SKIN PROBLEMS - SKIN CARE
Monday 31 March 1997
THIS PROGRAMME IS A REPEAT OF AN EARLIER HEALTH REPORT, ORIGINALLY BROADCAST ON 2nd OCTOBER, l995
Norman Swan: Welcome to the program. I'm Norman Swan. Today, new ways of looking after your skin when you're in the shower, when you choose your clothes, when you sleep and even when you travel.
Today's Health Report is about what some skin specialists might see as threatening and controversial ideas about skin care. It's a theory and practice based on the fact that many factors in our environment and lifestyle adversely affect our skin. So dandruff, dry skin in general, foot blisters in sport, hard-to-treat eczema, psoriasis and acne may all have environmental components which, if fixed up, can improve our skin condition and perhaps even reduce the need for medicated creams and ointments.
The concept is based on the experience, practice and research of Dr Hugh Molloy, a dermatologist who was once considered an iconoclast among his colleagues but now finds that internationally his ideas are becoming more accepted internationally.
As you'll hear, he doesn't suggest mung beans or crocodile dung, but sensible non-toxic ways of subtly changing our habits to turn our skin and hair back towards what the cosmetic companies like to promote as the ideal. But, says, Dr Molloy, they tend to peddle products which perpetuate skin and hair problems rather than solve them. So stop scratching and have a listen.
Hugh Molloy: My basic message is that a lot of the patients I see, probably well over half the patients I see, are causing their own skin problems.
Norman Swan: Causing their own skin problems?
Hugh Molloy: Yes, by the way in which they're looking after their skin. I think a lot of problems, be they psoriasis, eczema, or any other skin disorders, and a lot of types of acne, particularly that occurring later in life, are ways in which the skin is reacting to what is being done to it.
Over the last fifty years, life changed quite a lot. We've overheated ourselves; we've put ourselves into air conditioning; we've put ourselves into planes where the relative humidity gets down to 3% whereas human beings really like relative humidity to be between 46% and 65%.
We've overused soaps and shampoos. Those older members of society will remember washing their hair once a week with Sunlight Soap; now I frequently see people who are washing their hair twice a day with strong detergent shampoos. That detergent shampoo not only affects their hair, their scalp, their face; it runs down their bodies and they walk in it. And so it affects their feet too.
All of these things have insidiously crept up on us, and so our skins are getting drier and drier and are unable to function as well as they should do.
Norman Swan: And you think this breaks out as some skin problem? And you're generalising, you're saying that in some people it's eczema and in other people it might be psoriasis?
Hugh Molloy: People think that eczema is inherited. People think that psoriasis is inherited. I don't quite believe that. I think that a tendency to react in a certain way if you're insulted enough, is what you inherit. So it's rather like, I often say to patients, if I swear at you, well, you can pretend you didn't hear me, you can cry, you can laugh, you can throw something at me, you can hit me over the head, or you can get up and walk out. And that depends on your personality. And your personality has got two parts: what you've inherited - and I can't alter that; and the way you've been brought up. Your skin is rather like that. It has inherited a number of ways of reacting, and that depends on the personality of your skin. What you've inherited, I can't alter. But I can alter the way in which you look after your skin.
Norman Swan: Well let's look at the modern environment and see what you think are the public enemies number one to ten, as far as your skin is concerned.
Hugh Molloy: Well, some years ago I asked about a thousand people who were coming to see me, what they were doing to their skin. Six things came up as being important. The first one was having a dry skin. Now, most fair-skinned Caucasians with green to blue eyes, maybe freckles, and often with red or fair hair, really have dry skin. They often have long hands with very fine creases, not much muscle opposite the thumb, and sometimes palms that sweat a little bit. They often have a little bit of roughness on the outside of their upper arms, a thing called keratosis pilaris. A lot of Asians have dry skin. People seem to think that if you've got a tanned skin it must be oily, but that's fallacious. And so I think most of us have fairly dry skin. Then we have to think about climate. Human beings like relative humidity to be between 46% and 65%.
Norman Swan: On what basis do you say that?
Hugh Molloy: The scientific evidence that skin works best, and lots of other things. Your respiratory system works best within those limits. Now, my meteorological adviser, who has been around for a long time, tells me that there is nowhere in the world known to him that has a greater daily variation in temperature and humidity than the east coast of Australia. And so, if you've got a dry skin and you come to live in this climate, then that makes your skin drier.
Norman Swan: Simply because you can go into very low humidity at times of the year or even times of the day.
Hugh Molloy: Yes.
Norman Swan: What happens to your skin when the humidity drops down that low?
Hugh Molloy: It gets dry. You lose water vapour from your skin, and the barrier that is formed by the outer part of your epidermis doesn't function as well. That barrier also becomes disrupted in some way which we don't quite understand, and so you can't sweat as well. You can't keep yourself as cool. And often that sweat gets trapped within the epidermis and causes inflammation and irritation to your skin.
Norman Swan: So the natural exits, if you like, from the sweat glands, are blocked and you get a buildup of sweat, you believe?
Hugh Molloy: Yes.
Norman Swan: And that breaks out as a skin rash as well?
Hugh Molloy: Mm.
Norman Swan: What about cold weather? I'm one of these people with dry skin and my back turns into sandpaper in winter.
Hugh Molloy: Yes. Well, if you understand relative humidity you will know that cold air contains much less water vapour than warm air.
Norman Swan: So, step one, people living in coastal Australia are living in an environment which, surprisingly, although they're living on the coast, can be quite low high humidity and therefore not too good for their skin?
Hugh Molloy: Yes.
Norman Swan: But you also believe we do things in terms of our environment, which makes that worse.
Hugh Molloy: Yes. We then put ourselves into overheated buildings. If you heat up air, you dry it out. If you air condition air, you dry it out. So this tends to make your skin more dry.
When I go to the United States to a meeting and I'm in a hotel room with the windows all screwed up and the air conditioning on, I tend to switch the air conditioning off, open a window - if possible, but that's usually impossible. And then I chock the bathroom door open and I fill up the bath with water, and I leave a little note for the chambermaid saying, 'Please leave this full of water all the time I'm here'. Because it makes life more bearable! And it certainly makes a lot of difference.
Norman Swan: While we're talking about bedrooms, I think if you were to nominate your Public Enemy Number One, it would be the continental quilt, the duvet or the doona?
Hugh Molloy: Yes. That's true.
Norman Swan: Tell me about that - and you also believe that it's not just your skin that we're talking about here, it's the quality of your sleep at night.
Hugh Molloy: That's quite correct. One of the things that I decided after looking at the list of things that people told me they did to themselves, was that most people, in my opinion, overheated at night. Because of this, I took six months off and went to Oxford, where we put twelve people to sleep in a sleep laboratory. We covered them up with a standard 10-tog duvet, doona...
Norman Swan: Now we're going to have start talking about 'togs' here. This is a measure of the insulating quality of covering?
Hugh Molloy: It was first devised by the British Textile Technical Research Group at Shirley Towers in Manchester, and it's an electrical way of trying to work out the insulation capacity of any material, be it a building material, be it a carpet, clothing, etc.
Norman Swan: So, from your pyjamas to your quilt?
Hugh Molloy: That's right. A simple way to understand it is that the British Textile Technical Research Group left us with a table which said that shirting had a tog value of .2.
Norman Swan: Your standard cotton shirt?
Hugh Molloy: Standard cotton shirt. Underwear was .2 to .4. Thermal underwear, .4 to .8. Suiting, 1. Sweaters, 1. Cotton and wool blankets, 1 to 2 togs. A standard continental quilt was 10 togs.
Norman Swan: So ten times a blanket?
Hugh Molloy: Well, 1 to 2. So I decided 5 or 6, being on the generous side. They also pointed out that a 9-tog duvet or doona should keep people relatively comfortable when their bedroom temperature got down to 5 degrees Celsius. That's the temperature at which you keep the milk in the fridge. I wonder how many bedrooms in Sydney get down to that level.
Norman Swan: So what do you believe are the consequences of lying under the equivalent of five or six blankets?
Hugh Molloy: Increased sweating. But if your skin is dry, then that sweat can't get out onto the surface of your skin and evaporate and cool you down, so it gets trapped there. This does two things. It irritates your skin, and so causes your skin to react in one of the ways in which it wants to react in response to insult.
Norman Swan: This is the old eczema, psoriasis, or dermatitis story?
Hugh Molloy: Yes. And we also found that the people who got too hot had changes in their brain waves, including a reduction in rapid eye movement sleep. Now, it is known that if you don't get enough rapid eye movement sleep the quality of your sleep is reduced and you wake up feeling tired and hung over in the mornings. Many people report this when asked about it, but they haven't associated it with getting too hot at night. It's the same sort of feeling that many people who are depressed seem to have in the mornings, and their depression is said to be associated with a reduction in REM sleep.
We also showed that people had changes in their sleep stages. And there was some work done in Edinburgh in about 1972 which showed that if you had changes in your sleep stages for the middle of the night, of a certain type, then the upper part of your body and your face became irritable. And we noted that all of our subjects at about two o'clock in the morning started to rub their faces. When asked about it the next day they denied having done it. They had no recollection whatsoever of doing it. But we have noted that amongst the people that overheat, by our standards, at night, they develop what we called 'duvet or doona eye'. This seems to be increased tissue formation around the upper eyelid, increased folding of the upper eyelid, sometimes extending to the sides of the eye, with increased creasing and wrinkling. And, in the people who are able to pigment, they often get a lot of pigmentation around their eyes.
Norman Swan: The skin colour?
Hugh Molloy: The skin colour is dark brown.
Norman Swan: And you relate this also to dandruff?
Hugh Molloy: Well, if you are constantly putting shampoo on the top of your head and the shampoo, which is detergent, dries up the outer layer of your skin, then again you are blocking the exit of the sweat. And that causes irritation of the skin, which responds with the production of dandruff.
Norman Swan: And if you sleep in a doona it's even worse, because you're sweating from your head?
Hugh Molloy: Yes. 80% of the sweating which you do at night is done above the middle line. Most of it is done on the scalp. If you can't do it on the scalp then you tend to sweat on the face and neck and the upper part of your chest. And so we see a lot of people who get itchy rashes on the upper parts of their chests, particularly in the winter time when their skin is drier. And they are covering themselves up with a lot of bedding at night.
Norman Swan: Okay. So we've done air conditioning, and air conditioning in hotel rooms. And we've done the doona, and we've done what you do in the shower. Is there anything that you wear on your body that makes this worse?
Hugh Molloy: I think, too much clothing. I'm always impressed by the amount of clothing that children wear. And I think this gives rise to...
Norman Swan: You mean how little they wear?
Hugh Molloy: No, how much they wear. Since the days of Florence Nightingale, everybody has thought that you must heat up children, keep them warm. My view is that you probably cause them to have much more trouble by over-clothing them. And they are often much worse tempered, and they become fractious and difficult to manage, if they are overheated. You often see children in the city who have got loads of clothing on and then they've got a synthetic coat on top, and they're trying to drag it off and their parents are putting it back on, and a great fight ensues. The invention of the synthetic fibres has, I think, done us a lot of harm. Because they certainly don't breathe. They certainly are better insulators, they're certainly lighter, and they're certainly cheaper, and they certainly last longer than the natural fibres, and so they've become very popular amongst those people who don't have a lot of money to spend on clothing and who want to keep their children warm.
Norman Swan: It's the equivalent of the doona in some senses?
Hugh Molloy: Yes. And then the ladies who go to the gymnasium to do their aerobics, and wear lycra from their feet up to their neck, are doing exactly the same as the people who are sleeping at night with a doona or duvet.
Norman Swan: So the correct garb for aerobics would be light cotton?
Hugh Molloy: Light cotton, with a bare midriff and bare arms and legs.
Norman Swan: Just on the clothing side, one of the most popular interviews we've had on The Health Report was in fact with a podiatrist who was talking about shoes, and how certain types of shoes, particular non leather uppers, create a lot of problems on the feet, simply because the feet get too hot.
Hugh Molloy: And it's not only the synthetic shoes, it's the leather shoes also. In the old days the uppers were sewn to the soles, and so there was some ventilation around the seam. In these days, they are welded or stuck together. Also, even some of the finest leather shoes are sprayed with plastics, so-called 'anti-scuff devices', so that you don't have to polish them so much. And these plastics seal up all the little holes that normally would be in the leather, and so shoes become hot-boxes. All my shoes are ventilated, by me, soon after I buy them.
Norman Swan: You stick holes in them?
Hugh Molloy: I stick holes in them, in the instep, which I make with a little electric soldering iron - four little holes, three to four millimetres in diameter, about a centimetre above the weld in the instep. It means that every time you walk you can blow air in and out of your shoe. We tried this at Oxford, we put thermometers in our shoes and ran around for an hour, and measured the temperature inside our shoes. Then we ventilated them, put the thermometers back and ran around for another, and found that we could reduce the temperature inside our shoes by three to four degrees Celsius. And in fact they were much more comfortable. A lot of people said, 'Well, what happens when it rains?' I very rarely get water in my shoe through the little holes that I make. But if I don't make them, every night when I get home my feet are wet through with sweat.
Norman Swan: Let's start looking at some solutions here. We've spoken about the bathtub in the hotel room, to make sure that the air remains humid. What about the shower, what about washing, what's your advice for the person living in the modern world?
Hugh Molloy: My advice for people living in this modern world is not to use soap.
Norman Swan: At all?
Hugh Molloy: I personally haven't used any soap for twenty years.
Norman Swan: And I can testify to the listener that it's not an unpleasant experience sitting next to you in the studio.
Hugh Molloy: My patients have also told me that they have realised that once you stop using soap, you don't need to use deodorant. Now, who sells deodorant? The soap manufacturers!
Norman Swan: Now why is that?
Hugh Molloy: I don't know exactly, but my suspicion is that the constant use of soap changes the ecology of the skin.
Norman Swan: The bacteria on the skin?
Hugh Molloy: The bacteria on the skin. And it probably knocks out a lot of the goodies and leaves more space for the baddies to survive. And the baddies are the ones which, by their biochemistry and by their effects on the perspiration, produce odour. Once you get the normal population of bacteria back onto the skin, then we don't seem to produce as much odour.
Norman Swan: But you do need to remove the daily grime from your body. What do you use to do that?
Hugh Molloy: I use a simple, water soluble cream, like sorbolene and glycerin. And this will wash your body, all parts of your body, quite adequately.
Norman Swan: This is 10% glycerin and sorbolene, which is available in any pharmacy.
Hugh Molloy: 10% glycerin and sorbolene, yes. It won't take off ink stains, but nor will soap. But it also can be used as a moisturiser, so using it as a soap and then put some more on, always mixed with water... Remember that the man who stands outside Buckingham Palace each day, if asked how he keeps the toes of his boots shiny, will tell you, 'With two things, spit and polish'. In order to refurbish the outer layer of his boots, and in order to refurbish your skin, you need two things: grease and water. And so the cream should be mixed with water before it is put on. It can be put on very simply, and you can put your clothes on straight away because it doesn't stain your clothes.
Norman Swan: And when you're washing in the shower - sorry to get into the mechanics of this - do you actually just put it on your hands the same as you put on soap, and rub it on the way you would normally?
Hugh Molloy: I take a little bit in my hands, I take some water with it, I mix the two together, and I use that as soap to wash myself. I rinse it off, get out half dry, take a little bit more, mix it with water, put a thin layer all over, put my clothes on.
Norman Swan: And what about your hair?
Hugh Molloy: Shampoos are, really, industrial detergents. They are very strong, and they do damage skin. They do damage your hair also. There is a condition of hair called 'weathering', which we see around the streets all the time. This is purely the effect of shampoo on the hair, the damage that it has done.
Norman Swan: And what is this weathering?
Hugh Molloy: Weathering makes the hair look straggly and thin, it reduces the calibre of the hairs, and the hairs tend to catch each other and tie themselves in knots. Because little cuticle cells on the outside, which normally lie over each other, dry up and stick out. And so they become like the barbs on a fishing hook, and they catch through to one another. And if you measure the calibre of a hair right up against the scalp and then follow that hair out to the periphery and measure the calibre again, you'll find that the calibre is reduced probably to about a sixth of what it is. So it can't hold itself up, so after a few hours, with a little bit of sweat on it, it will become lank and will go flat. It loses its bounce.
Norman Swan: You're describing the situation that most people see on television all the time, particularly aimed at women with long hair.
Hugh Molloy: Yes. And most of those will tell you that...
Norman Swan: So it's a self-perpetuating problem?
Hugh Molloy: Of course! And they will wash their hair and blow dry it and it will stand up beautifully. But eight, or six, or four hours later it will just go flat. And the only way they can get it to stand up again is to rewash it and re-blow dry it. And if you keep doing this, then you damage the hair!
Norman Swan: So what do you use on the hair?
Hugh Molloy: Well, some of my patients use sorbolene and glycerin, take a little bit, mix it with water, rub it into their hair at night, and just rinse it out with water in the morning. Others use hair conditioners. Hair conditioners don't contain detergents, they contain spreading agents called surfactants. There are various types of surfactants - four types of surfactant, in fact, depending on the charge which is on the molecule in solution. Some of these have some detergent capacity, but they are nowhere as destructive as the detergent shampoos. So you can wash your hair quite satisfactorily with hair conditioner, provided you use a lot. You need at least a couple of tablespoonfuls if you've got long hair. The people who say that hair conditioner makes their hair greasy are the people who don't use enough.
Norman Swan: I've known you for awhile and I've tried this. And I found that glycerin and sorbolene made my hair greasy, but in fact conditioner works quite well. But you've got to go for it, it takes you a while to get beyond a certain point, where your hair is not that greasy and it starts to work.
Hugh Molloy: Yes, that's perfectly true. I've had some comments with some organisations who test shampoos and hair conditioners. And they tend to run their tests over a period of a fortnight. From experience I have learnt that it takes at least eight weeks to get over the hump, but it's certainly worthwhile. And you can use hair conditioner as often as you like, because it's nowhere near as damaging as the shampoos. And people often find that in the early stages they have to use hair conditioner quite a lot, but later on, towards the end of the eight weeks, they find that they only need to wash their hair a couple of times a week.
Norman Swan: Now what will do about the bedroom? Most of us invested in the continental quilt. What do you suggest is the solution for the bedroom?
Hugh Molloy: I think that unless one is in Kosciusko at this time of the year, or out in central Australia where the nights can get very cold, two to three blankets made of either cotton or wool should be the absolute maximum - in a house with no heating and the windows up. Now, there is a problem, that we are born with what I call a little man in our brains who enables us to cope with cold. He is like any other function in our body. If we use him and recognise him and respect him, he will work very well for us. But if we misuse him he stops working.
Norman Swan: So you reset your sense of cold?
Hugh Molloy: That's right, that's perfectly correct. If you jump into a swimming pool you will feel cold. But if you stay there for four minutes you will warm up. If you get out of that swimming pool and sit on the side you will feel cold. But if you stay there for four minutes you warm up. So, if you put clothing on the moment you feel cold, then you do the little man out of a job. If you put clothing on in case it might get cold, then you obviously spend a lot of your time being too hot, and again, you do him out of a job, so he packs up. If you overheat him at night, he will persist for a while, but after some weeks or months he will pack up. So you're left there now without this little man who enables you to cope with cold. And in this situation, I believe that your thermostat slowly gets pushed higher and higher and higher, and you feel the cold more.
Norman Swan: You become addicted to your duvet?
Hugh Molloy: And you become addicted to your duvet, and you learn how to feel the cold. So most people who use duvets or doonas have their thermostat set much higher than they should have it. In my experience it takes ten consecutive cold nights to pull your thermostat down. And I advise my patients to go home, put a sheet and two blankets on the bed, and I warn them that they will wake up a number of times during the night for the next six nights, they may wake up every hour or so. They will certainly wake up between four and five in the morning, which is the coldest time of the night. But after about six nights, they'll start to sleep through. And by ten nights they are usually sleeping through and waking up feeling much better in the mornings.
Norman Swan: And when you wake up feeling cold, do you advise putting on a pair of socks or something like that?
Hugh Molloy: No. The most important parts of your thermoregulatory mechanism are your extremities, your hands and your feet. If they are cold, it means they are working very well, they are helping your body to conserve heat. If they are hot it means that they are being used to try and get rid of heat from your body. And so if you overheat your feet you make it more difficult for your body to conserve heat, and therefore you feel more cold. And in fact, if you put a duvet or a doona on the bed, it takes much longer for your feet to warm up. As soon as you lie down and put the bed clothing on, the body's main function is to come to an equilibrium with that bedding. And if that bedding has no heat source, it will be colder than your body. And so heat flows from your body into that bedding to warm it up. During that phase of warming up your bedding you are trying to conserve as much heat as possible, and so your hands and your feet go cold. And so the more bedding on top of you...
Norman Swan: The more there is to heat up?
Hugh Molloy: The more there is to heat up. Therefore your extremities stay cold for longer, which is the opposite of what most people think. If you have terribly cold feet when you're going to bed, then I find the simplest thing to do is get a bath towel and heat it up over a heated towel rail or a heater of some kind, making sure that it doesn't catch on fire. Or you can even put it in the microwave oven for a few minutes, making sure that you don't burn it. Pop that into bed and put your feet on that. It's safer than a hot water bottle. You can't burn yourself with it. It will take you through that initial stage of having cold feet and then it will rapidly cool down, so it won't upset your thermoregulatory mechanism.
Norman Swan: Of all the people who come in to your office with eczema or psoriasis and so on, how many respond to these simple environmental measures and how many go on to need the dermatologists' friend, which is cortisone cream?
Hugh Molloy: That depends on the reason why the patient came to see me. If the patient came to see me to buy the cure, then they go away disappointed.
Norman Swan: What do you mean 'buy the cure'?
Hugh Molloy: Well, for me to give them a prescription for some pills or some cream that's going to make them better. I don't believe that I can cure anything. Pills and creams are like umbrellas. They don't cure things, they just stop the uncomfortable feeling for a while. But usually when you stop the creams or the pills, the condition returns if you keep on insulting your skin. So all I can do is teach people how to manage what they have and get the best out of their skin.
Norman Swan: Dermatologist, Dr Hugh Molloy.