Dr Louise Newson: [00:00:00] So today on the podcast, I'm very excited to reintroduce to you Dr saj Rajpar, who is the most amazing dermatologist, skin specialist extraordinaire, who I know very well but respect a lot as well. So we talk a lot about skin, what the skin is, what it does for us, what hormones in the skin do when hormone levels are changing, and also about Saj's rather unique clinical practice as well, so listen, share, enjoy. [00:00:27][27.1]

Dr Louise Newson: [00:00:30] Welcome Saj to the podcast. I think you're my most frequent guest actually. I think, you've just topped a couple others because I think this might be your fifth time even. [00:00:41][10.6]

Dr Saj Rajpar: [00:00:42] Well, that's a fantastic statistic and it's a real pleasure to be invited back. It's always lovely to speak to you and actually learn from you during our podcast. [00:00:52][10.7]

Dr Louise Newson: [00:00:53] Well, do you know what, we've learned a lot from each other over the years. And it's probably been about six or seven years maybe that we've known each other. And let's go back to how we met really, because for those listeners that don't know, Saj is a dermatologist, works and runs Midland Skin in Birmingham and you wrote me a letter about one of our patients. So we had a mutual patient who had hair loss and I've been very used to getting letters from other specialists that are just one-liners and they say all these weird and wonderful treatments that may or may not work with nothing else, whereas your letter was incredibly detailed with all the different investigations you've done, all the ways to try and exclude other medical causes. And you were also sort of really keen to have a dialogue about the role of hormones and hair loss. And I think I might have emailed you or phoned you and now we've got this lovely relationship. That's right, isn't it? [00:01:49][55.7]

Dr Saj Rajpar: [00:01:49] Yeah, it's absolutely brilliant that a patient brought us together and we are here to serve our patients and we just wanted to get that person the best possible outcome from medical treatment. And yes, it was great because we connected and we exchanged ideas and this patient was experiencing hair loss and it was trying to connect the dots as to what a massive impact this patient's perimenopause was having on her hair loss and how eventually optimising her hormones was one of the cornerstones in treating her hair loss. And had we not done that, and had you not done in fact, we would not have got the outcomes from the rest of her hair treatments that we did. And because it was that collaborative care and it was understanding that it's not just one solution, there could be more than one thing going on. You've got to address that, you've got identify it, you know, that's good medicine, isn't it? It's kind of work out. [00:02:53][64.1]

Dr Louise Newson: [00:02:53] Well, it's really important to really be holistic in our care, whatever strand of medicine we do. But you're a dermatologist, so for those people that don't know what dermatology is, can you just explain what it means being a dermatologist? [00:03:08][14.9]

Dr Saj Rajpar: [00:03:10] Yeah, it means a lot of things actually to me. To me it means somebody who has a medical degree who's medically qualified and has specialised in the diagnosis and treatment of disorders and conditions affecting the skin, hair and nails. And those treatments might be medical treatments, they might be surgical treatments or they might be procedural treatments with devices such as lasers that we use for medical indications and a dermatologist may treat adults and may treat children as well. [00:03:49][39.9]

Dr Louise Newson: [00:03:50] Yes, it's really interesting because this is what's really important. Well, there's lots of important things, but dermatologists are medical doctors. So you've had the same medical training as me. And also usually, dermatologists have done different medical specialties before going into dermatology. So a lot of people have done other areas of medicine, haven't they? [00:04:13][23.2]

Dr Saj Rajpar: [00:04:14] Yeah, so it's really important to have your foundation in medical practiec, but also expose yourself to various other specialties because the skin does not function in isolation. And if you're not aware, and the same with you, Louise, you've done, you know, jobs across several medical specialties, I know cardiology and cancer medicine and so many others. And it's really important to get that grounding because things come through the door that if you can't rely on your basic medical knowledge, you'll never pick up because the skin is the external visualisation of many internal problems. You can see things like hormone deficiencies, like menopause and perimenopause in the skin, but you might see thyroid hormone deficiency in the skin. You might see cortisol deficiency first on the skin. You might say iron deficiency on the skin, you might see diabetes on the skin, for the first time. So there are a lot of systemic conditions that present on the skin and the other thing is that dermatology has become more and more complex and medications available in dermatology have become more sophisticated and you cannot deliver those medications if you don't have an understanding of physiology, the kidneys, the liver, the blood system and how all those things interact especially if somebody's got other comorbidities, that means they've got other conditions or other medications that they're taking. And that transcends across all aspects of dermatology, really, even procedural dermatology. You've really got to understand how you might treat something, you know, I might see somebody with skin lesions because they're in, and they've had a kidney transplant and they're on a medication from that kidney transplant that's causing those skin lesions. And I might need to have knowledge and oversight of that in order to best treat them. So, you know, everything works together. [00:06:10][115.5]

Dr Louise Newson: [00:06:11] And that's really crucially important because, you know, medicine has become even more siloed than it was. I mean, I'm older than you, but when we were training, we did a lot of, even as undergraduates, we saw a lot of specialties, we were constantly exposed to different specialties. And then when we we're doing our exams to be a member of the Royal College of Physicians, we did lots of different specialities. And when we're on call, we'd see anybody that would walk in or be stretchered in. So we weren't selective on what we saw. So you had to join the dots a lot more. So if someone was in liver failure and their skin was yellow and they had bruising on their skin and it was spontaneous. Then you think about alcohol, you think about the cirrhosis so you've constantly got these differential diagnosis going on. But sometimes in medicine, and the two specialties that I deal a lot with, which frustrate me a lot, are gynaecologists and psychiatrists because gynaecologists seem to think they own hormones because they come from the ovaries, but they also come from the brain and other tissues. But gynaecologists go straight into gynaecology. They don't have the beauty of being able to have all these other postgraduate experiences that we have as junior doctors. The same with psychiatrists who obviously mental health is the commonest sort of one of the commonest symptoms of hormonal change, mental health symptoms and psychiatrists tend to go straight into psychiatry training. So they become very siloed very quickly. Whereas I think people forget with dermatology, that you are often using the skin as a window into the body because the skin is an organ, it's not just a protective layer and it's certainly not just how our face looks because I was talking to my husband recently and we were saying it's really hard now to see how old people are because they all have cosmetic treatments. Very few people have lines anymore and it is really difficult to know is this person a dodgy looking 60 year old or are they really 30? It's really hard, but when you look at their whole body, obviously you know a lot more, but dermatology has to always look at the bigger picture and think about the organs and what else is going on, don't you? [00:08:23][131.8]

Dr Saj Rajpar: [00:08:24] Oh, absolutely, absolutely. You've got to, as you said, connect the dots and say, take something as simple as itch. You know, the cause of itch, there's a list as long as my arm. And if you're not familiar with the body, the physiology of the body, how to investigate different aspects and different organ systems, you may miss potentially important causes. And you know, common causes of itch might be skin disorders like eczema and psoriasis, and hives and urticaria, but internal conditions like iron deficiency, thyroid disorders, and even cancers, some lymphomas. And in fact, in my career, I've diagnosed one young person with lymphoma who actually presented with itch, you know. When an 18-year-old comes in and is itching all over for no particular reason and has never had any skin history, you've got to put your diagnostic hat on and say, well, this is rather odd, you know, what's going on here. And this person had been through several doctors, had had treatments for eczema and scabies, which is the obvious typical thing that everybody jumps to. But when you take a history and you say, oh, well you've got night sweats, you're not feeling great. And then you examine them and you check other parts of their body, you check their lymph glands, you check their liver. You know, that's what we're trained to do, aren't we. We're trained as diagnosticians. We don't have a scan in our room. We don't have, you, know, blood test machines in our room. We've just got our eyes and our hands and our ears, and we've just got to kind of put it all together. And you know it's very similar to what you're doing. You're, seeing patients and women with multiple symptoms and you're trying to figure out, you now, where are these symptoms coming from. [00:10:17][113.1]

Dr Louise Newson: [00:10:18] Yes, it's totally true and I've written quite a lot about it in my book, The Power of Hormones, is that we have to listen to our patients and you know, I'm the same as you, we didn't have training about menopause hormones when we were undergraduates or even, you know, when we're junior doctors, which is very frustrating. And I think back to a lot of my patients I saw in general practice who did come in with itchy skin. And a lot of them were women. And I did all the usual checks, made sure their liver, their kidneys were fine, they didn't have iron deficiency, their thyroid was fine. And I never once thought about their hormones. And now my work is obviously not just menopause either. So I see a lot women with PMDD, premenstrual dysphoric disorder, PMS, premenstrual syndrome. But also increasingly we're seeing a lot more people in my clinic with postnatal depression. And I see lot of women who've had postnatal psychosis as well. And one of the things that we always do, as you know, with every patient is we give them the symptom questionnaire, which is the same as the one on Balance app. And it asks all sorts of symptoms, including there's a whole section on skin, so dry skin, itchy skin, acne, any skin changes. And usually, not always, but usually, people with PMS, PMDD, postnatal mental health, if you ask them specifically those questions, they will say they have skin changes before their periods. But if you're not joining the dots and I never used to, I would be concentrating on the symptoms the woman was complaining of, because it's so accepted that it's just a hormonal change of skin. But actually, it's the body again saying something internally is out of balance and it's the hormones. And it's really important, do you see that much in your clinic where people have skin changes throughout their cycle? [00:12:03][105.7]

Dr Saj Rajpar: [00:12:04] This is so interesting to me because we see a huge number of women with hormonal acne and, you know, it is so common for women to come in through, you know, their adult life to us saying, you know, ever since I was 11 or 12, you know, in the week just before my period, my skin completely changes. It'll go greasier or drier, I'll have more bumps and texture. Usually that means comedones and I'll break out. Typically along the chin and the jawline, but anywhere, you know, anywhere on the face, the neck and the back. And it is, you now, a reason for which many women struggle because it's something that just does not always easily come under control. Many women will have tried synthetic combined hormones. [00:13:03][58.4]

Dr Louise Newson: [00:13:03] Yes. [00:13:03][0.0]

Dr Saj Rajpar: [00:13:04] You know, and this is so typical, they'll come in and say, you, know, I'd say about 50 to 60% of women will say it didn't work for me or it made my skin worse. That's combined contraception. And then many others will say, look, yeah, it helped my skin, but my God, my mood, my weight, you know, all these, and I just don't want to, you know, I really don't wanna go back on that. Can you help? So, and, and the other sort of time that we see this issue with acne is in the perimenopause. It's very similar. And often the same women will say I've only just had five or six good years with my skin, and now it's started... [00:13:45][40.8]

Dr Louise Newson: [00:13:45] No, it's coming back. [00:13:45][0.7]

Dr Saj Rajpar: [00:13:46] ...all over again. And the first thing I do is I say, and I would never have done this, Louise, had I not met you or understood or learned and come to your conferences and courses and done the online course myself. The first thing I ask is what's happening with your hormones? And it's kind of, like the penny then drops and they're like, well, actually nobody's asked me, but you know, this is happening, that's happening. And it's like, you know, before I give you another acne cream or another acne directed treatment, let's talk about optimising your hormones and can you go and seek help on that... [00:14:24][38.2]

Dr Louise Newson: [00:14:27] Yes. [00:14:27][0.0]

Dr Saj Rajpar: [00:14:27] Get your hormones figured and then come back to me, and then we'll pick up where we've left, you know, where you're at then. And it's been a game changer, and I really, I would encourage all my colleagues who are seeing skin, to try and think critically about what's going on in that person in their hormonal situation. [00:14:45][17.2]

Dr Louise Newson: [00:14:46] It's so important and I worry, I worry a lot about every woman, but I worry a lot especially about younger children, girls, young adults who have these skin changes and sadly I used to do it as an uneducated GP, I used to prescribe the contraceptive pill because I thought it was skin friendly and some of them are marketed as being skin friendly. And they, like you say, they might help, but then in medicine we have to think about the root cause and what we're doing. So synthetic hormonal contraceptions do not contain hormones. They contain substances that block hormones and even a very commonly prescribed progestogen, synthetic progesterone called medroxyprogesterone acetate, actually works as an aromatase inhibitor. So it blocks the action of estradiol on the skin, in the brain, and every other organ in the body. So I'm sure you've seen people have the Depo-Provera injection and their skin completely breaks out. And I always, when I was younger, thought, oh, progesterone is bad for the skin because it's called medroxyprogesterone, so you think it's got progesterone in it. If you look at the chemical structure, it's not progesterone at all. It's a synthetic chemical. And then when you read it, I mean, there's great articles from the 80s and 90s showing how it blocks the action of estradiol. We know estradiol, which is a good anti-inflammatory form of estrogen, is very beneficial on the skin, it helps build collagen, it helps the blood flow to the skin, it helps the skin texture, everything. So it's such a shame that people are blaming hormones when the right bioidentical hormone can be transformational. [00:16:24][98.3]

Dr Saj Rajpar: [00:16:25] Yeah, well, this is really interesting because it was just the other week where I saw one of my patients with acne who's been stable for years on treatment and her acne destabilised. It's a lady in her late 40s, early 50s. She'd had perimenopause and menopause about seven years ago. So she was already on hormone replacement at this point, very stable. And her acne broke out. And we were trying to figure out what has changed. And she was asked to switch from her oral bioidentical progesterone to the Mirena coil. So that's all that had happened and nobody thought anything of it. This had, you know, been going on for, her acne flare had been going on for at least nine months. And we were just trying to backtrack on what could it have been when this person was so beautifully controlled. I mean, going from very severe lifelong chronic acne to brilliant control, and it was that. It was such an eye-opener because it's marketed as something that is local. There's not going to be any systemic spread, you're not going have any side effects anywhere. Well, that's not true. [00:17:42][76.8]

Dr Louise Newson: [00:17:42] Well, I've seen it a lot and it's very interesting because I used to tell patients, again, that the Mirena call only works locally in the womb. But let's think about it. Our womb is very vascular, it's got lots of blood vessels in it. The blood vessels connect with every other blood vessel in the body and brain. So there's not a Teflon sheet around the womb, so of course this synthetic progestogen, it's a low dose, but for some women who are very sensitive, are going to have this effect and I see people who have severe mental health problems with Mirena, but also skin changes as well. And we have to be thinking about the difference between the natural bioidentical and the synthetic hormones all the time. And patients sometimes don't know the difference and they'll tell you they're on a progesterone and they're often not. But I'm gonna ask you something that I know that in the last podcast we got lots of views about, about using topical hormone preparations. So these are vaginal hormone preparations. So I'm not talking about systemic Oestrogel, but some of the estradiol gels and creams, quite a few people use them on their faces intermittently and there is small data to show it will help, but there's logical data. Like anything that I put in my vagina or on my vulva is going to help the blood flow. It's going to help circulation. It's gonna help the tissues. We know that, you know it's very repairing these things and what I wondered and I don't know the answer here and I think you will, what if someone used a low-dose vaginal estradiol or estriol cream or gel preparation on their acne on their face? Like it might have an effect mightn't it? We don't know. [00:19:18][96.0]

Dr Saj Rajpar: [00:19:19] Well, do you know that's potentially a very interesting idea to look at because recently a topical preparation has been licensed in the UK that blocks testosterone. Now that might not actually be the reason why somebody's breaking out. It might be because of the exposure to estrogen has dropped, leaving whatever the balance between estrogen and testosterone. What we're doing now is we're saying oh I know let's drop your testosterone, what we haven't understood is actually the primary reason was the estrogen and progesterone have dropped and that's why you're getting the flare in the week before your period so can you put the estrogen back topically rather than block the testosterone topically. [00:20:08][49.6]

Dr Louise Newson: [00:20:09] And it's a bit like... [00:20:10][1.1]

Dr Saj Rajpar: [00:20:11] Yeah, it has merit, doesn't it? [00:20:12][1.2]

Dr Louise Newson: [00:20:12] So women with PMOS, which used to be PCOS, everyone's always blamed the testosterone, whereas in fact, and I've done a YouTube about it, people with PMOS often have low estradiol and low progesterone. So relatively speaking, their testosterone is higher than their other two hormones. We always used to block the testosterone and a lot of people still do with people with PMOS and those people often feel dreadful. But in our clinic, we often give them systemic estradiol and progesterone and they feel amazing, and their skin improves because they're having systemic hormones, their mental health improves, they have more regular periods, if we give them the right dose and type of progesterone. So we know systemic hormones work, and there are some people that do use low-dose estradiol, but also low-dose progesterone cream topically on their skin. But people seem really scared of that. I don't have a problem with it at all because sometimes in medicine you try something. With a logical reason and then you have a review. One of my sort of reservations is we shouldn't just be looking at the face and I worry if we're only putting something on our face, if it's PMOS, which is a metabolic problem, we need those hormones systemically because estradiol and progesterone are very good, as you know, for insulin resistance and metabolism and so forth. But I think we should do a study, I think, we should look at this more because actually there's a lot of preparations that girls, women are spending fortunes on, including my children over the years have done. And if a low dose estradiol was going to help a little bit, they would love it rather than going for roacutane or something else. So it's something to think about, isn't it? [00:21:51][98.8]

Dr Saj Rajpar: [00:21:51] Absolutely, it's something that also would be a treatment that could work in the medium to long term. Whereas a lot of the acne treatments that exist may not have durable results. In other words ruractane doesn't always clear somebody's skin and their skin doesn't always stay clear. So you do need to have something else. And if it is a hormonal basis to somebody's acne, then looking at the hormones, it's a fantastic idea, Louise, and you know, this is how treatment of conditions will move forward, isn't it? [00:22:26][34.4]

Dr Louise Newson: [00:22:26] Well, it's interesting and I constantly think, partly because I've got three daughters, and you know, contraception is really difficult because every single hormonal contraception contain synthetic hormones. We do have Zoely, which contains estradiol, but it contains a synthetic progesterone and often I will add back natural bioidentical progesterone to people who have Zoely as well. But sometimes they still have breakouts in their skin and so it's just something to think about. But there are so many different treatments. And one of the things I worry about with dermatology, not with you, I hasten to add, but I see they come up on my Instagram and they're often advertised in different, even shops and department stores now seem to have dermatologists that do all these high end, very expensive treatments just for the skin. And often they involve lasers and injections and all sorts of treatments. Some of them look quite painful, but I worry that It's just a skin deep thing, it's just looking at an immediate result and I've been to your clinic several times, lots of my patients have, you have loads of lasers but I've never seen you do it just for a pure cosmetic, it is more than, I mean you're always analysing the skin and you do a lot with melasma, we've done a podcast about that and different skin conditions, so tell me where these high end treatments if you like, because I can see the appeal for some people, but I'm really worried about how they're just, anybody can go and have a bit of laser or something. So tell me the difference. [00:24:03][96.3]

Dr Saj Rajpar: [00:24:03] Yeah, I think it's really interesting that you point out that you're seeing these treatments being delivered on the high street and in department stores now. And I just point out the fact that dermatologist as the title is not even protected. So that means anyone, whether they're medically qualified or not, can call themselves a dermatologist. So you will hear the terms cosmetic dermatologist, aesthetic dermatologist and laser dermatologist all sorts of terms and people trying to use authority to sell treatments and so I would encourage anyone to first just know who they're being treated by and what their qualifications are. Lasers are interesting, I find them fascinating. I did my very first laser qualification in 2003, that's 23 years ago, before I even got my first job in dermatology, my first very junior SHO job. I know at the interview they said, my God, you've done this BTEC in lasers. Many of our registrars haven't done that. And I said, look, I really am fascinated by the physics of lasers but also how you can harness that energy and actually have positive impact on the skin for medical concerns as well as aesthetic concerns. But there are a huge list of medical concerns that lasers work for, like melasma, as you mentioned, or rosacea, or acne, and really importantly, scars, whether they're surgical, post-surgical scars or burn scars or keloid scars. So there's a whole host of medical reasons why doctors like myself use lasers and laser knowledge is getting better and better and the machines are getting better as well, so the outcomes are getting better. And there is definitely a role for lasers in facial rejuvenation for the right candidate at the right time and I think the key thing here is making sure it's the right candidate. I saw somebody the week before last who came in for a heavy laser treatment consultation and it turned out that her skin ageing happened in the five preceding years and that was around the menopause. Quite dramatic, quite dramatic skin ageing, you know, more profound than you see on average. Now we know we lose 30% of collegen or women can lose 30% of collegen in the first five years after menopause. But this looked very much 30% plus. And I thought, gosh, that this is, you know we know, we know things are in a normal distribution, aren't they, in medicine, and most people are bang in the middle. But there will always be some outliers. And I felt gosh, this is an outlier and the timing here does not fit with general chronological ageing with some menopausal changes if their estrogen hasn't been corrected. And really, so that person wanted laser, wanted a solution and I actually said, no, you are not suitable. This is not the right treatment for you, you're not the right person for this. Optimise your hormones and actually wrote a referral to you guys straight away. [00:27:33][209.2]

Dr Louise Newson: [00:27:35] That's amazing though. [00:27:35][0.1]

Dr Saj Rajpar: [00:27:35] And I said, go and, yeah, you know, that is your priority here. And the sagging issue as well, facial sagging and the fact that women's faces change in a different way to men's faces around the menopause where you know jaw bone, which is the lower facial bone, mineral density goes down a lot quicker and therefore the skin sags more. There's a lot of changes that are happening at that point. And really you can't necessarily just cover it all up with a laser treatment or a surgical treatment. You really want to get to the root cause as you mentioned. [00:28:08][33.2]

Dr Louise Newson: [00:28:09] Absolutely and there's no harm at all for having rejuvenation, having treatments, but it's looking at the underlying cause. And I think if there's one thing for people to learn from this podcast is if you're seeing a dermatologist, don't look at the title. Don't even get hoodwinked by doctors, because a lot of them might have only done one, two years as a medical doctor. Look at their, ask for their CV, see what experience they have, and make sure that you're treated really holistically. And Saj's and my relationship professionally is very, very close because I need help often with people with hair, skin, nail problems that only an expert dermatologist like him can help with. And he often needs help from our clinic, with the hormone balance, and the two together can really transform people's lives and future health. So don't dismiss skin, but make sure you see someone who's really experienced. So I'm very grateful for your time because we're recording this on a Saturday morning and Saj is a bit like me, he doesn't often switch off because he's constantly working and helping people which is what we went into medicine for. So before I end though Saj, I always ask for three take-home tips. So, I'm going to ask you three reasons why the skin is the most important organ in the body in your eyes. [00:29:23][74.3]

Dr Saj Rajpar: [00:29:24] Good question Louise. The skin is the most important organ because if you look after it, it will treat you very very well and it's very easy to look after and that starts with looking after yourself with your diet, your lifestyle, you know not smoking, sun exposure, those things will pay dividends and the third one is what we touched upon before which is the skin is a window to your body. And if there's something that's not right with your skin, then getting it checked out can reveal and help you with problems that you're experiencing in the body. [00:30:03][38.3]

Dr Louise Newson: [00:30:04] Perfect. So what we're trying to say is don't ignore the skin and make sure if you're treating the skin you're looking internally as well because as doctors we need to be as holistic as possible and a multi-system approach is always going to help. So thank you again for your time Saj and I don't think it's going to be the last time that you're coming on to this podcast, so thank you. [00:30:24][19.7]

Dr Saj Rajpar: [00:30:24] Thanks Louise, it's always a pleasure. [00:30:24]

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