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Total Skin Nerds S1:E3


[Amy Risley] Total Skin Nerds is brought to you by Skinfix. We're clean, clinically active and on a mission to help heal your skin.

[Amy Risley] Welcome to Total Skin Nerds. I'm Amy Risley, the CEO of Skinfix and a first rate skin nerd myself. On this episode, my guest is Dr. Rita Linkner, a Manhattan based board certified dermatologist at Spring Street Dermatology and founder of RVL Skincare, an exciting new line of pads and lip plumpers. But what first drew me to Dr. Linkner was her excellent Instagram account, where she skillfully and passionately explains complex dermatological procedures and trends from the points of view of doctor and patient, both roles she plays herself.

[Amy Risley] Because Dr. Linkner has a knack for talking through the skin issues that consume us, we thought she'd be the perfect resource to unpack the nuances and treatment options for a skin condition that we all deal with and through way more of our lives than any of us would like. I'm talking about acne. From teenage zits to menopausal blemishes, stay tuned now as Dr. Linkner offers curative strategies, definitive prescription advice and the latest ways to keep scars from forming and lingering. Plus perfecting the art of the extraction, foam cleansers versus cream cleansers and what natives from Papa New Guinea can teach us about break outs. Stick with me nerds, don't go away.

[Amy Risley] Well, welcome Dr. Linkner to the Total Skin Nerds podcast, we're so very honored to have you here. I know you're super busy.

[Dr. Rita Linkner] No, thank you for having me. It's such an honor for me to be here please.

[Amy Risley] Well, we love having you, I know you have two young kids and a very busy practice.

[Dr. Rita Linkner] Oh my goodness, it never ends. But you got to make time for yourself and important things like this, so it's an honor to be here.

[Amy Risley] One, as dermatologist you bring the expertise and the credibility to skincare, then now you have a product line?

[Dr. Rita Linkner] Yeah.

[Amy Risley] We'll talk about a bit, RVL, which is great.

[Dr. Rita Linkner] And it's such an honor. I think everyone is injecting these days, everybody. And it's nice to be able to reel it back in. It took me 14 years to become a dermatologist, it's just a lot of late nights, hours studying and figuring out all those nuances about the skin. So it's nice to be able to flex that expertise all this time later.

[Amy Risley] Well, and that's where you get your stamina too, medical school, all of the long hours and the residency and all of those things. It's incredible how much you do in the run of the day. So one of the things that I really loved and when I was doing some research about you is that you learned from your mother to treat patients like the gold that they are?

[Dr. Rita Linkner] Yes.

[Amy Risley] I think that was just such a beautiful statement.

[Dr. Rita Linkner] Yeah, it's so funny. She saved it in the first grade, they asked you to paint a picture of what you want it to be. And it was me next to a patient with an IV in. Ever since I was a little girl, I always spend time with my mom in the hospital. And she's a small woman just like me and I remember this one day in particular, she's an anesthesiologist, but she mainly does pain management. They have to wear these very heavy lead vest because they're using fluoroscopy X ray machines all day long. She was in her foreign shields wearing the vest all day, I was shadowing her all day. I fell asleep in the car ride home. We got home she cooked a full Indian meal for dinner, fed me and my sister and I fell asleep before she did. I just remember thinking to myself, this woman her stamina, how does she do it? Literally up every morning five o'clock getting her stuff done herself. So I guess that's kind of where it started for me.

[Amy Risley] Great mentor. So today Dr. Linkner, we're going to talk a bit about acne, and do a deep dive, we get a lot of questions at Skinfix about acne. So tell us a little bit about physiologically what's going on when someone has an acne breakout.

[Dr. Rita Linkner] Great question. So acne really is a hormonally mediated skin disorder. The reason people kind of pigeonhole acne as a teenage disorder is that's usually when it first comes out and is most pervasive, but I'll tell you realistically at my waiting room at Spring Street Dermatology, I see a lot of female adult acne. And that has to do with the change in sensitivity to the male kinds of hormones that all women have and that sensitivity fluctuates throughout life.

[Amy Risley] To the male hormones? So testosterone [crosstalk 00:04:23]?

[Dr. Rita Linkner] Testosterone derivatives, yes.

[Amy Risley] Androgens?

[Dr. Rita Linkner] Correct. So you see that peak a lot in teenagers. Teenage acne also has a stronger genetic component to it, so you're more likely to see body acne, more stubborn, recalcitrant acne that's not as amenable to topicals because you're involving larger sebaceous glands that go beyond the face. So I was someone who struggled with teenage acne myself, I did Accutane twice. I did it when I was 12. My sister was also doing it concomitantly. My mother who's a doctor, as we said, had seen me start to get a little bit of scarring and she took the initiative. At that point in time an anesthesiologists could write for it. Now you can't, only dermatologists can, but she put me on it then. I ended up relapsing in med school, I think it was the stress of moving to the University of Miami and being all on my own, so I did a second fuller course in my early 20s. It's been 16 years now since I did my second course, I've had two children.

[Dr. Rita Linkner] So when we talk about things that are more curative, Accutane falls in that category. I think it's getting more demystified now. People used to be very concerned with the side effect profile, but I will tell you I run an Accutane clinic in my office. I very comfortably write for it every day, we do a lot of bloodwork monitoring and hand holding. [crosstalk 00:05:38].

[Amy Risley] Let's talk a little bit about what Accutane is, and how it's working to treat the acne and then some of the symptoms because we also get a lot of questions about that. The dry lips, the sort of flaking dry skin, irritation, the sensitivity. So let's talk about what's going on with Accutane.

[Dr. Rita Linkner] Perfect. So Accutane is oral vitamin A, and the way vitamin A works to cure people of their acne is it basically resets your oil productivity. It has a 50% cure rate, which is extremely high. In medicine, you rarely see medications hit that efficacy rate. So 50% of people who take a course of Accutane are cured, they never have to do topicals, birth control, anything. That also means 50% of people live in that other boat where they might do a birth control pill, topical benzoyl peroxide, an oral antibiotic course every now and then. Or they might do a certain course of Accutane, that's not unheard of, the relapse rate is around 20% and I was someone who fell into that category.

[Dr. Rita Linkner] People who are good candidates for Accutane are people who have that genetic component. If you're exhibiting any scarring, which is more of a secondary long term change from acne, then you're a good candidate for Accutane. The scarring is A, difficult to treat and B, expensive to treat. And body acne as we were suggesting earlier, that just suggests that you have a higher oil productivity rate and you need to reset that with Accutane.

[Dr. Rita Linkner] Side effects, everyone wants to talk about the side effects with Accutane. You cannot get pregnant on Accutane, it causes miscarriages and birth defects. So women of childbearing potential have to show that they're on two forms of birth control when they take Accutane if they're sexually active.

[Amy Risley] Okay, interesting. So Dr. Linkner, explain to us the link between birth control and acne prevention.

[Dr. Rita Linkner] So right now there are five birth control brands that are FDA approved to treat cystic acne. I reflexively write for Ortho Tricyclen low. When you see cystic acne, it's the lowest rung on the therapeutic ladder is birth control. You can't be prone to migraines, you can't smoke, you can't have a history of any coagulation issues to be put on birth control. But the nice thing is that after that first month of taking birth control pills, it also gives contraceptive protection. So the great majority of women like that. It does have a pretty high efficacy rate when in terms of treating cystic acne, but it's synergistic with spironolactone, which is the next step on that ladder. And then if spiro is not something that a patient's responding well to, then you're thinking about Accutane. So that's kind of the therapeutic ladder when you're trying to treat cystic acne.

[Amy Risley] Interesting. And how young would you prescribe a low dose birth control?

[Dr. Rita Linkner] Because of the issues with being on birth control, long term and fertility, I think the movement now is to just try and do Accutane younger, because it's a more manageable shorter course. And I think it teaches teenagers a lot of responsibility to be taking a pill twice a day with meals, and those are good habits to have when you're in your parents house and learning about before you venture off to college, and that responsibility of seeing a doctor every month. And so I see a lot of parents, especially on the Upper East Side, handing that responsibility over to their teenage kids and kids do extremely well.

[Dr. Rita Linkner] The thing with Accutane, is only the first month you truly purge, after that your skin clears. So there's nothing as gratifying as with Accutane, because after that first month where patients normally purge to be able to clear someone of what could be a long chronic disorder of acne and acne scars. So it's a gratifying medication to be able to prescribe.

[Amy Risley] I imagine. And is there a period of time that you would have to be off Accutane before you were to try to get pregnant?

[Dr. Rita Linkner] So the true half life of Accutane is actually 24 hours. But we tell patients, you should wait one menstrual. And that's kind of how the Accutane... I mean, it's just guidelines just so that it's easier for women to understand once they menstruate that they can go ahead and try and get pregnant again.

[Amy Risley] And is that true for topical vitamin A as well?

[Dr. Rita Linkner] The halflife of topical vitamin is even less. The only topical vitamin A you have to be careful with when you're trying to get pregnant is Tazorac. It's category X, it can cause birth defects. But other than that, topicals just like oral vitamin A are just used very commonly in dermatology to treat acne.

[Amy Risley] So an over the counter retinae that you would buy at a Sephora for instance would be fine to use during pregnancy, breastfeeding [crosstalk 00:10:00]?

[Dr. Rita Linkner] No, so I tell patients, the only thing you can't really lean on during pregnancy and breastfeeding is vitamin A. You can use glycolic acid, salicylic acid is also common, but I'll coach patients to use in a room. Clindamycin is another active that's safe, Azelaic acid on that list as well. But vitamin A and it's topical form should not be used when you're trying to get pregnant, pregnant or breastfeeding. That's a good question.

[Dr. Rita Linkner] And the statistics interesting, they say 40% of women who never had acne will have acne during pregnancy. So that's another shift in hormone state where you'll start to see acne come about during pregnancy. There's so many different things happening during pregnancy, the stress itself, the cortisol changes. But pregnancy acne is harder to treat, you're using third, fourth line active ingredients because you can't use things like benzoyl peroxide and vitamin A as we were just speaking of.

[Amy Risley] So benzoyl peroxide is something that you would also want to avoid when you're pregnant?

[Dr. Rita Linkner] Correct. That's on the avoid list, yes.

[Amy Risley] Okay. Interesting. So teen acne, Accutane, potential low dose birth control pills, clindamycin. But what else could you do topically to help treat [crosstalk 00:11:10]?

[Dr. Rita Linkner] If there is any component of cystic acne, then you're better off doing something oral. You get to maybe a 60% clearance, you won't get someone all the way to 80, 90, 100% clearance. So that's why you lean more so on Accutane. I do a lot of teenage acne on Accutane. The one thing I always like to look out for is boys should be past their growth spurt. You don't want it to be affecting bone growth. Even the data is not as solidified, it used to be much more strongly against it when you're in your growth spurt. Now that Accutane has been FDA approved for almost 30 years, we know it doesn't have a true effect. But I always like to wait. These boys, you don't want their mother coming back to you. [crosstalk 00:11:54]

[Amy Risley] Better safe than sorry.

[Dr. Rita Linkner] But Accutane is one of these easy or fixative medications. Whereas if you talk about birth control or spironolactone, those are more band aids. You're working on that hormonal pathway and you're mediating it but you're not turning it off. So the last thing I think it's been an epidemic, I was on birth control for 12 years and I had some fertility issues where we had to do IVF with our first baby. And so I think there's this big movement away from having teenagers starting on birth control pills for acne and moving towards more comfortably writing for Accutane for for teenagers who have both white head, black head acne, cystic acne, body acne, things like that.

[Amy Risley] Will the growth spurt be equally applicable to young teen girls?

[Dr. Rita Linkner] Yeah, girls usually peak a little bit earlier than boys do on that. So I always tell parents, they're the sweet spots when they're good times do Accutane in life, before college, before you're drinking is a great one.

[Amy Risley] You don't want to drink alcohol [crosstalk 00:12:55].

[Dr. Rita Linkner] Right. Because vitamins get processed through the liver, as does alcohol. So I preach abstinence of alcohol while you're on Accutane. It's also at post college up until the age of 26 when you're still on your parent's insurance plan, that's a nice time to do it too. But I'll tell you, I mean, it's one of these medications that when I worked on the Upper East Side of Manhattan, I tapped into this big South American crowd of mothers. And in South America, it's very common to write for five milligram doses of Accutane to take daily. And these women aren't on birth control, and they're just living their lives, drinking every day. Not that we advocate for that in the States, but it's more demystified outside of the US. I mean, it's something that you can get over the counter in a lot of foreign countries.

[Amy Risley] So in my age group, I'm 49, going to be 50 in May. So Dr. Linkner, what would be the sort of typical or optimal dosage of Accutane?

[Dr. Rita Linkner] Great question. So the way Accutane works, and now that there's been 30 years of clinical data on what the actual regimen should be, it's weight based. So we take your weight, we run it through an algorithm and you have to ingest a total amount of vitamin A proportionate to your weight to hit this cure rate. So most people will start at a 20 milligram dose twice a day. So 40 milligrams in a day, times 30 days in a month, you're ingesting 1,200 milligrams of Accutane your first month. We try and escalate it to 30 milligrams twice a day, and then you tap out at 40 milligrams twice a day and that's the dose you really coast at for the entire course until you've hit that cumulative dose where you know you've hit your cure rate.

[Amy Risley] And how long is the course typically?

[Dr. Rita Linkner] So let's take like 120 pound girl, you're looking at four months, so very attainable, right?

[Amy Risley] Yes. Four months is doable, and then it's pretty well taken care of the acne and hopefully you don't have a relapse.

[Dr. Rita Linkner] Women do have to demonstrate two negative pregnancy tests to be written the prescription, so that's one thing to take note of. Men reflexively once their blood work passes with flying colors they can be written the prescription reflexively.

[Amy Risley] Two consecutively, or after two full cycles of-

[Dr. Rita Linkner] It has to be at least 30 days I should say, two negative pregnancy tests in order to be written the prescription. And that has to do with iPLEDGE which is the nationwide registry of all people who take Accutane in the country, which also makes everybody every month go in and answer five multiple choice questions stating that they're not sharing their medication with anybody else, that they understand that they can't get pregnant on the medication. We joke the most depressing thing about Accutane is just iPLEDGE it's just such a barrier of entry I think, and it's a lot of work on the officers part to make sure that patients are educated on how to log into the system and monthly are answering these questions. If you go to a well run dermatologists office who's doing blood work in house, it's a very easy thing to get you through.

[Amy Risley] Could it cause liver damage though, if you were drinking while on Accutane in theory, is that why you-

[Dr. Rita Linkner] Being on Accutane is like drinking two glasses of wine a day.

[Amy Risley] In terms of the liver and the work it has to do to process it.

[Dr. Rita Linkner] Exactly. So if you're drinking on top of that, yes, you could create full damage. We check bloodwork every single month.

[Amy Risley] In terms of extracting your own acne. My daughter has one of those comedone extractors that she has at home. What would you recommend when there's a whitehead or blackhead and you're a teenager and you want to get rid of it?

[Dr. Rita Linkner] I mean, my best clients who still come to me still have facialist. I don't know if that's a thing of New York City, but-

[Amy Risley] Probably. I don't think any young teens in Nova Scotia have facialist.

[Dr. Rita Linkner] It's a nice way to just clear out, unclog pores and dermatologists do this as well. You can go in and bill it under insurance, believe it or not. [crosstalk 00:16:44]

[Amy Risley] You still have extractions?

[Dr. Rita Linkner] Yeah, just have extractions. And if anything needs a cortisone injection, if it's cystic, that's something that I do very often in the office when girls have events that night, and they just need something that comes up with your period and you need it to be gone yesterday.

[Amy Risley] Is there a sort of safe way to extract your own [crosstalk 00:17:00]?

[Dr. Rita Linkner] I don't advocate for this, a lot of those tools, the way we sterilize them in the office is they run through medical grade solution, they sit in that solution for hours, and then they're scrubbed down and they're put in a very high temperature oven for a period of time so they're properly sterilized. So I always advocate for people to not touch stuff on their own, I think it's easier to get a blemish or a scar if you're doing it on your own. I mean, it took me 14 years to learn how to do an extraction properly, there's an art to it.

[Amy Risley] So leave it alone and let it kind of-

[Dr. Rita Linkner] I mean, there's something to say about trying to use a topical steroid in combination with a vitamin A night cream if you feel like that spot erupting beneath the surface of the skin. That usually does the trick overnight, that's my personal trick. But again, if you are prone to cystic acne, if you're prone to scars, not everybody is, then you should try and figure out a way to access a dermatologist if you can, that can help you out in a bind.

[Amy Risley] So treated systemically rather than-

[Dr. Rita Linkner] The longer it sits there in place there's the higher likelihood you're going to get a blemish or a scar. It's just inflammation. And that's where the cortisone comes in handy, it turns that inflammation off.

[Amy Risley] Okay. Shifting a bit to something that's more closer to my age group is this sort of adult cystic, hormonal, perimenopausal, menopausal acne, post pregnancy. What's going on there? And it tends, in my experience, and in talking to others to be more of the cystic variety, seems to be more embedded in the dermis and the epidermis. How do we deal with that?

[Dr. Rita Linkner] So again, it's that sensitivity to the male derived testosterone hormones that all women have and that shifting come menopausal years. Usually the women I see who struggle with this are women who had teenage acne. So it is that stronger genetic component in there. I don't really advocate for birth control at that age group without consulting with an OB GYN if you're above the age of 45. Spironolactone is a great option though. So spironolactone works on the derivative of testosterone nerve blocks that receptor so that the testosterone can hit that receptor. It was originally formulated as a diuretic, so it makes you pee, so you have to make sure you're drinking lots of water on it. And it's not ideal if you have any kidney issues or if you've low blood pressure.

[Dr. Rita Linkner] The other thing to know is spironolactone. It's a twice a day dose. So you have to be diligent with that and on top of that for compliance. Side effects, we do bloodwork monitoring, less intensely than Accutane, but it can increase potassium levels in the blood. So diet wise, you have to be wary of bananas, coconut water, kale, these cleanses that everyone's doing now, high potassium foods have to be avoided.

[Amy Risley] Because you have too much potassium in the system.

[Dr. Rita Linkner] Yes, and that could cause an arrhythmia, so [crosstalk 00:19:43]. Yeah. In a young, healthy woman, it's overkill doing monitoring but we do it anyway just to be very cautious with that. The nice thing about spironolactone is it doesn't have the dryness. It has a high efficacy rate too, in terms of treating cystic acne. Around 78% of women who take spironolactone see an excellent improvement in their cystic acne within two menstruals. It's not overnight like Accutane is, but it does have that high efficacy rate. When combined with a birth control pill that efficacy goes up to like 90%.

[Amy Risley] What is fundamentally the difference between sort of teen pubescent acne and adult hormonal acne?

[Dr. Rita Linkner] There's more of a sebaceous component to it when you're younger, so that's why you see more body acne.

[Amy Risley] More oil production.

[Dr. Rita Linkner] Exactly. And that burns out a lot over time with life, we just aren't as oily as we grow up. I think everyone can know, you have dry skin now, you don't remember having dry skin when you're a little kid, right?

[Amy Risley] We'd love that oil back.

[Dr. Rita Linkner] Right. But also, I think there's so much in skincare now that's oil based and people are getting that so wrong. If you're acne prone, you should not be using oils, it's just adding fuel to that fire. But if you walk into Sephora, Bluemercury, everything is oil based these days. Everyone wants to be organic, and do things with tea tree oil, which was allergen of the year in 2014. I mean, it's just such a conundrum that a lot of what I do in the room is just educating patients and creating skincare routines. So I truly believe a true skincare routine is five steps in the morning and five steps at night.

[Amy Risley] Let's talk a bit about what those steps look like if you're acne prone.

[Dr. Rita Linkner] So if you're acne prone, cleanser is the first step morning and night. You should be looking for something that foams. Foaming cleansers just signify that there are detergent, they're bringing your skin level to a pH where you're actually cleaning out pores and you're decreasing oil production. So foams are better than like a cream cleanser for instance.

[Amy Risley] There are sulfate free foams that-

[Dr. Rita Linkner] Totally. Listen, if your eczema prone though, you should be using something that's cream based, you don't need to be doing such a harsh detergent job cleaning out those pores. Step two, I really truly believe in eye cream. I wish I was younger when I started eye cream. Eyelid skin is the thinnest on a woman's body, so you have to use the right product. And that varies, some women are just crepey, others or have dark circles. So whatever the main issue at hand is should be addressed with the eye cream, but again, it should be morning and night.

[Amy Risley] You would recommend putting the eye cream on the lid itself to [crosstalk 00:22:15].

[Dr. Rita Linkner] You stay on bone but upper and lower lid ideally and there should never be vitamin A in an eye cream. If you ask me it's just too thin on a woman's body to work.

[Amy Risley] So no retinol in eye cream?

[Dr. Rita Linkner] Correct. Step three in the morning is sunscreen. So it should be something that goes on the skin every single day. Everyone says [crosstalk 00:22:32].

[Amy Risley] As a separate product versus in a makeup [crosstalk 00:22:35].

[Dr. Rita Linkner] Correct. You don't want to double dip on that stuff. So you want a product that's your dedicated sunscreen. I get this question all the time. I'm in an office building. I go from my subway to the office and I'm home, I'm not outside. There's a lot of data coming out now that infrared heat is actually a big ager of the skin and it causes melasma and things like that. So this newest age of sunscreens is adding an infrared blockers which is really interesting.

[Amy Risley] And there's blue light as well if you're exposed to daily from your screens.

[Dr. Rita Linkner] Exactly. So even it's that heat energy when you're standing next to a stove or a fireplace. It damages the skin so it's nice to be able to use a sunscreen that's going to give you that additional blocker on it.

[Amy Risley] What is the ingredient in infrared.

[Dr. Rita Linkner] So it's derived from an algae called thermophilus that lives in very, very high temperature, hot springs in the ocean and certain skincare lines have basically mixed the algae into their sunscreens which is new technology.

[Amy Risley] Very cool.

[Dr. Rita Linkner] Yeah, super cool. After sunscreen in the morning, I believe in vitamin C. Vitamin C is what makes your sunscreen work harder and stronger throughout the day, so they should be coupled together.

[Amy Risley] Dr. Linkner looks like she's in her early 20s. For those who can't see her right now.

[Dr. Rita Linkner] It's all this stuff in my face, it's working its magic.

[Amy Risley] You look amazing. So can you clarify the difference between good blue light and bad blue light.

[Dr. Rita Linkner] So blue light falls in like the visible light spectrum. And it's mainly been shown to be anti inflammatory. So I think the crossover is infrared heat, which is what emanates off of light bulbs, iPhones, computer screens, that's what's being shown now in the literature to age and discolor the skin.

[Amy Risley] So it's not the blue light [crosstalk 00:24:12]?

[Dr. Rita Linkner] No, it's more infrared heat technology that you should be more wary of. And that's why this newest age of sunscreens is adding in that thermophilus algae into it to start protecting people beyond UVB and UVA light, which is what we all know about and what regular physical blocking sunscreen does. Is now nice to be able to add that extra layer of protection that's anti aging you almost. And what better way to convince someone to use sunscreen but to tell them that anti ages you. And at the end of the day, the best active ingredient you can put on your face is actually sunscreen and that's what the data shows in terms of skin cancer and melanoma and things like that. But in terms of fine lines and wrinkles too, it's just very important to be using a sunscreen every single day.

[Amy Risley] That was great clarification. So blue light is actually potentially helpful-

[Dr. Rita Linkner] Correct.

[Amy Risley] ... it's infrared heat that we're getting from our devices, which we haven't really heard about.

[Dr. Rita Linkner] Well, all these women are going to infrared saunas. You go to Bikram Yoga and they're elevating the temperatures up to crazy temperatures, it's not healthy for your skin.

[Amy Risley] So infrared saunas are not good for your skin?

[Dr. Rita Linkner] No, it causes a lot of melasma. So whenever I see melasma in young girls now, I mean yes, birth control is a huge contributor do not get me wrong, but the second question I ask is are you on birth controls? Are you sitting on these infrared saunas? There's a huge disconnect. People think it's healthy, it helps lymphatic drainage. I mean, I can tell you it ages your skin, so not ideal if you're someone who's looking to age in reverse.

[Amy Risley] Which is probably all of us realistically. So we're talking about melasma, which occurs often when you're taking birth control, when you're pregnant it can happen, lots of people are prone to it. I was very prone to it in pregnancy. Tell us a little bit Dr. Linkner, about what melasma is.

[Dr. Rita Linkner] So melasma is skin discoloration that's commonly seen on the cheekbones, on the forehead and then notoriously on the upper lip, where it gives that impression that you have like a mustache when there's no hair there. It is hormonally mediated, so you see it most commonly in women on birth control, but it's activated by UV exposure and infrared heat exposure. It's very common in women, but you will see it in men often of Asian descent, it's common to see in men as well.

[Amy Risley] Interesting. Do hyperpigmentation topicals help with melasma, in your opinion?

[Dr. Rita Linkner] Yeah. So my favorite ones to use and part of the reason that that's what I kind of based this RVL Skincare is alpha hydroxy and beta hydroxy acid. So glycolic acid is a great way to function as a brightening agent. It does really help with oil production, yes, so if you're acne prone, but beyond that it really helps to target melasma. The nice thing to know about glycolic acid as is pregnancy safe. So they're pads that I sell called Pregame Pads. They're 5% straight glycolic acid, they are pregnancy safe.

[Amy Risley] And 5% is okay in pregnancy?

[Dr. Rita Linkner] Yeah, I mean, we do glycolic acid peels in the office that are 40% on pregnant women. Stronger, yes, you might actually peel but when you're using a 5% pad, you shouldn't see that visible exfoliation.

[Amy Risley] What about salicylic and pregnancy [crosstalk 00:27:12]?

[Dr. Rita Linkner] You should talk to your dermatologist, I will fight with some. There's some notorious OB GYNs on the Upper East Side who will tell patients not to use it. There are a lot that tell them that it's safe though. So I always consult with an OB GYN. But remember salicylic acid is a salicylate, so like acetaminophen, it's all derived and these are pregnancy safe things to be taking. But again, I don't like stepping on toes when it comes to these OB GYNs on the Upper East Side of Manhattan. So I always consult with them when I ask patients who are acne prone to start salicylic acid.

[Amy Risley] Let's talk about food for a minute, Dr. Linkner, because I'm a big believer in food as medicine or food as potential pathogen. And I've had a lot of experience in my own life treating things with diet and avoiding certain foods. And there's been a big link between high glycemic foods and dairy for acne. So let's talk a little bit about that. I struggle with trying to convince my son, that eating lots and lots of carbs and pizza is probably not great for acne. So what are the links there? And do you think that there's something to shifting your diet?

[Dr. Rita Linkner] Of any of the chronic skin disorders that you studied, the only one that really has a true basis with diet that's been proven over and over is with acne. The most interesting study that I like to talk to my patients about is there's a population of natives in Papa New Guinea that has a very low glycemic plant based diet, and there's never been acne demonstrated in the population. So yes, these high glycemic diets that are very characteristic of Americans are contributing to acne. Interestingly enough, in terms of dairy it's considered skim milk more so than whole milk. It has to do with how they lessen the fat content in it and the correlation.

[Amy Risley] High sugar content?

[Dr. Rita Linkner] Yeah. It also translates with cheese and dairy and yogurt as well. So if you have a patient who's eating a lot of ice cream and things like that, it's worth thinking about cutting it out to maybe just one meal portion a day. I don't see a lot of people coming in and making diet changes and that fixing everything. I think it's something that is a multifactorial kind of skin disorder, and it adds to it.

[Dr. Rita Linkner] The other thing that I see a lot of these teenagers using are a lot of whey protein additives into juicing and things like [crosstalk 00:29:43]. Yes, and so that's also something that's a big thing to make sure that you're asking patients who are struggling with acne. Every now and then you'll get a really lucky patient who's depending on whey protein, you knock it out and their acne goes away. But overwhelmingly I think if you're coming to a dermatologist, you haven't figured it out on your own, you're most likely going to walk out that door with a prescription.

[Amy Risley] Well, it's at least something to consider.

[Dr. Rita Linkner] Correct.

[Amy Risley] I think if you're going to your prom or you're going to a big event, and if it could potentially be of help to scale back on the milk you're drinking or shift to nut milk or some sort of other dairy source. Which is interesting to me that it wasn't until 2016 that the American Academy of Dermatology actually listed it as a potential treatment was to avoid certain foods.

[Dr. Rita Linkner] It just hadn't been proved yet. And there was a question that had been investigated and investigated. And it wasn't until those large cohort randomized studies that were actually showing that it was not just a confounding factor. So yes, I agree with you, it is a newer message that you have to carry over into the exam room and make sure patients are aware of.

[Amy Risley] One of the questions that we get all the time, and I'm sure you deal with a lot and you've talked a bit about is scarring. And you did a really interesting study that was published in the JDD about using topicals and microdermabrasion to treat acne scarring.

[Dr. Rita Linkner] The study was interesting. The thing with acne, the reason I love it so much is that at the end of the day, it's a cosmetic kind of skin disorder. And treating scarring is very challenging. And not everybody scars, it's actually a genetic component to it. The study itself was done with microdermabrasion along with Aminolevulinic acid. So ALA is something that's topically applied to the skin and then gets activated by blue light. You basically put someone in front of a blue light for 10,000 seconds which equates to 16 minutes and 40 seconds. And it the blue light activates the ALA to initiate this massive anti inflammatory effect.

[Amy Risley] And what is ALA?

[Dr. Rita Linkner] ALA is a plant based derivative that has been shown when topically... And it not only activates with blue light, but UV light too, so that's important to let patients know if you're doing it over summer months. But when it integrates into skin cells, it turns off reactive oxygen species which is very anti inflammatory. That being said, it's been shown blue light even alone is very anti inflammatory for acne. It works on the bacteria that is notorious for causing acne called P. acnes and is able to murder P. acnes within the skin cell. Which is interesting, a lot of pregnant women who are on these third and fourth line topical treatments oftentimes we'll put them in front of just a blue light for 16 minutes and 40 seconds a couple of times a week and it can help them during pregnancy and it's considered pregnancy safe.

[Amy Risley] Is that something you could do at home?

[Dr. Rita Linkner] It's medical grade, it's this massive light that works like a sea and encompasses your entire head. You have to wear protective eyewear with it. Going back to the study, it was interesting to be able to show that we did a mock, on one side there was no ALA, on one side there was ALA. And we were able to show on photography, which is really hard to show, that the side that had the activated ALA that the scarring improved and it was-

[Amy Risley] By 80%?

[Dr. Rita Linkner] Right. And it was the type of thing that we could get graders to actually notice on photography. So it's a lot of parameters and it was a small cohort. It was my residency research project.

[Amy Risley] So is this something that's being done in office now, the ALA microdermabrasion to treat acne scarring?

[Dr. Rita Linkner] I think the now technology to treat acne scars is really relying on micro needling with radio frequency energy. So this is one of those trends in 2020 that we can touch on now. So micro needling started when I graduated residency about five years ago that the vampire facial became big in vogue treatment. It was like Kim Kardashian just made it, she took all that blood and smothered and all of her face and everyone the next day wanted to come in and get their vampire facial done.

[Dr. Rita Linkner] Now the technology basically has been made laser grade. Meaning you're taking needles, you're stamping them in the skin, every time it stamps to adapt up to three millimeters in the skin, which is deep. You're delivering radio frequency energy into scars, into loose skin, into fine lines and wrinkles even, things that are more superficial you can target. The needles themselves or coagulating blood, so it's blood less, which is amazing so there's no downtime.

[Amy Risley] So what do you mean by their coagulating blood? What does that mean?

[Dr. Rita Linkner] The needles are driving in and out of blood vessels. You want to go to a depth where blood vessels live because that's how you stimulate new collagen growth. But as opposed to old school vampire facials, you get off the table and there's not a drop of blood on you. The blood itself is just being coagulated by the needles so it doesn't come to the surface of the skin. The downtime with a lot of these platforms now there is none. It's amazing, you can come in, you can numb for 10 minutes, you can do the procedure in 15 minutes, you can be back at your desk within your lunch break.

[Amy Risley] And that can help with acne scarring and as you said, loose skin wrinkles [crosstalk 00:34:48]?

[Dr. Rita Linkner] Pore size, fine lines and wrinkles. It's this lifting tightening effect too. If you're doing this stuff earlier and earlier, you're not going to need that full blown overhaul when you're in your 60s at plastic surgeons office, so it's that movement towards doing-

[Amy Risley] Which is nice. And so pore size, I've always thought that that's something that you can't actually decrease.

[Dr. Rita Linkner] Oh no, you totally can.

[Amy Risley] With this particular [crosstalk 00:35:10]?

[Dr. Rita Linkner] And then there are a couple of topicals that have been able to show efficacy with pore size. So glycolic acid is one and vitamin A is the other. So those are two really important ingredients to have in your skincare routine if you're prone to acne, large pores, things like that.

[Amy Risley] And for my daughter's benefit, Dr. Linkner, what do you think about people micro needling at home?

[Dr. Rita Linkner] So goes back to people doing extractions at home. I mean, I don't know how people will be cleaning these things. The newer age ones I've seen are actually disposable, which I like a little bit better. But you have to remember to hit the depth where you're stimulating new collagen, you have to bleed. You have to hit the papillary dermis, which is the middle layer of skin in order to get new collagen to be born.

[Amy Risley] So let's not do that at home.

[Dr. Rita Linkner] And I don't think you can do that comfortably at home without proper medical grade numbing. The last thing you want to do is make your scars worse by just trying to do this on a budget or something by yourself.

[Amy Risley] Talk a little bit about the mommy makeover. In my day, it was the tummy tuck, boob job, 15 years ago, but what's happening with that today?

[Dr. Rita Linkner] So when I started out of residency, I was on Park between 86 and 87th and there were 13 plastic surgeons and dermatologists on that block. I was like, "How am I going to get these Upper East Siders to start coming to me?" So I read this great book, Why She Buys. I don't know if you've ever read this book.

[Amy Risley] Yeah.

[Dr. Rita Linkner] It's a great marketing book. No one teaches you marketing when you're in med school. But the entire premise of the book is that if you can tap into a mom, you can tap into the entire family and all that spending power. And that women are just so detail oriented and experiential. So if you can really relate to a woman when you have her at that consultation, that's amazing. But if you can keep that message lingering after she walks out the door, that's like coup d'etat.

[Dr. Rita Linkner] So I started figuring out, who might who could I possibly attract? I'm not going to get these women that have been going to this dermatologist for 20 years, I'm going to get women just like me. Because mommy makeover is really a very important entry point into cosmetics. The only one that comes before that is wedding prepping, which is very common for first time injectables. But a lot of women don't do that and they wait until they had their first baby and it's that massive weight gain and then that sudden weight loss, it ages you. And that 40 week period of being pregnant you really go through a lot in that survival mode period in that first year thereafter.

[Dr. Rita Linkner] So we talk a lot about yes, baby Botox, but moreso fillers. A lot of hollowness and deflation that occurs with that weight loss needs to be corrected for in terms of refilling the fat pads that you've lost and creating balance and proportions again. It's this idea though, that when you're young, you don't need more than a syringe and I think a lot of what women get nervous about with doing injectables younger is this pillowy face to look that you see constantly when you walk around the Upper East Side of Manhattan.

[Amy Risley] We all know the look.

[Dr. Rita Linkner] It's terrifying. And I spend most of my day teaching women that that person has six, seven, eight syringes in her face. I say a lot of nos in my exam room. I don't want those people in my waiting room honestly, that's not the message I'm trying to portray. I think it's my generation of millennial cosmetic dermatologists that are reeling people in, less is truly more. That might mean you see me more frequently and we do smaller things but the big picture is to make you look like you on your last day of vacation 365 days a year. So I very commonly just started putting myself on my Instagram and going through all the motions about what I was dealing with having these two little kids. And it just started resonating with people and I was finally capturing girls that I was eyeing on Instagram, they were finally coming in to see me and it kind of just took off from there.

[Dr. Rita Linkner] But the idea of mommy makeover beyond the face, things that I've done for instance, I put Sculptra, which is a semi permanent filler in my butt. After my second baby I could not stand the stretch marks that I had on my butt. And I've had them since I was like 12 for my growth spurt, but they definitely worsened with both pregnancies. And I was like, "In a bathing suit, this is what bothers me the most so let's fix this."

[Amy Risley] Did you do that yourself?

[Dr. Rita Linkner] No, the only injections that I did-

[Amy Risley] I see you on Instagram doing a lot of things to yourself, but I don't know how you do.

[Dr. Rita Linkner] I do my own neuromodulators like Botox and Dysport, fillers I would never do to myself. I think you see a lot of kind of scary dermatologists walking around out there who are injecting themselves, but the angles, the depth where you have to go with fillers and when you need to stop, that's why I go to close girlfriends to do this stuff with me. But that being said, with the Sculptra in the butt, it's this idea just when you look at the Kardashians and you look at how voluptuous they are, they probably have close to 25 or if not 30 vials of Sculptra in each butt cheek. I'm someone who ended up putting five and on each side and just like the face deflates in ages, I mean women realize this, you're butt deflates in ages.

[Dr. Rita Linkner] So using Sculptra, not only to lift my buttock, but also to treat the stretch marks in such a way where the injections are done to break down that tethering between the stretch marks. I mean, it worked wonders for me just having done two treatments. The coolest thing about Sculptra, and why it's more considered non invasive now and so attractive to clients is that it's semi permanent. So you're stimulating collagen that lasts between two to five years.

[Amy Risley] Oh, well, that's great. And normal fillers are [crosstalk 00:40:42]?

[Dr. Rita Linkner] Normal hyaluronic acid fillers. Honestly, people who are heavy exercisers, you might go six months or nine months [crosstalk 00:40:49]

[Amy Risley] Metabolize quickly.

[Dr. Rita Linkner] Right, exactly.

[Amy Risley] So one of the things that strikes me just to segue for a second, there's a lot of emotions that come with the patient through your practice, through your door every day. You've got teenagers that are dealing with acne and such a psychological roller coaster of a time of life, and then they've got acne to boot. And then you've got moms who've just gone through the changes of pregnancy and possibly don't recognize their body. So tell me a little bit about how you talk to your patients and sort of how you tackle the psychological aspects of skincare and skin concerns.

[Dr. Rita Linkner] Right. It's funny, I really like just connecting with people in the room. And I'm the type of person that I'm going to ask you where you grew up, what you do for work, all of those variables are so important to creating a game plan for what we're going to do not just in that visit that day, the next time I see you, six months from now a year from now. But it's true, the skin is just so visible to everybody and it kind of shows what you're going through. And it's such a power to be able to create beauty and to correct things like psoriasis or acne and really change somebody's life.

[Dr. Rita Linkner] So that's why the field that I'm in it's an unbelievable field, especially for a mother, especially for a woman. But I would add on a probably another really important entry point into cosmetics is I'm seeing a lot of these divorced people coming into it, who are trying to resurface and recreate and rebuild and renew and so it's nice to be able to catch people with these life changes. If it's a wedding, if it's a pregnancy, if it's divorce, whatever it is, and help someone through that.

[Dr. Rita Linkner] A lot of what my job is is like therapy. And I think the reason people come to me is for retail therapy. I mean, I can barely find time to do this stuff for myself, but it feels good when I finally make that time for myself. So it's a huge part of my day is not just putting the gloves on and holding the needle in my hand, that's literally 5% of it, but all of the rest. So I'm notorious, I give my cell phone number out to every patient, like a tic tac, and I've only regretted it once in five years. But it's nice that I do follow up with everybody the next day myself-

[Amy Risley] On text, or?

[Dr. Rita Linkner] I text with everybody. And it's really time consuming, but patients love it. And it's this high touch kind of concierge care where people think it's a premium and they're willing to [crosstalk 00:43:20].

[Amy Risley] That's incredible. And so how many patients do you see in the run up a day?

[Dr. Rita Linkner] Right now I'm at probably 12 to 15 which is a really nice happy medium. I like doing a full 45 minute cosmetic consult. I think you come in, that's the amount of time required for me to understand who you are, and where you want to go. And for us to figure out what we're going to do over a course of a year. And then thinking about someone's budget, what they do for work? How much downtime can they truly afford? That's a lot of strategy.

[Dr. Rita Linkner] Everyone always asks me, I mean, the first thing I do is I hand people a mirror and I ask them to delineate number one, number two, number three, what bothers you when you look in the mirror. And invariably, all women have the same three complaints. So it's lines, folds and complexion. Every woman puts it in a different order that pertains to her. And then always The fourth thing that happens is women asked me, "What would you do if you were in my shoes?" And I never answer that question, because at the end of the day, I punt it back to the patient, you're investing in yourself, your image, you should go home and look in the mirror at the end of the day, and you should be checking off boxes in the order that you think you should be checking them off with.

[Amy Risley] It sounds like you learned a lot of that from watching your mom and her bedside manner, but there's such a bedside manner to dermatology that right we often I don't think [crosstalk 00:44:38].

[Dr. Rita Linkner] Yeah, and it's a cosmetic jungle up here. It's crazy. It's just everyone's doing this. So you have to figure out where you live in this universe, and you have to just attract people to you and create desire for people to want to never, ever leave you.

[Amy Risley] That's not a problem for you because you have that charisma.

[Dr. Rita Linkner] Thank you, you're so sweet.

[Amy Risley] So for those that love to pop their own zits, you were talking about how there's a real art to extraction. It took you 14 years to learn how to properly extract acne from the skin. So talk to us about what that art entails.

[Dr. Rita Linkner] One of my biggest secrets and I'll leave it here for you guys on your skin nerds podcast is I love telling patients to use a little bit of a topical steroid on an extracted cystic pimple to really truly make it disappear yesterday. That anti inflammatory effect on an extracted pimple usually take like 72 hour, of course run itself downtime, maybe 24 to 36 hours. So that's one other tip.

[Amy Risley] And that's sort of a 1% hydrocortisone cream.

[Dr. Rita Linkner] Yeah, oftentimes you can go over the counter with that stuff.

[Amy Risley] So just a low dose hydrocortisone cream can help take that inflammation down after you've extracted?

[Dr. Rita Linkner] Correct.

[Amy Risley] Dr. Linkner, thank you so much. We covered so much in a short period of time. I don't know how you keep that all in your brain.

[Dr. Rita Linkner] It was so much fun, honestly.

[Amy Risley] It was great. It was wonderful to talk to you. I really appreciate you taking the time out of your very busy schedule. And we look forward to seeing you at Spring Street Dermatology.

[Dr. Rita Linkner] Yes, I can't wait to hear the podcast. I can't wait to hear it.

[Amy Risley] We can't wait as well. Thank you again. You can learn more about Dr. Linkner's work, innovations and products at www.rvlskincare.com and wwwspringstreetderm.com.

[Amy Risley] I learned so much from talking with Dr. Linkner. Here are three things I can't stop thinking about. One, I love the idea of bedside manner being so important and hearing a dermatologist acknowledge the psychological impact of skin conditions. We'll want to explore that topic much more in future episodes, stay tuned. Two, from micro needling with radio frequency to 10,000 seconds in front of a medical grade blue light, it's always fascinating to me to hear what treatments are cutting edge, which are worth trying and which are just well publicized hype backed by powerful celebrity endorsements. It's great that there are doctors like Dr. Linkner out there who can put aside that hype and explain things in terms of science. I'm always grateful for a concise, digestible scientific verdict like the ones she offers.

[Amy Risley] And third, the idea of morning and evening routines for skincare whether it's for acne prevention, or a host of other issues is simple yet significant. Dr. Linkner's routine has five parts. Yours might only be one or two, but I think it's great practice just to set aside that time in the name of paying attention and creating good habits with regard to your skin. To have Dr. Linkner answer your acne questions, follow us and DM us on Instagram @skinfixinc. Watch our feed for her answers.

[Amy Risley] Thank you for listening to this episode of Total Skin Nerds. Please come back next time and please subscribe to our show on iTunes and Spotify. Total Skin Nerds is produced by Rob Corso, Casey Khan, and Howie Khan for FreeTime Media. Our theme music is by John Palmer. Special thanks to Kathryn Spears, Kara Canning Jane Meredith, Megan Collins and Jenny Chen. And I'm your host Amy Risley. Till next time, nerds. Total Skin Nerds is brought to you by Skinfix. We're clean, clinically active and on a mission to help heal your skin.

Speaker 3: Total Skin Nerds is a podcast created to educate. It is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical advice. If you are looking for help with a skin concern, we would encourage you to seek the advice of a board certified dermatologist, functional medical practitioner, or other qualified health care provider. You can find a registry of board certified dermatologists in the US at find-a-derm.aad.org and in Canada at dermatology.ca. For our registry of qualified functional medical practitioners, you can visit ifm.org. Thank you so much for joining us on this episode. We hope that you enjoy listening to Total Skin Nerds as much as we enjoy making it.