um, accordingly,

Dr. Jen Gunter:
Like Dr. Lester said, the studies on this are low quality and conflicting. It’s really hard to study how food impacts acne. You might see people making extreme dietary changes or demonizing a specific food, like chocolate.
There isn’t enough evidence to say that these dietary restrictions work, or that one food is particularly problematic.
And it’s important to note that some of those diets can be restrictive and restrictive diets can lead to disordered eating.
If you’re looking to treat acne, first turn to products available over the counter.

Dr. Jen Gunter:
So what specific active ingredients do you think people should be looking for when they're, um, you know, looking for acne treatments?

Dr. Jenna Lester:
So to address oil, production and bacteria, I often tell people to look for acne face washes that contain benzoyl peroxide or salicylic acid. Both of those also have exfoliant properties as well. That can help a little bit with those plugged pores that we talked about.

Dr. Jen Gunter:
If those over the counter treatments aren’t helping, then a doctor is a good next step. Our next skin concern is eczema, a condition characterized by inflammation and itching. It may seem minor, but it can be a real pain in the ass. Itching all the time is no joke. There are many factors that contribute to whether a person has eczema, but one big one is disruption in the skin barrier

Dr. Jenna Lester:
So I always describe the skin barrier as like a brick wall. That brick wall is responsible for keeping things out of your body and out of your skin that can irritate it. And in people with eczema, that brick wall starts to crumble and crack in different areas.

And oftentimes it occurs in the creases, like in the folds of your elbow or behind your knees. Some people get it on their neck. Some people get it on their eyelids or on their hands.

Dr. Jenna Lester:
And in some skin tones that can look, um, more red or pink. If you have lighter skin and in darker skin, this could look more dark Brown, or even a little bit purple in appearance.

Dr. Jen Gunter:
There can be environmental factors that play a part too. I know because I have eczema and it was pretty mild until last year when we had all the fires in California. The sky was literally filled with smoke. Since then, I have really struggled, itching all the time. And I’ve had to make a lot of changes.

Dr. Jenna Lester:
The treatments you might get are topical steroid treatments, which could help soothe, um, the inflammation, um, using moisturizers that, help build your skin barrier, your brick wall back up

Dr. Jen Gunter:
Dr. Lester says dry skin can be a major contributor to eczema.
Treatment for both dry skin and eczema can be deceptively simple: cutting back on super hot showers, using fragrance free products and gentle cleansers instead of soap.
And sealing in moisture after a shower or bath with a moisturizer-- one option is, petroleum jelly--which you might know by the brand name vaseline.

Dr. Jenna Lester:
I think if you were to ask any dermatologists what they would have on a desert Island, assuming that the sun is not an issue, maybe that desert island is not necessarily equatorial, cause they probably would say sunscreen, but they, I think many, many would say Vaseline.

Dr. Jen Gunter:
It’s cheap! And it works! If you’ve got dry or itchy patches that don’t respond to those treatments, you should visit a qualified healthcare provider. You may need a prescription product for your eczema. But there’s also some more serious conditions that masquerade as dry patches or eczema, like psoriasis, peripheral vascular disease, or even basal cell carcinoma, which is a form of skin cancer, associated with sun damage...which brings us to sunscreen.
More on sunscreen--why it helps and who needs to wear it.

We can’t talk about skin health without talking about sunscreen. It’s like brushing your teeth -- it’s essential preventative care. Many people think about sunscreen as a way to prevent signs of aging, like wrinkles or age spots. And that's true. But it's most important function is preventing skin cancer."
Still, there’s a lot of confusion out there about who needs to wear sunscreen.

I want to talk about you know, sort of a myth that I definitely heard early on in, in my medical school was that, you know, people who have darker skin tones, that they don't need to wear a sunscreen, but that's not true is it.

Dr. Jenna Lester:
So I think the blanket recommendation that people of color, um, do not need to wear a sunscreen is incorrect, but we need to be clear about why it is incorrect. Prevention of skin cancer isn't the only reason one might wear sunscreen so people with dark skin can develop signs of photo aging over time that may not be fine lines and wrinkles, but can be uneven skin tone. And that is something that sunscreen can help with. For people of color out there who are wondering if they get, can get skin cancer: The answer is yes, but the nuance is that it can occur in different areas.

Dr. Jen Gunter:
The cancers that are more prevalent - and more fatal - among Black people can be different from the ones that affect white people. Dr. Lester makes sure to tell her patients about acral melanoma-- a type of skin cancer that has particularly grim outcomes for Black patients. It develops on parts of the body that don’t get a lot of sun, like the palms, soles of feet and nail beds. It appears as a small dark brown or black patches.

Dr. Jenna Lester:
I think it begins with education of patients, if patients don't know to look at their palms and soles for acral lentiginous melanoma, specifically, they may never say like, this is a problem. I need to see someone about this. And if then on top of it, they've had a negative experience with a dermatologist before, or they feel like dermatologic care is like a luxury and not something that they should, have access to, they might not ever think, “I should go to this doctor.”

Dr. Jen Gunter:
If a Black patient does go to a dermatologist , there isn’t a guarantee that their doctor will understand the unique risks they may be facing. Just 3% of dermatologists are Black. Some white dermatologists may have a limited experience with how skin conditions present on darker skin.

Dr. Jenna Lester:
I usually spend at least a few minutes of most of my visits unpacking what I would consider medical trauma that these patients have experienced being dismissed by other providers or just feeling like their concerns haven't been heard.

Dr. Jen Gunter:
In fact, in many dermatology textbooks, examples of skin conditions in mostly show white people. As if whiteness is the default.

Dr. Jenna Lester:
Many of my patients, um, say, you know, I've been looking for a black dermatologist for 15 years, 20 years. Like people, people often give me trust that I don't think I've earned yet. Having just met them. And so then it becomes my job to take really good care of them and earn that trust that I feel like they're giving me before I, before I feel like I'm deserving of it.

Dr. Jen Gunter:
Unfortunately not every dermatologist is familiar with how skin conditions impact Black patients. For example, checking for acral melanoma.

Dr. Jenna Lester:
Are they getting a full skin check? Are they getting, are they getting a check of their palms and soles is the doctor asking them to take their socks off to check those areas?

Dr. Jen Gunter:
One study found that Latinos and Black people are less likely to get skin cancer, but they die of the disease at around 1.5 times the rate of white people. The stakes are high here.

At the skin of color clinic at UCSF patients can be confident that doctors understand their needs. It’s all part of Dr. Lester’s mission to correct the inequities that people of color face in dermatology.

Dr. Jenna Lester:
We should say that people of color is a pretty all encompassing term. Um, and within that, there are people of many different racial, ethnic identities, and then also many different skin colors from, from lighter to darker. So, um, that creates a very wide range of appearances.

So this collective term is probably overly simplistic in terms of what happens to each individual person. So even people that identify as black, for example, I have patients who have very light skin to very dark skin and the way that their skin behaves is totally different

Dr. Jen Gunter:
When doctors are taught to view whiteness as the default they’re going to fail their patients of color.

Dr. Jenna Lester:
So I think all of these marks in the, in sort of the process through the system are potential areas where someone can be, could, may not return for followup or someone may find it too challenging or something else might happen that they prioritize over this. So there are so many cracks in the road where someone can get lost along the way.

Dr. Jen Gunter:
Fixing those cracks in the road is part of why Dr. Lester got interested in medicine. But at first, dermatology didn’t seem like a natural fit.

Dr. Jenna Lester:
I couldn't really fit in my head like how that could work with dermatology. And I remembered, um, advice that had gotten when I was interviewing for medical school, uh, um, someone that I was interviewing with is like, you know, you don't have to be in primary care in order to address issues of equity.

Dr. Jen Gunter:
When I was a medical student, many textbooks were printed in black and white, and the images inside were mostly of white people. We learned the normal ranges for tests and measurements that we take, like, blood pressure or temperature or the level of salt in your blood. These are often called reference ranges, because there are ranges in which a normal result may fall.
For example, normal body temp can range between 97 degrees fahrenheit to 99 fahrenheit. These ranges were typically based on samples of mostly white men.

I know I wasn’t the only doctor taught this way. I wanted to understand the impacts of excluding people of color from medicine… so I called up Sociologist Sabrina Strings.

Dr. Sabrina Strings:
The very first thing is that when we see that this reference range is the quote unquote healthy range, we need to recognize that this may not be racially representative or representative in terms of gender.

And therefore it may miscategorize people of color and women as unhealthy when they are perfectly fine.

Dr. Jen Gunter:
Dr. Strings studies race, aesthetics and the history of science and medicine. Basically she thinks deeply about the message the medical establishment sends to women, particularly Black women: that your body, and your skin should be perfect.

Dr. Sabrina Strings:
So when people talk about perfect skin, they usually mean skin that's free of blemishes. That's the lowest bar, but it also implies skin that doesn't have a lot of wrinkles. So it doesn't show age. It implies skin that is plump and youthful, and it often implies skin that is light. I'm not sure how familiar you are with these various products to improve the quote unquote tone and texture of the skin. But many of them are actually just skin lightening products.

And so it's deeply troubling that when people imagine that they're moving towards quote unquote, perfection, that what they're actually doing is moving toward whiteness.

Dr. Jen Gunter:
Some of those whitening products have ingredients that can thin the skin, or cause scarring… they can even damage the liver, kidney or nerves.

They are NOT about health. They sell and support a racist beauty standard, with roots in white supremacy and misogyny and ageism. And it goes way beyond the beauty aisle. So let’s go deeper into the many ways racism shows up in medicine… starting in medical school.

Dr. Sabrina Strings:
Yes, but there seems to be a couple of different things going on. I mean, so we have to keep in mind that there is this legacy of the medical establishment in the United States, misusing the bodies and mistreating the humanity of people of color. So this has meant that they were often pulled into experiments without their consent.

Dr. Jen Gunter:
During the antebellum period doctors performed surgery on enslaved people to learn more about human anatomy. Dr. J. Marion Sims, who is commonly, and unfortunately, referred to as the “father of gynecology” conducted experimental surgeries on enslaved Black women without anesthesia. Until recently, there was still widespread praise for the limited work he contributed to the medical field. And then there’s the Tuskegee Experiment. Researchers didn’t give Black men treatments for syphilis… A simple shot or two of penicillin could have cured them… but the researchers wanted to understand the disease’s long term effects, so they let these men suffer for decades. The experiment continued into the 1970’s. And--let’s be clear… racism in medicine isn’t just a thing of the past.
In a 2016 study medical students and residents were surveyed to see if they had any false beliefs about biological differences between Black and White people, for example the idea that black people have thicker skin than white people.
A startling 50% of white medical students and residents believed in at least one of these false biological differences, and they also rated pain felt by Black patients as less intense than that felt by white patients." Black women are more likely than white women to unnecessarily have their ovaries removed before menopause … a procedure that shortens life expectancy. And maternal mortality rates are much higher for Black women.

The only explanation for that is racism. There are lots of reasons for Black people to distrust the medical establishment. At the same time, for medical research to serve everyone better, more people of color need to be part of studies

Dr. Sabrina Strings:
A lot of the rhetoric surrounding why it is that black people and other people of color do not appear in these studies suggest that they don't want to be. “Well. They don't want to be in studies”. And therefore, when we deliver reference ranges, they only include white persons. This to me is a tremendous cop-out.

Dr. Jen Gunter:
Dr. Strings says that the medical field needs to go the extra mile to earn the trust of Black people as research will never be complete without a diverse pool of participants.

Dr. Sabrina Strings:
I think people imagine that when we're talking about diversity, it is some kind of uncomfortable way of forcing people to unnecessarily incorporate representation from various communities. And that there's no real reason to do what except for, to be “PC.”

But if we actually want to be scientists who are doing our best to capture what's happening within our universe, what we need to do is realize that people from different backgrounds have different experiences and they have different genetics and cultures and histories. And this means we can not expect that they're going to produce similar results from any type of medical examination.

Dr. Sabrina Strings:
Our medical institutions want us to believe that what they're telling us is valid and important and that we should follow these instructions. They also need to hold themselves accountable for being representative of the entirety of the population

Dr. Jen Gunter:
It’s important to recognize that lack of diversity and racist data aren’t just values in a textbook. This affects real people. Racism impacts whether people have healthcare, how they get to a doctor’s office, how they’re treated when they get there, the medical care they recieve, and whether they return for another visit.

Dr. Sabrina Strings:
Doctors often come in with, I want to say common sense racism. Those are the stereotypes about what people of different groups are like that they should know better than to apply, but do apply quite commonly.

Dr. Jen Gunter:
I know that I read so many stories of how, um, you know, black women, especially, uh, you know, have their symptoms ignored or dismissed that, you know, each time I have, a black patient, I, I go through her chart an extra time just to see, what has been missed, what, what might, what roadblock might she have hit upon?

Dr. Sabrina Strings:
Yes, you know I mean, I think what people want and I believe this to be true, you know, regardless of their background, what people want when they speak to their physician, is that they actually care about them, that they know something about their family history, that they bothered to ask about what they eat and how frequently they move their bodies.

Because quite commonly, when individuals, especially minoritized folks come in and speak to doctors, what they experience is the opposite of that.

And so this is why I think it's so important that when we're providing medical education, that we provide significant portions or segments about the history of racism within the medical field but unfortunately you rarely see this kind of willingness to change within the medical field or at least I do.

Dr. Jen Gunter:
So what do you wish medical professionals, particularly white ones understood about treating people of color.

Dr. Sabrina Strings:
I wish they understood that they can not take the cookie cutter model of what they have learned in medical school and apply it to all populations. If you're going to work with people, you need to be willing to meet people where they are. And that means really finding out about their genetics, about their history, um, about their parents, about their children. And unfortunately that is not what a lot of black women experience.

Dr. Jen Gunter:
Which might lead a patient to search for a new doctor altogether. And in the U.S. changing doctors isn’t always easy-- it can mean a fight with your insurance company, travelling further to find the right doctor, more expenses, navigating an unfamiliar, often hostile health care system. And these things aren’t always possible. Not everybody has a car or widespread public transportation, or money for the co-pays. All of that is made more difficult for people who have been marginalized because of racism.

After spending so much time talking about the racist and patriarchal messages that Black women hear about their bodies, I wanted to flip the script. I wanted to know what Dr. Strings loves about her body.

Dr. Sabrina Strings:
Oh--something that I love about my body and wouldn’t want to change--oh yes, let’s see, it has to be my energy levels. Um, but honestly, like for whatever reason, I'm a person with a naturally explosive amount of energy. So when I was a kid just growing up, it manifested as me always running to do things.

Like if someone asks me to do something or didn't, there was anything I needed to do, you would catch me running to do it. And it drove my parents crazy for a while until they just accepted it. And do you know that that's often the way I still behave? Like for whatever reason, I'll be like, Oh, I gotta go upstairs and I'll run.

Dr. Jen Gunter:
I love that, I think often when we ask these questions, people think about like their hair or their, you know, they, they think about what the male gaze might fall upon.

Dr. Sabrina Strings:
It's difficult as a woman because we know how much currency youth have. And let me just state openly how much I enjoy being in my forties. It's amazing. because I know who I am and I know what I'm about.

Dr. Jen Gunter:
Let’s return to skin-- the massive organ that’s more complex than we give it credit for. Medically speaking there’s no such thing as perfect skin. There’s intact skin.-- As doctors we ask, is the epidermis intact? Is it keeping out things that cause infections? You can keep it intact by using a gentle cleanser that doesn’t strip your acid mantle of helpful oils. Moisturizers keep it from cracking. Sunscreen prevents sun damage. Our skin protects us from the elements… AND it’s how we meet the world… part of how we hug our friends, hold our kids, or just enjoy the feeling of sun on our face after a long winter.

But our skin is also a big way we are judged, for some much more than others...because we’re in a culture that prizes youth, wealth and whiteness.
And those toxic ideals are part of medicine too... and we need to do a lot of hard work to fix it

Next week on Body Stuff:

Anxiety. When I feel anxious, it's like my mind can’t let something go…and everything around me feels more intense and I can even feel a tightness in my chest.

We’re going to get into what’s happening in our brains and bodies when we feel anxious… the difference between normal anxiety and an anxiety disorder… And what can help.

And so it's really powerful actually that, you know, a talking form of therapy can do all this.

Body Stuff is a member of the TED Audio Collective. It’s hosted by me, Dr. Jen Gunter, and brought to you by TED and Transmitter Media. This episode was produced by Alice Wilder and edited by Sara Nics, Lacy Roberts and Jordan Bailey. The rest of the team includes Camille Petersen, Gretta Cohn, Michelle Quint, Banban Cheng, and Roxanne Hai Lash. Alex Overington is our sound designer and mix engineer. Krystian Aparta and Neeraja Aravindan are our fact checkers. And special thanks to my boys who got me started on this journey of making health information accessible to everybody. And to my moisturizer. Really, you’re doing a lot of heavy lifting!

We’re back next week with more Body Stuff. Make sure you’re following Body Stuff in your favorite podcast app so you get every episode delivered straight to your device. And leave us a review! We love hearing from our listeners.

See you next week!