The claims are vast, from clearer skin to fresher breath. Yet experts say the science is shaky.
TikTok is bringing in big business for doctors, but they’d kindly like it to stop.
“I always know when something is trending on TikTok because I’ll have an influx of patients coming in and asking me about the same thing,” said Dr. Niket Sonpal, a gastroenterologist in New York.
Most of the time, that “thing” is a beauty or wellness tip that’s gone viral on the video-sharing platform, without evidence that it actually works. The advice may be ineffective or outright dangerous, from drinking chlorophyll to induce weight loss to using sunscreen only in select areas to “naturally” contour your face.
“We talk about TikTok all the time in my office,” said Dr. Dendy Engelman, a dermatologist and cosmetic surgeon in New York, “and I think it might be worse than other platforms because people are really looking to create content with that wow factor, the thing that will go viral, even if it’s not grounded in science.”
It’s not surprising that the app that brought us the “Benadryl challenge” (taking large doses of the antihistamine to induce hallucinations) and “the Everclear test” (doing shots of the high-proof alcohol) is not a fount of doctor-approved beauty guidance. But many consumers throw reason and caution to the wind when faced with these trends, underscoring a growing subversion of authority in which an influencer’s word is replacing that of experts.
“It’s funny because patients are often so timid in our office about trying treatments,” Dr. Engelman said. “But when they see something done on Instagram from an 18-year-old influencer, they’re like, ‘Sure!’”
What Not to Try at Home
Compiling an exhaustive list of TikTok’s bad beauty advice is next to impossible because the content on the platform seems to multiply in step with our increasingly short attention spans and insatiable craving for the new. But a few trends that have dominated the platform of late are especially mind-boggling to doctors.
Take “slugging,” a TikTok trend advising people to sleep with a thick layer of Vaseline on their faces to aid hydration. Videos with the hashtag have 14.4 million views on the platform, and the trend has been promoted by influencers like Hyram Yarbro and Cait Keirnan. But dermatologists warn that it can have adverse effects on your skin.
“Putting an occlusive on your skin and letting it sit overnight sets you up for exacerbating clogged pores and breakouts,” Dr. Engelman said.
Then there’s the “sunscreen contouring,” which Dr. Neera Nathan, a dermatologist at Massachusetts General Hospital in Boston heard about, to her horror, from one of her patients.
Some influencers have advised people tired of contouring their faces with makeup to use a thick sunscreen with high SPF, applying it only on the areas they want to highlight, like the top of the cheekbones and bridge of the nose. The rest of the face is left to tan (and burn), sunscreen free.
It’s a tip that flies in the face of the American Academy of Dermatology’s recommendation that everyone wear a broad-spectrum SPF of at least 30 on any exposed skin. “We know that this is crucial to do from a very young age from both a skin cancer and anti-aging perspective, so the idea that these videos are suggesting otherwise to a very young audience is disturbing,” Dr. Nathan said.
In April, drinking chlorophyll, which has had moments on other social media platforms, had a spike in interest on TikTok, driven by the endorsements of influencers like Amelie Zilber, according to Traackr, an influencer marketing platform. It has been called a “miracle product” that can increase energy levels, induce weight loss and clear up skin, but doctors say these claims are not backed by research.
Drinking chlorophyll is one of the more harmless recommendations on TikTok, but it’s likely a waste of money. (Sakara Life’s Detox Water Drops with chlorophyll cost $39, and raw chlorophyll drops on Amazon cost about $20, on average.) “If people are seeing ‘results’ from drinking chlorophyll, it’s likely because they’re drinking more water than normal, so their skin is getting better and their bathroom trips are more regular,” Dr. Sonpal, the gastroenterologist, said.
What trend do doctors really want to see left to the professionals? Microneedling, which involves puncturing the skin with tiny needles in an effort to generate new collagen. On TikTok, conversation around at-home microneedling grew in 2020 and is already experiencing five times more engagement in 2021, per Traackr, but experts say it’s incredibly risky to do at home.
While some studies have shown that medical-grade microneedling can improve skin suppleness and lessen wrinkles, “it needs to be done in a really clean, safe setting,” Dr. Engelman said, pointing to the high risk of infection. “If you go hard enough on your skin, it can lead to color change, textural change and scarring, essentially worsening what you’re trying to make look better, like fine lines and acne scars.”
Tilly Whitfeld, a reality TV star from Australia’s “Big Brother,” has learned firsthand just how dangerous beauty trends can be. After spending her time on the 24-hour surveillance-style show wearing clay face masks or heavy makeup, she was questioned by viewers about what she was hiding and confessed vaguely on Instagram in May that a TikTok beauty trend had damaged her skin.
Ms. Whitfeld, 21, said by phone from Sydney that she hadn’t told anyone exactly what it was because she “knew” she would look like an idiot.
Last August, she was browsing TikTok when she came across a video teaching people how to give themselves freckles using sewing needles and ink that were said to fade within six months. Since the video didn’t clarify what type of ink to get, she ordered brown tattoo ink she found on eBay, which she later discovered was a counterfeit product made with high levels of lead, and began pricking her face in a freckle pattern.
“It didn’t hurt at all, so I didn’t think I should stop,” said Ms. Whitfeld, who went over the marks multiple times, as advised by the video’s creator.
There weren’t any faux freckles, and her face swelled up from infection, which caused her to briefly lose sight in one eye, she said, and she now has scarring across her cheeks and nose. With nearly $12,000 already sunk into doctor’s visits, Ms. Whitfeld has yet to find a solution to correct the damage. Laser removal is apparently not an option because, doctors have told her, the ink she used will turn black rather than fade.
“The main response has been that I’m stupid, and, yeah, I agree,” she said.
For doctors, it’s a terrifying scenario. “You have a lot of people claiming to be experts who have no real consequences for giving really bad advice,” Dr. Sonpal said.
Stories like Ms. Whitfeld’s have doctors hoping that the companies running these platforms will place disclaimers on beauty content stating that it’s unverified or dangerous to try at home, but they’re not holding their breath.
In the meantime, they’d prefer that you reach out to, yes, a doctor, via appointment or direct message on social media, before putting your faith in a TikTok video. As Dr. Sonpal put it, “We can counsel and educate you for more than 60 seconds.”
Much of the marketing suggests that they’re safer than more traditional underarm products, but that hype is not based on science.
Google “natural deodorant” and you’ll find countless articles detailing all the reasons you should buy them. Some claim that the aluminum in most conventional antiperspirants can lead to Alzheimer’s disease or cancer. Others assert that certain ingredients in traditional deodorants and antiperspirants are “toxic,” or that they can kill off the “good” bacteria in your armpits.
Many natural deodorant companies have seized on these perceptions, implying in their marketing that the ingredients in conventional deodorants are the “stuff you don’t want,” and that what you do want is their “natural” product that is made from “plant- and mineral-based odor fighters” and “clean ingredients.”
But experts, including an oncologist, an epidemiologist, a skin microbiome expert and several dermatologists, said that there is no definitive evidence that regular deodorants or antiperspirants are worse for your health than natural deodorants. In fact, they said, they’re perfectly safe.
And while natural deodorants might contain seemingly healthier ingredients than your conventional drugstore antiperspirant, they can still have substances that might irritate your skin. In the end, the experts said, the way a deodorant makes you feel (and smell) should guide your decision to use it.
Are natural deodorants better for you?
No. One of the biggest and most alarming false claims made about conventional antiperspirants is that they cause breast cancer — a rumor that began with an email chain letter from the 1990s. It said that antiperspirants, which minimize perspiration by blocking sweat ducts, prevent the armpit area from “purging toxins,” which could build up in “the lymph nodes below the arms” and cause cell mutations and ultimately breast cancer. The letter also claimed that razor nicks from shaving could further increase breast cancer risk by allowing chemicals from antiperspirants to enter the body.
This, say experts — including those from the American Cancer Society — is false. “To date, there’s absolutely no evidence that breast cancer is caused by exposure to anything in antiperspirants or deodorants, full stop,” said Dr. Harold Burstein, a breast oncologist at the Dana-Farber Cancer Institute and professor of medicine at Harvard Medical School.
The same goes for another cancer-related rumor, which is that the aluminum from antiperspirants could be absorbed into the skin and increase breast cancer risk by altering breast cell estrogen receptors. Again, Dr. Burstein said, the evidence just isn’t there to support this idea. “The well-done human studies have really never suggested this,” he said, and the studies that have were often performed on animals or cells (like breast cancer cells in a petri dish) and used “unbelievably toxic levels” of the ingredients they were testing.
Anyway, Dr. Burstein added, only a minuscule fraction of aluminum can be absorbed through the skin, so your exposure to it from an antiperspirant is trivial.
There’s also been concern derived from decades-old research that found that Alzheimer’s patients’ brains had high levels of aluminum. This suggested that the metal — perhaps not only from antiperspirants, but also from other personal care and household products like pots and pans — could be a potential risk factor for this degenerative disease. But scientists now disregard the idea that aluminum can cause Alzheimer’s. “The evidence is of poor quality, generally speaking,” said Amy Borenstein, a professor of epidemiology at the University of California, San Diego, who studies the causes of Alzheimer’s disease. “The whole topic has kind of been abandoned.”
She did note that the link between aluminum and Alzheimer’s is challenging to study because aluminum is the third most common element in the Earth’s crust, which means that everyone is exposed to it in small quantities.
“We believe it’s important for people to have choices to find the everyday products that are right for them,” said Justin Boudrow, a spokesman for Tom’s of Maine, which makes a variety of natural personal care products including toothpastes, mouthwashes, soaps and underarm products. “This is why we offer natural deodorants without aluminum that provide odor protection, as well as antiperspirants that do contain aluminum for wetness protection.”
Are natural deodorants good for your microbiome?
There isn’t enough evidence to show that they are. There have been claims that regular deodorants and antiperspirants can disrupt or kill off the “good” bacteria living in your armpits, leading to skin irritation, redness, bumps and overall poor skin health. Some natural deodorant brands have marketed their products as “microbiome friendly,” claiming that they’re not only good for the health of your skin, but also minimize odor by promoting the growth of “good” bacteria.
But Jack Gilbert, a skin microbiology expert at the University of California, San Diego, said that he wasn’t aware of any rigorous studies that have borne this out. “There’s a lot of associative work, but nothing that definitively links deodorant or antiperspirant disruption of the skin microbiome to skin health.”
Are the ingredients in natural deodorants better than those in traditional ones?
No. Just because a deodorant is labeled “natural” doesn’t mean it won’t contain any problematic ingredients itself. In fact, the term “natural” has no regulatory definition, so its labeling on personal care products is essentially meaningless.
“You can get irritation or allergic rashes, and that’s far and away the more common health issue seen with deodorants — all deodorants, whether traditional or natural,” said Dr. Jennifer Chen, a clinical associate professor of dermatology at Stanford Medicine. The most common issue with deodorant is irritant contact dermatitis, or skin irritation, Dr. Chen said, which “usually can’t be pinned down to a specific ingredient, even though some ingredients are more irritating than others.”
The most troublesome ingredient in any kind of deodorant or antiperspirant, whether it’s “natural” or not, is fragrance, said Dr. Nina Botto, an associate professor of dermatology at the University of California, San Francisco. This includes essential oils, which many natural deodorant brands play up in their marketing. “Botanicals, plant extracts and essential oils are often touted as having health benefits,” Dr. Botto said. “But those natural components actually cause a lot of health problems and trouble for the skin.”
The combination of the underarm’s thin, folding skin, hair follicles and moist environment makes this area of the body more susceptible to irritation or an allergic reaction compared to, say, if you put deodorant on your back. In fact, Dr. Chen noted, one study on fragrance allergies found that among many of the scented personal care products tested — like scented deodorants, lotions, shampoos, shaving creams and hair dyes — the deodorants caused the most cases of allergic contact dermatitis, a skin rash caused by contact with an allergen.
Dr. Botto said that while she still sees allergic reactions to synthetic fragrances, she’s been getting more and more patients who are dealing with allergic contact dermatitis after using products with natural fragrance, like those containing linalool and limonene — natural compounds extracted from certain plants, like citrus fruit peels, which are commonly used in natural deodorants.
Even worse, “a lot of times you’ll see that someone gets a rash with a natural deodorant and they’ll put on balms and other ‘natural’ remedies that contain more of the same ingredients,” Dr. Botto said. “It’s kind of like adding gasoline to a fire.” She noted that such rashes can also cause breaks in the skin, which can then lead to infection. “It can be a real mess,” she said.”
Does natural deodorant even work?
The experts said they weren’t aware of any studies that reliably looked into how well natural deodorants work. But the way they’re formulated can offer clues.
Because regular and natural deodorants don’t contain aluminum (which is what helps antiperspirants minimize sweating) they typically rely on ingredients like fragrances and baking soda to mask body odor. This means that natural deodorants generally should function as well as regular deodorants do in terms of keeping you fresh. However, while the experts were not aware of any rigorous, head-to-head studies comparing the efficacy of natural deodorants versus antiperspirants, it stands to reason that they may not counteract smell in the same way that an antiperspirant does. “Bacteria are stimulated to grow by the available water and nutrients found in sweat,” Dr. Gilbert said. “So antiperspirant is getting to the main route of the odor problem.”
Dr. Arielle Nagler, an assistant professor of dermatology at the N.Y.U. Grossman School of Medicine, said that the effectiveness of a product will also depend on how it interacts with your own biology. “Everyone smells a little bit different,” she said, which depends on how much you sweat and what kinds of bacteria are on your body.
Should I buy natural deodorant or not?
Natural deodorant is not better or worse for your health than traditional deodorant or antiperspirant. “A lot of the claims that one product is better than another are just marketing claims that are not based on scientific evidence,” Dr. Chen said. “I don’t think there’s any proof that one is safer than another.”
The Personal Care Products Council, an industry group that represents cosmetic and personal care product companies, echoed a view from Dr. Chen and other experts, which is that people should make their choice based on personal preference. “Our members work to ensure consumers have access to an array of safe and effective products that help meet the differing needs for themselves and their families,” the council said in a statement provided to The New York Times. “This includes offering ‘natural’ products for those consumers who prefer them. It’s all about consumer choice.”
Still, dermatologists do recommend fragrance-free options, especially if you are allergic or sensitive to fragrance. “The more exposure one has to some of these fragrance chemicals, the more at risk you are for potentially developing an allergy,” Dr. Botto said.
If you enjoy using scented deodorants, though, “that’s fine,” she added, “but particularly if you have any sort of skin sensitivity, it’s a risk.”
Or, you could simply choose not to wear deodorant at all.
Annie Sneed is a science journalist who has written for Scientific American, Wired, Public Radio International and Fast Company.
Julia Calderone contributed reporting.
I’ve failed to practice what I preached about limiting sun exposure, but a new report has prompted me to reform.
Pick your favorite cliché: Do as I say, not as I do; an ounce of prevention is worth a pound of cure; better safe than sorry; forewarned is forearmed.
Mea culpa. All the above relate to my failure to follow the well-established health advice about sun exposure that I’ve offered repeatedly to my readers: Routinely protect your skin from the cancer-causing and aging effects of the sun’s ultraviolet rays.
For decades I’ve failed to practice what I preached (OK to wince) and am now paying for my negligence with unsightly splotches, bumps and bruises and at least one cancerous lesion on my sun-damaged skin. My litany of excuses has included: hats mess up my hair, long sleeves and pants are too hot in summer and exercising while coated with sunscreen is suffocating.
Annually vowing to do better, every summer I dutifully purchase the latest dermatology-recommended sunscreen that, alas, spends the summer unopened on a bathroom shelf. I hereby pledge to do better this year, albeit late in the game.
A new report from a dermatology team at Kaiser Permanente health care centers in California has prompted me to reform. The team, headed by the epidemiologist Lisa Herrinton in Oakland, followed nearly half a million patients seen at the centers for up to 10 years. Half had already developed one or more actinic keratosis, a precancerous rough, scaly skin lesion caused by years of unprotected sun exposure.
As you might expect, these lesions most often form on the face, ears, back of the hands, forearms, scalp and neck and are — or should be — routinely removed when found by dermatologists to prevent progression to cancer. The lesions are markers of sun damage and can serve as an early warning system for people at risk of developing cancer somewhere on sun-exposed skin.
While the hazard is greatest for people with light skin, blue eyes, freckles or red hair, having a dark complexion is not a free pass. Tanning, not just burning, is a form of sun damage.
Among patients in the Kaiser Permanente study who were younger than 50, those with a diagnosis of actinic keratosis were nearly seven times more likely to develop a skin cancer called squamous cell carcinoma during the decade-long follow-up. The cancer risk was eight times higher among patients older than 50 who had one or more actinic keratosis removed, and the more such lesions these patients had, the more likely they were to develop skin cancer during the follow-up.
Furthermore, the older the patient, the sooner cancer was diagnosed after actinic keratosis was found and presumably treated. It took seven to eight years for 10 percent of patients in their 50s with an actinic keratosis to receive a diagnosis of skin cancer, but it took only three to four years for patients in their 70s and one to two years for those in their 80s.
Alas, those of us in the upper decades of life knew little in our younger years about the risks of sun damage beyond the need to avoid a bad sunburn. Many youngsters like me swam, hiked, biked and played sports minimally clothed while the sun tanned or burned our skin. We sunbathed coated in baby oil in a misguided effort to acquire a rich tan. And many of us, myself included, failed to reach adulthood with sun-protective habits that could have prevented the skin damage now woefully apparent.
Given that the risk of ultraviolet light to healthy skin has since been widely publicized, I’m astonished at how many people today visit tanning salons or use tanning beds at home, damaging the wholesome cutaneous barrier nature gave us.
Happily, the new study suggests that more people now have a greater understanding and respect for the sun’s effects on skin and can look forward to a healthier future, said Dr. Sangeeta Marwaha, a dermatologist in Sacramento and co-author of the study. Among people who entered the study in 2018, the risk of developing skin cancer was two-thirds that of study entrants in 2008 who were followed for an equal number of years.
“There’s been an increase in sun-protective habits and a resulting decrease in the development of skin cancer,” Dr. Marwaha said in an interview. “Parents today are more likely to protect their children from undue sun exposure, and the use of sunscreen is now more mainstream.”
But there’s still a long way to go. Fostering a healthy respect for sun protection in young children is especially important because experts estimate that 80 percent of a person’s lifetime sun exposure is acquired before age 18.
Repeated exposure to the sun’s ultraviolet radiation causes most of the skin changes — wrinkles, age spots and tiny broken blood vessels — generally considered a normal result of aging. Yes, aging plays a role, but these effects occur much earlier in life on sun-exposed skin. UV light damages the elastin fibers in skin, causing it to stretch, sag and wrinkle. It also damages surface blood vessels, rendering them more fragile and easily bruised.
And Zachary W. Lipsky, a biomedical engineer at Binghamton University, found that UV radiation weakens the bonds that help the cells in the top layer of skin stick together, damaging the skin’s structural integrity and leaving it more vulnerable to infection.
But while some of these effects can be masked by cosmetic treatments and plastic surgery, the most serious damage done by UV radiation — to the DNA of skin cells — is permanent and irreversible and can result in cancer-causing mutations.
Furthermore, preventing sun damage is easier and cheaper than reversing it and less likely to result in premature wrinkles and scars. Try to schedule your outdoor activities early or late in the day, avoiding the peak sun hours of 10 a.m. to 4 p.m.
Routinely apply a broad-spectrum sunscreen with an SPF of 30 or higher to exposed skin year-round even on cloudy days, using at least a quarter teaspoon on your face alone. Apply sunscreen half an hour before going out and reapply it every two hours and after being in the water. Modern sunscreens are not greasy or pasty, but they lose effectiveness with time so be sure to check the expiration date. Even if you sit under an umbrella at the beach or in the park, the sun’s reflected rays will hit your skin.
Wear a hat with a wide brim, especially important for men who are balding. If you have the means, invest in top-quality sunglasses and clothing, including swimwear, with built-in SPF protection. The darker and heavier the fabric, the better. “A plain white T-shirt has an SPF of 4, whereas dark blue denim jeans could have an SPF of 2000,” Dr. Marwaha said.
This summer I plan to apply sunscreen daily and wear a long-sleeved sun-protective shirt when I walk, cycle and garden, even on cloudy days, a habit I wish I’d cultivated decades ago.
While most experts agree that you should use sunscreen year-round to prevent damage from the sun, harmful ultraviolet rays are strongest during late spring and early summer. We’ve partnered with health reporters from Wirecutter, The New York Times site that reviews and recommends products (and publishes annual ratings of sunscreens for the face and body), to answer some of the most common questions readers have about sunscreen, including how safe and effective it is, how to use it properly, and how to pick the right one for you.
Is sunscreen bad for you?
No. In fact, it can mitigate a lot of potential damage from the sun, which can lead to premature skin aging and increased risk of skin cancer. However, experts have acknowledged that some people may be concerned about past evidence that has shown that some of the active ingredients in many sunscreens sold in the United States can reach the bloodstream and remain there for days.
“We don’t know what the health implications are yet, or even if there are any,” said Dr. Jenna Lester, an assistant professor of dermatology at the U.C.S.F. School of Medicine, “but we want to give credence to people’s concerns.”
Keep in mind that sunscreen is just one of many topical products whose potential health effects are not completely understood. “Of course it’s very alarming when people think there’s a chemical being absorbed by their skin and detectable in blood,” said Dr. Belinda Tan, a dermatopathologist in Torrance, Calif., “but we put a lot of things on our skin — lotions, cosmetics, fragrances — and studies aren’t done on whether or not those ingredients are detectable, so we need to step back and put the sunscreen conversation in context.”
If you’re concerned about the possibility of sunscreen chemicals seeping into the bloodstream, consider using those that contain either or both zinc oxide and titanium dioxide as their active ingredients, which have not been found to reach the blood.
— Nancy Redd
How much SPF is enough?
Sun protection factor (SPF) is a measure of how well a sunscreen protects against sunburn, which is most often a result of exposure to ultraviolet B (UVB) rays, the type that cause most skin cancers. Most dermatologists, as well as the American Academy of Dermatology, recommend an SPF of at least 30 for most people and most climates. “There’s no harm in going higher, though,” especially for people whose skin burns easily or who have sun-exposure allergies, said Dr. Vinod Nambudiri, a dermatologist at Brigham and Women’s Hospital in Boston.
Once you go past SPF 30, the protection is more incremental than you may think when looking at the numbers on the bottle. When properly applied, for instance, an SPF 30 sunscreen shields skin from around 97 percent of the sun’s UVB rays, while an SPF 50 protects against roughly 98 percent. No sunscreen blocks 100 percent of the sun’s rays.
Most of the experts we spoke with said that more important than the actual SPF is finding a broad-spectrum sunscreen — one that protects against both UVA rays (which mostly cause skin aging and wrinkles) and UVB rays — that you enjoy wearing and can afford to consistently use and reapply. “Most people aren’t getting the SPF benefit on the sunscreen’s label because they aren’t applying a thick enough layer to their skin, and they usually aren’t reapplying often enough — usually every 80 minutes or two hours, depending upon the formula,” Dr. Tan said.
The average adult needs about one ounce of sunscreen to cover all exposed skin. “We often say a shot glass of sunscreen for the whole body,” Dr. Lester added, “but I tell my patients to fill the shot glass up to the brim and use even more if needed so you don’t miss any spots.”
— Nancy Redd
Is it safe to wear sunscreen every day?
Yes; in fact, it’s recommended. “Whether it’s sunny or cloudy, UV rays are present 365 days a year, and I encourage my patients to use sunscreen year-round,” Dr. Nambudiri said.
While it is not necessary to wear sunscreen on body parts that aren’t exposed to the sun (usually because they’re covered by clothing), it’s important to apply it to the face, ears, hands, forearms, neck and other often-exposed body parts to help prevent sun damage.
— Nancy Redd
Which type of sunscreen is better: chemical or physical, and why?
The best sunscreen for you is the one that you will apply (and reapply) often, but there are pros and cons to each type. Physical (or mineral) sunscreens reflect UV rays away from your skin, while chemical ones absorb UV rays so that your skin does not.
One pro of mineral sunscreens is that their active ingredients — zinc oxide and titanium dioxide — haven’t been shown to absorb into the blood. “If you’re a person who is concerned about the potential safety of applying chemical sunscreen to your skin and you also want the benefit of protecting your skin from harmful effects of UV rays, I would say mineral is best,” Dr. Tan said.
Mineral sunscreens, however, “are generally more expensive and less cosmetically elegant than chemical ones,” said Dr. Lawrence Eichenfield, chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. Mineral sunscreens tend to take longer to rub in and appear chalkier than chemical ones, which tend to rub in easier, feel less noticeable on and blend in better with the skin.
“People who don’t like the way a sunscreen looks or feels are less likely to stick to consistent use,” said Dr. Lester, whose work focuses on skin color-related disparities in research and health care. In her own practice, she said, “brown-skinned individuals often avoid mineral sunscreens because they tend to leave a white cast on the skin.”
Wirecutter testing has found that chemical sunscreens with active ingredients including avobenzone, octocrylene and oxybenzone tend to feel lighter on the skin, rub in easier and appear less visible.
— Nancy Redd
Does sunscreen harm coral reefs?
It can. “Certain ingredients in some sunscreens do contribute to coral reef damage,” Dr. Lester said.
Oxybenzone, octocrylene and octinoxate are among the primary sunscreen ingredients of concern. The only two “reef-safe” active ingredients approved by the Food and Drug Administration are “non-nanotized” zinc oxide or titanium dioxide. (A non-nanotized ingredient means that it is 100 nanometers in diameter or more.)
However, no sunscreen is known to be totally safe for aquatic life, so the best way to protect yourself and the environment is to cover as much of your body as possible with UPF (ultraviolet protection factor) clothing (though you’ll still need to use sunscreen on exposed skin).
— Nancy Redd
Are there any alternatives to sunscreen?
Avoiding the sun (especially between 10 a.m. and 4 p.m., when the sun’s rays are strongest) is one excellent way to protect your skin from sun damage. So is wearing protective clothing, like long-sleeved shirts and wide brimmed hats. Alternatives like sunscreen pills or supplements “are being studied right now,” Dr. Nambudiri said, but none are approved by the F.D.A. and there is no evidence that they are safe and effective.
— Nancy Redd
What’s the difference between sunscreen and sunblock?
While the two terms are often meant to refer to the same thing in conversation, you shouldn’t see the word “sunblock” on labels at all. The F.D.A. banned its use on approved sunscreens in 2011, considering it to be an overstatement of effectiveness since no sunscreen can block UV rays completely. The agency similarly does not allow the terms “waterproof” and “sweatproof.”
— Nancy Redd
Do you need sunscreen if you have dark skin?
Yes. “It’s a misconception that darker skinned people can’t get skin cancer,” said Dr. Nambudiri. Even though darker-skinned people may not burn as quickly as fairer-skinned people, it doesn’t mean their skin isn’t experiencing deleterious effects from the sun’s rays. “Sunburns, aging, uneven skin tone and hyperpigmentation are all problems that can be exacerbated by sun exposure in dark-skinned people,” Dr. Lester said.
— Nancy Redd
Can I use sunscreen with makeup or moisturizer?
There’s no real consensus on whether you should apply sunscreen before or after you apply makeup or skin scare products like moisturizer, but if you lather up with sunscreen first, make sure that it has fully absorbed (it should feel mostly dry to the touch) before you apply anything else. It’s also important to apply sunscreen even if you’re using foundations or powders with SPF built in, since these products may not provide consistent sun protection.
Make sure to reapply sunscreen every two hours (or more frequently, especially after sweating or swimming), even if you’re wearing makeup. This may require reapplying sunscreen on top of it. There are plenty of options for on-the-go sunscreen reapplication, including sunscreen sticks or sprays (though you still need to rub these in). You could also use a makeup sponge to dab on your favorite sunscreen in an even layer over your makeup.
— Caira Blackwell
Adding collagen powder to your daily smoothie? Opting for a collagen bar as a snack? Proceed cautiously.
Like many of us with our thumbs stuck on scroll, Chrissie Buckley has a weakness for Instagram fads. At their worst, the products she has tried after a convincing influencer endorsement have been minor money drains she can shrug off with a laugh. But when she added collagen powder to her cart earlier this year, those whims took a darker turn.
Collagen supplements had been dominating her social feeds for months, as new formulations from brands like Bulletproof, Dose & Co. and Vital Proteins have grown in popularity. Instead of the sleepy pill format, these companies are selling collagen coffee creamers, drink powders and protein bars that claim to support healthy skin, hair, nails and joints.
In February, a post from the model Cindy Prado espousing the wrinkle-diminishing benefits of Vital Proteins Collagen Peptides powder convinced her to give it a try.
“I’m going to be 29 in the fall, and I want to get a new skin care routine going to help with anti-aging so I thought maybe I should try some collagen,” said Ms. Buckley, a medical supply equipment coordinator in New York.
After a month or so of having a scoop in her coffee each day, changes to her face were nonexistent, but a red bump was forming on a finger. Over the next few days, what at first looked like a bug bite spread across her ring and pinkie fingers.
“The skin on my hands looked and felt so tight, like my fingers were stuffed sausages, and I couldn’t bend them,” said Ms. Buckley, whose eventual visit to urgent care proved unproductive. “They had no idea what was going on.”
An always risky deep dive on Google left her convinced it was scleroderma, a rare autoimmune disease in which the immune system causes the body to produce too much collagen, resulting in thick, tightened skin and connective tissues.
Horrified, Ms. Buckley threw out every product that mentioned collagen, and within days the swelling subsided and mobility returned to her fingers.
“It’s the devil to me now,” she said.
But there’s no evidence for or against the possibility of collagen supplements causing scleroderma, said Dr. Fredrick M. Wigley, the director of the Johns Hopkins Scleroderma Center, noting that it’s unstudied but biologically unlikely. “The body is very efficient at regulating things, so if you take too much of something, your body will get rid of the excess and balance it out,” Dr. Wigley said.
Whatever its origins, Ms. Buckley’s reaction highlights the lack of research on new collagen formulations — which, like most supplements, are not regulated by the Food and Drug Administration — and comes amid a sea of online chatter about negative effects and lack of efficacy that is only beginning to break through the much noisier hype.
“Everyone has been on the collagen bandwagon lately,” said Dr. Niket Sonpal, a gastroenterologist in New York. “It’s the new charcoal bandwagon.”
The Truth Behind the Hype
Google search data reflects the growing obsession: People have searched for collagen an average of 1.4 million times each month this year to date, a number that’s jumped 35 percent from last year, according to research firm Spate. Collagen powders and drinks lead those searches.
Increased consumer interest in so-called functional foods and beverages that claim to offer health benefits over traditional supplement pills is partly responsible. As with other beauty and wellness trends, so, too, is a Kardashian.
In October 2020, Khloé Kardashian signed on as an equity partner and global spokeswoman for Dose & Co., a collagen supplement company in New Zealand. Since then, her more than 140 million Instagram followers have been inundated with footage of the star adding the product to her daily smoothies and sharing convincing before and after photos that display customers with clearer skin and thicker hair.
It was enough to convince Whitney Joseph, a 36-year-old stay-at-home mom living in Stamford, Conn., to give the product a try.
“After I had my last child, my hair was falling out and got really brittle, which Khloé said had happened to her, too, and she was helped by the product,” Mrs. Joseph said.
That didn’t happen. Instead, her normally clear skin broke out within days of adding the supplement to her drinks, a result she discovered was common after digging into Reddit threads. When she stopped taking it, her skin cleared up.
“I’ve tried so many supplements, and at this point, I’m over it,” she said.
Since many of these collagen products include a variety of other ingredients, including biotin and hyaluronic acid, it can be difficult to pinpoint what’s actually triggering a negative reaction. “Many of them are bundled with whey protein, which has lactose in it and can induce acne flares, as well as a lot of sugar,” Dr. Ivy Lee, a dermatologist in Los Angeles, said.
Collagen supplements that come from marine sources instead of the more common bovine-sourced collagen have become popular as many people lessen their beef intake, but they’ve brought with them a host of new issues. Experts report that they are more likely to ignite allergic reactions because of potential shellfish contamination.
Since collagen can lead to increased fullness and satiety, which is common with any protein source, some companies have attempted to frame it as a weight loss tool despite a lack of supporting evidence, per Dr. Lee. In some cases, these products can actually have the opposite effect because of their often high sugar and carbohydrate content, as well as a tendency to cause bloating.
And some of the most common side effects are gastrointestinal: Dr. Sonpal regularly hears patients who try them complain of diarrhea, heartburn and constipation.
So Is There an Upside?
Experts say that studies claiming to show collagen as having a positive impact on skin elasticity and overall youthfulness are too small and anecdotal to lend the products real legitimacy. “It’s more of a branding opportunity for the beauty industry since people are so interested in looking younger,” said Dr. Rabia De Latour, a gastroenterologist and assistant professor of medicine at New York University.
Last month, however, researchers published a systematic review of clinical trials on oral collagen supplements. “The results support that ingesting collagen can reduce skin wrinkles and improve elasticity and skin hydration,” Dr. Lee said. But the study isn’t geared to the new formulas. “The challenge is that research has not identified optimal dosing regimens or formulations,” she said.
For this reason doctors recommend moderation when trying such a product for the first time. Beyond talking to your doctor to ensure that it won’t interfere with other medications or worsen chronic health issues, Dr. Sonpal suggests starting with half of the recommended dose and tracking how your body is or isn’t reacting. Make sure the collagen is hydrolyzed, a process that breaks it down into easier to absorb particles. And most important, Dr. Sonpal said, have an end date in mind, as supplements in any form are not meant to be taken indefinitely. If you don’t see results by the three-month mark, it’s best to stop the supplement.
However unsexy it may be, avoiding such buzzy ingestibles is still the safest bet. Dr. De Latour recommends incorporating more foods that help your body maintain its collagen supply into your diet: chicken, fish, green leafy vegetables and foods high in vitamin C. Following the sun protection advice you’re pummeled with — to wear SPF daily, wear a hat and seek out shade — can also prevent collagen breakdown.
If you’re willing to spend, you can also visit a dermatologist for microneedling or laser treatments that have been shown to promote collagen production.
In the face of never-ending beauty and wellness porn on Instagram, the key is remembering that, behind the pretty filters and gushing endorsements, there’s no one magic bullet for perfecting your skin. Dr. De Latour put it bluntly: “You can’t turn back time with a supplement.”
The actress, mom and co-founder of Onda Beauty talks about the skin-care products she’s excited about now and why she’s so invested in her skin.
The actress Naomi Watts has been wearing several hats since the pandemic hit. She is a founder of Onda Beauty, an indie retail store with branches in TriBeCa and Sag Harbor, N.Y. She has also been filming, including a couple of movies that will be out this year: the thriller “Lakewood” and “Infinite Storm,” a tale of survival.
A mother of two living in Manhattan, Ms. Watts, 52, has, like the rest of us, been living through the ups and downs of this strange time. Find out the beauty rituals and regimens that keep her centered and how something as simple as a mani-pedi can be so restorative.
Discovering Skin Care
I’ve always had sensitive skin. Working on set, with multiple applications of makeup and under hot lights, I became really, really reactive to everything. My friend Larissa Thompson, who was a lifestyle and fashion editor at various publications, and Sarah Bryden-Brown had joined together to found Onda Beauty. Larissa had been telling me about products and brands she was interested in, and I had tried stuff out of her makeup bag. They instantly smelled right and felt right on. My skin said: “Yes.”
As Onda was kicking off, I got more involved. First, I was an ambassador and influencer, and later I got more interested in the business side of things. The pandemic was so tough on small businesses. We just closed our Notting Hill store. We had opened it right before the pandemic hit. We just couldn’t handle the third shutdown. Our TriBeCa store was closed for six months. All things considered, though, we’ve managed to stay afloat.
My morning routine moves around a lot because I’m often trying things. That’s one of the perks of the job. I don’t really cleanse in the morning unless I’m working out. Then I use African Botanics cleanser in the shower, or sometimes I use just water. Right now, I’m very excited about Furtuna skin-care products. I’m also very into the Answer by Symbiome. It’s a serum, and it feels good on.
I also mix things all the time. I love the hyaluronic acid from Dr. Barbara Sturm. I’m not someone who wants to put too many things on at once, but I’m at the point in my life where I’m invested in my skin. Before it was all about a pair of shoes or what jeans are trending. That’s for a 20-something.
Time for Yourself
Being a mom, I do love that moment at the end of the day when the kids are in bed, where I’m taking time for a ritual for me. I’d rather have a bath than a shower. I just love the feeling of being in really hot water. I love Vertly bath salts.
Then I make sure my skin is cleansed properly — sometimes a double cleanse. Maybe I’ll do a face mask. I love the Osea White Algae Mask. It’s a good price point. Then I mix an oil or serum with a moisturizing cream. I love the Beautycounter vitamin C serum — it’s a really strong product.
I’ve always been a five-minute kind of girl when it comes to getting ready. I don’t do a lot with hair and makeup when I know there won’t be cameras. When I see my friends, I’ll spruce up, but I don’t go far with it. I always love a lipstick, and the ones from Beautycounter aren’t too dry. Masks and lipsticks are a nightmare, though! Usually that’s when I do a lip balm. But if I’m going out, I bring it with me to put on at the restaurant and wipe it off before I put on the mask.
I love an eyebrow. I’ve been using the pencils from Beautycounter or RMS. I like Beautycounter if I need some coverage. They have this Dew Skin that comes in a silver tube. Every time I work on a movie, I introduce it to the makeup artist. It’s great for film when you just need a little makeup but you don’t want it to be readable.
My hair is a nightmare. I’ve always had fine hair, but I was told I had lots of it. Now that’s not the case. Reaching a certain age, I think hormones play a part as well as overusing hot tools. And there’s the color. I definitely color my hair. I’m naturally blond, but I’m very, very ashy. I definitely need a little brightening. There’s no way around the damage, though.
I go to Mark DeBolt for my color. Ryan, his partner in life and in business, has also done my hair for film and red carpets. They had just opened their salon before Covid struck. I went recently for the first time in a year. It felt really good. I couldn’t quite believe it when I stepped out of the salon.
I used to have a shelf of fragrances in my bathroom, but I don’t love them anymore. I do have this lovely little pocket-size scented oil by Ayu, this Australian brand. I love the Rose and the Ode.
What a Mani-Pedi Can Do
Recently I went to have a manicure and pedicure for the first time in ages. All of those things feel like such a treat now. You feel like a feral beast coming out of the woods with your ingrown toenails! I’m having a facial at Onda for the first time. We do treatments at the store.
I grew up in the ’70s, and my mom would make her own bread and make her own dresses. I’m super into food and a believer in not denying myself much as long it’s in moderation. I crave crunchy salads and fruits and vegetables. I think that’s mainly my comfort food because that’s how I was raised. I also love plenty of white foods. I’ll never deny myself a great pasta when I’m traveling.
Fitness is a big part of my life. It’s great for mood, isn’t it? I’m a physical person. I like to move my body. I bounce around because I can get bored easily. With the pandemic we got heavily into exercise and working out online with our friends, filming ourselves, and now what? It’s hard to sustain.
I exercise three times a week. I love a bit of strength training. I do Zoom classes with a guy called Keith Anthony. It’s all on the mat with some weights and some lunges and squats. I do yoga.
I also do the Class by Taryn Toomey. I like her approach to movement because it’s not just the body but the mind and spirit as well. I get a lot out of her energy and her ability to shake up the mood. She taps into our psyches.
Will starting injections in your 20s and 30s make you look older? Preventive Botox explained.
Forget what you think you know about Botox. Once considered the not-so-secret tool of celebrities and the wealthy with a bad rap for freezing faces, the wrinkle-melting injections have become a commonplace activity of a normie class with money to spare.
“Many millennials prioritize taking care of themselves early on and really believe in prevention,” said Dr. Panta Rouhani Schaffer, a dermatologist in New York who has seen an uptick in younger patients requesting Botox in the last few years. “That just got amplified during the pandemic, when people have spent so much time staring at themselves on screens.”
But they’re looking for results à la J. Lo, not Jocelyn Wildenstein. It’s a softer approach, called “baby Botox” by some and “preventive Botox” by others, that is changing the common question, “Would you ever get Botox?” to “When will you start?”
The answer from millennials and Gen Zers is, increasingly, in their 20s and 30s, ages when most baby boomers and Gen Xers were not yet fretting over aging with the same all-consuming anxiety. (See: sunscreen, considered a must today but an afterthought for many until the early 1990s.)
Leah Walkiewicz, a 27-year-old product manager in Manhattan, has been getting Botox in her forehead since she was 24, a decision spurred by what she felt was early wrinkle formation and a close look at how her family has aged.
“I always had obvious fine lines on my forehead, and makeup would settle into those lines really obviously,” she said of her decision to start so young.
Despite some nerves, the discreet shots her dermatologist administered led her to return for more, roughly every 10 months. This year she moved beyond getting Botox in the forehead and glabella (the area between the eyebrows) to test out injections in her “crow’s feet.”
“It’s been crazy to see the progress,” Ms. Walkiewicz said. “If more people had told me what you can do with Botox sooner, I think I would have gone a couple of years earlier.”
From Stigma to Sharing
Social media has been both a blessing and a curse in our relationship to Botox. While the selfie-heavy platforms have made it easier than ever for people to compare and despair over their looks, they’ve also helped destigmatize and increase education about the once-taboo subject.
Kathryn Gongaware, a 32-year-old yoga teacher and comedian in Chicago, was always curious about Botox, but it wasn’t until she started mentioning it to friends and realized that people she wouldn’t have expected (including her au-natural-everything acupuncturist) were getting it that she felt comfortable making the jump at age 30.
“The more people were open about it, the more it felt destigmatized,” she said.
This forthrightness has been particularly transformative among women of color, who are often left out of conversations and marketing about cosmetic procedures. There’s also a deeply rooted stigma in many communities of color that by opting for cosmetic procedures that have inclined toward European beauty ideals, you’re rejecting your roots, said Dr. Onyeka Obioha, a dermatologist in Los Angeles who has been getting Botox since she was 25.
“Historically, and even today, the majority of advertisements for cosmetic procedures do not feature or target minorities,” Dr. Obioha said. “But now with social media, there’s more attention given to the fact that women of color also get cosmetic procedures, so the stigma surrounding them seems to be decreasing.”
While online sharing has helped reduce the stigma, it has brought with it some downside, too — namely, young people thinking they need to start Botox because their friends are doing it.
“I’ve had 20-year-olds in college come in without knowing anything about Botox who really don’t need it, but they have this sense of FOMO because their friends are doing it,” said Dr. Sheila Farhang, a dermatologist and cosmetic surgeon in Arizona, who doles out skin-care tips to thousands of followers on Instagram and YouTube. “I will not inject someone that age, and I try to explain to them why they really don’t need it.”
The Difference in ‘Baby Botox’
A shift in how Botox is administered has also helped convince younger people to try it. “When Botox first came out, people were using it to really isolate and freeze the muscles, so that frozen look was what people associated it with,” Dr. Schaffer said. At the time, doctors were using 20 to 30 units in one area or muscle alone, a dosing that has lowered significantly in the last 10 years.
“People are starting to appreciate that by doing less, you still get a very nice softening that gives people enough of what they want to see in terms of tightening and retexturizing,” she said.
“Baby Botox” involves using 20 to 35 units spread out across multiple muscles in the face, most commonly in the forehead (two to 12 units), glabella and brow area (20 to 22 units) and the corners of the eyes (three to four units per eye). The result when done right is a refreshed look that doesn’t render one’s face immobile.
Most patients in their 20s and 30s are looking to smooth out fine lines and prevent the formation of deep, static wrinkles in the future. “With Botox, over time, you’re thinning out that muscle and using it less, so those lines don’t really get etched in,” Dr. Schaffer said.
For some patients, the benefits of Botox extend beyond preventing wrinkles. Dr. Farhang has used small doses of Botox in the muscle above the lip to flip it out so it looks fuller; in the columella area just below the nose to raise the nasal tip a millimeter; and in the muscles at the corners of the jawline for slimming purposes.
While these injections don’t last as long as traditional Botox, because of lower doses and increased muscle movement in these areas, “they offer little tweaks” that can make a difference in one’s appearance,” Dr. Farhang said.
What Could Go Wrong?
While less risky than filler injections, Botox is not always the Benjamin Button miracle cure it’s made out to be. Proceeding with caution, particularly when starting young, is key.
“Botox is very much a medical procedure,” Dr. Farhang said. “It’s not a Groupon situation.”
On the plus side, the impermanence of Botox means that even if an injector overdoes the dosage, it will wear off without long-term facial alteration. With continued high doses, your muscles can technically atrophy, or lose their strength. But with other muscles moving in the face, that’s not something you’ll necessarily notice, Dr. Farhang said, and some research has shown that if you take a break from Botox, those muscles rebuild.
Although it’s rare, some patients who start with high doses in their 20s say their skin has thinned over time, but experts say this has not been shown in research literature. In fact, some studies suggest that Botox can improve the elasticity of skin.
Still, Dr. Schaffer said, “one could postulate that the skin may feel thinner or appear crepey because the muscle mass that was providing volume under the skin has decreased.” To avoid such eventualities, it’s best to find a doctor with a conservative touch and supplement the procedure with skin-supporting routines like daily SPF.
As for the concern that your body will get “used to” Botox and stop working, doctors say there’s little such evidence. “In my experience, many patients just require fewer units over time because their facial muscles are less dynamic and thus require less,” Dr. Schaffer said.
Despite its impermanence, “bad” Botox can last for months, making it risky for your self-esteem. A few weeks ago, Dr. Farhang saw a bride-to-be three weeks out from her wedding with a droopy eyelid from having been injected too low and too deep in the forehead and brow area.
“There’s literally nothing I can do to fix it until it wears off, besides prescribing her an eyedrop that activates that muscle a bit,” she said. “It may be temporary, but four months is a really long time to look wonky.”
Perioral dermatitis, a complex facial rash that is often mistaken for acne, is becoming more common, some experts say. Here’s how to spot, treat and prevent this irritating condition.
It started as a mini constellation of red dots near the right corner of my lips. Probably just “maskne,” I figured. I slathered on some acne cream and tried to forget about it.
But the inflamed, rashy spots didn’t fade away. In fact, they grew larger, spawning dandruff-like scales and flakes. Within days, the red dots had spread to the left side of my mouth, and even — to my horror — sprinkled across my eyelids. When I opened my mouth, I felt the raw, burning skin at the corners crack.
After a telemedicine visit with my dermatologist, I learned that I had perioral dermatitis — a noncontagious facial rash that often shows up as clusters of tiny, scaly, red, uncomfortable bumps above irritated skin. “We see it mainly around the mouth,” said Dr. Anna Chien, a dermatologist at the Johns Hopkins University School of Medicine. “Some people can have similar breakouts around the eyes.”
Cases have become more common since the coronavirus outbreak began, some experts say. In one Canadian survey of 77 dermatologists published in September, more than a third reported either a large or slight increase in perioral dermatitis instances since the beginning of the pandemic.
“In our clinic,” Dr. Chien said, “we are seeing many more perioral dermatitis and other rashes related to masks.” Dr. Jessica Sprague, a dermatologist at the U.C. San Diego School of Medicine, noted a similar phenomenon. “Masks alter the skin environment, and they can also cause a lot of skin irritation,” she said, adding, “I’m definitely seeing it more now in the setting of mask wearing.”
What causes it
Perioral dermatitis might look a lot like acne, but the resemblance is deceptive, said Dr. Carrie Kovarik, a dermatologist at the Hospital of the University of Pennsylvania and a member of the American Academy of Dermatology’s Covid-19 task force. “People confuse it with ‘maskne,’ and they are two different things.”
With mask-induced acne, your pores get clogged with dirt, skin flakes or oil, giving rise to inflamed cysts that may burst. But perioral dermatitis is more of an inflammatory rash. There can be various causes, but it tends to be triggered by a disruption of your skin’s natural equilibrium, Dr. Sprague said, from the use of topical substances like steroid medications or irritating cosmetics.
The humid, enclosed space behind a mask may also encourage perioral dermatitis rashes to form. “Depending on what kind of mask you’re wearing, you could really have a lot of moisture sitting there on your face,” Dr. Kovarik said. “You’re almost creating this skin fold-type area,” a little like the damp crevices that can form between rolls of skin.
That can modify the face’s natural microbial balance, research suggests, contributing to perioral dermatitis and related conditions. “When you wear a mask, you’re basically changing the terrain,” said Dr. Whitney Bowe, a dermatologist based in New York.
This can encourage or discourage the growth of certain microbes, like bacteria and yeast, which may be involved in perioral dermatitis, and can touch off “this cycle of making the disease even worse,” Dr. Kovarik said.
The rash appears most often in adult women, but can also crop up, albeit less frequently, in young children. Unlike cold sores, perioral dermatitis bumps are not thought to be caused by a specific virus and usually do not migrate onto the lips themselves.
How to prevent and treat it
Since perioral dermatitis is so complex, it can be challenging to treat and may take a long time to clear, Dr. Sprague said. But if you monitor your skin closely and follow some simple rules, you might be able to steer clear of the condition completely or nip it in the bud.
Practice good mask hygiene. Masks are currently a public health necessity, but cleaning them regularly may help keep perioral dermatitis at bay.
As soon as you are home and can safely remove your mask, wash your face with a gentle, fragrance-free cleanser, Dr. Sprague said. When it’s time to don your mask again, resist the temptation to use one that is dirty, since it can disrupt your face’s microbial balance. “It’s like underwear,” Dr. Bowe said. “You wouldn’t wear your underwear two days in a row.”
Avoid steroid-based skin creams. Many people use steroidal anti-inflammatory medications, like hydrocortisone cream, to manage symptoms of perioral dermatitis, Dr. Chien said, but while such medications may clear redness temporarily, a rebound rash is likely to appear once you stop using them. “It’s very reasonable to think, put on some steroids, but that tends to make it worse,” she said. “The minute you stop, it comes back with a vengeance.”
Researchers don’t completely understand why this happens, but some think that steroid creams might allow bacteria to overgrow by suppressing the body’s local immune response.
If you have allergies or asthma, think about switching your meds. As with steroid creams, Dr. Sprague said, inhaled or spray steroidal medications commonly used to treat allergies or asthma — like Flonase, Nasacort or Symbicort — are thought to trigger perioral dermatitis, perhaps because they modify the body’s immune response.
If you use any of these medications and are worried about perioral dermatitis, talk with your doctor about your treatment plan. Some allergy or asthma sufferers may need to remain on steroid medications, Dr. Sprague said. However, others may be able to consider other nonsteroidal drugs, like cetirizine (Zyrtec), which are not thought to cause perioral dermatitis.
Streamline your skin-care products. Using too many skin care products can throw off your skin’s natural balance, according to Dr. Bowe, increasing the risk of an outbreak. In one study of 232 people in Australia, those who used foundation, night cream and moisturizer were 13 times more likely to develop perioral dermatitis than those who used moisturizer alone.
Similarly, if you’re managing a flare, minimalism is key. “The best thing you can do is baby your skin,” Dr. Sprague said. “Stop any thick cosmetics, serums, etc.”
Dr. Jennifer Holman, a dermatologist in Tyler, Texas, recommended washing your face twice a day with a gentle cleanser, such as a sulfur face wash, and following up with a fragrance-free moisturizing lotion. It’s OK to use a little mineral makeup, she added, because it doesn’t tend to aggravate the rash.
Don’t dabble in unproven treatments — see your dermatologist. Plenty of alternative treatments for perioral dermatitis are available on the web, from swabbing the skin with apple cider vinegar to taking supplements of certain herbs, like neem. But those haven’t been scientifically proven to work, Dr. Holman said. And since the rash is notorious for sticking around, it’s important to seek professional help.
Dr. Sprague said she’ll often start by prescribing a topical antibiotic, like metronidazole — not to banish an infection per se, but to reduce the inflammation and give the skin a chance to heal. Pimecrolimus, a nonsteroidal anti-inflammatory cream that is commonly used to treat rosacea and eczema, can also help clear up the rash.
When these treatments fall short, Dr. Sprague said she’ll sometimes recommend a several-week course of an oral antibiotic, like doxycycline, which can also help to reduce inflammation.
Perioral dermatitis “seems like something minor, but you can really get into difficult situations” where the rash persists, Dr. Kovarik said. “You want someone who’s familiar with treating this.”
My own perioral dermatitis has improved since I started treating it with a topical antibiotic and a gentle, fragrance-free lotion, but it hasn’t yet vanished. I still have some tiny bumps around my mouth and eyes, so I’m leveling up with a monthlong course of oral doxycycline. I hope it will restore my clear skin — and I look forward to a post-pandemic future when I can let my face breathe freely once again.
Elizabeth Svoboda is a science writer in San Jose, Calif., and the author of “What Makes a Hero?: The Surprising Science of Selflessness.”
Cuando se trata de belleza limpia, lo “natural” no siempre es lo mejor. Los dermatólogos advierten de los peligros de usar algunos aceites, entre ellos el de árbol de té.
Cuando Kristen Fanarakis salió de un tratamiento facial en un salón que solo usa productos de origen natural en Atlanta, su rostro no tenía el resplandor fresco y brillante que había esperado.
“El rostro prácticamente se me estaba desprendiendo”, dijo y señaló que el resultado se parecía más a lo que sucede después de un tratamiento de láser Fraxel, el cual puede dejar a los pacientes con la piel roja y descamándose durante varios días. “Parecía un poquito como Frankenstein”, comentó.
Para Fanarakis, la fundadora de 44 años de una marca de ropa, esta no era una reacción normal. Posee lo que describe como un “cutis griego firme” capaz de soportar exfoliaciones químicas y un uso considerable de retinol. Lo que, al parecer, su piel no pudo soportar fueron los aceites esenciales de papaya y calabaza que se usaron durante el tratamiento facial.
“El cuidado de la piel es una ciencia, así que es arriesgado suponer que algo ‘natural’ es mejor”, explicó. “En la naturaleza existen muchos compuestos que no son buenos para nosotros”.
Este sentimiento crece en medio de un auge de la belleza “limpia” no regulada en el que muchas marcas nuevas se posicionan como mejores para la piel simplemente por sus ingredientes naturales y no tóxicos. Los aceites esenciales, que a menudo se añaden a los productos por su fragancia o por sus propiedades antibacterianas, se han convertido en algo especialmente controvertido a medida que han ido ganando popularidad, y empresas como doTerra y Young Living han recaudado miles de millones de dólares con la venta de estos aceites.
Los dermatólogos hace mucho tiempo advierten que los aceites esenciales son peligrosos para la piel, pero los clientes están empezando a darse cuenta de las inesperadas y a veces dolorosas reacciones cutáneas. El marzo del año pasado, un artículo del sitio web satírico Reductress, titulado Essential Oils to Cure Your Rash From That Other Essential Oil (Aceites esenciales para curar el sarpullido de ese otro aceite esencial), ofrecía un resumen de la reacción negativa.
Annie Gonzalez, una dermatóloga de Miami, ha visto un incremento en las reacciones a los aceites esenciales y las considera una de las causas principales de dermatitis de contacto. Gonzalez señaló que esta situación ha empeorado durante la pandemia debido a que la gente experimenta con remedios de aceites naturales mientras está confinada en su casa.
“Es cada vez más problemático porque la gente usa versiones sin diluir de estos aceites para elaborar su propio producto”, afirmó Gonzalez.
No obstante, los productos de laboratorio pueden ser igual de inseguros.
En febrero pasado, Gabrielle Puig, una estudiante de 21 años de la Universidad George Washington, decidió probar la mascarilla Jet Lag de Summer Fridays, una marca muy publicitada de productos para el cuidado de la piel de la influente Marianna Hewitt, para suavizar su piel reseca. Unos minutos después de la aplicación, la piel le comenzó a picar y a cosquillear de una manera que parecía que estaba teniendo el efecto contrario.
“Me la retiré de inmediato, pero ya tenía la piel más roja e irritada que nunca”, aseguró Puig. Luego de revisar la lista de ingredientes, quedó convencida de que los culpables fueron los aceites de pimienta y cítricos.
Después de recibir una serie de críticas negativas que hablaban de sarpullidos y urticaria como efectos colaterales en enero, Summer Fridays ofreció una disculpa pública a sus clientes. Pese a que la marca atribuyó estas reacciones a un lote del producto que fue dañado por un fabricante externo, subrayó que tomaría medidas para eliminar de sus productos los aceites esenciales “a fin de disminuir cualquier posibilidad de que se produzcan irritaciones en el futuro”.
Por qué los aceites esenciales son tan peligrosos
Para entender por qué los aceites esenciales pueden ser peligrosos para la piel, es importante comprender lo que son y lo que no son. Los aceites esenciales se extraen de flores, cortezas, tallos, hojas, raíces y frutas seleccionadas mediante un proceso de destilación o de presión en frío y son componentes químicos muy concentrados que contienen la esencia o el aroma de una planta.
“Para su procesamiento, requieren una gran cantidad de material de la planta, así que por lo general tienen concentraciones de ingredientes activos mucho más elevadas de las que estamos acostumbrados”, señaló David Petrillo, químico de cosméticos en Los Ángeles. Por ejemplo, son mucho más concentrados que los aceites populares como el de coco y el de argán, los cuales se consideran aceites “portadores”, que son más suaves y a menudo se usan para diluir los aceites esenciales más fuertes.
Aunque se ha demostrado que inhalar ciertos aceites esenciales impacta al sistema nervioso central y estimula al cerebro para que libere neurotransmisores como la serotonina, que ayudan a regular el estado de ánimo, también se ha visto que alteran el funcionamiento normal de las hormonas. En lo que respecta a la piel, algunos expertos dicen que en pequeñas concentraciones ofrecen beneficios antibacterianos, pero muchos creen que más allá de dar un aroma agradable a un producto, hacen más daño que bien.
“Usarlos en la piel casi asegura que una parte llegue al torrente sanguíneo”, afirma Petrillo, que enumera una lista de efectos secundarios comunes, como enrojecimiento, quemaduras químicas, dolores de cabeza, hinchazón y ampollas. Y aunque muchas marcas sostienen que las propiedades antibacterianas de los aceites esenciales ayudan a combatir el acné, en realidad pueden empeorar los brotes.
“Muchos de nuestros clientes con acné utilizan marcas ‘más limpias’ para el cuidado de la piel que, en realidad, pueden obstruir los poros debido a los aceites y productos botánicos con los que están formulados”, afirma Sofie Pavitt, esteticista de Nueva York.
Aunque se puede tener una reacción alérgica a cualquier aceite esencial, se sabe que con algunos existe un mayor riesgo que con otros. Los aceites cítricos, que incluyen el limón, la naranja y la bergamota, son en especial peligrosos, ya que pueden ser fototóxicos, lo que significa que reaccionan a la luz ultravioleta y pueden hacer que la piel sufra quemaduras y ampollas. También se sabe que los aceites de corteza de canela, clavo, zacate de limón, orégano, pimienta y jazmín producen irritación.
Pero el aceite esencial que con mayor frecuencia causa estragos es también uno de los más recomendados por los naturópatas y los promotores del cuidado de la piel por medios naturales.
“El premio se lo lleva el aceite del árbol de té”, afirmó Gonzalez. “Veo muchos pacientes con acné u hongos que están convencidos de que el aceite del árbol de té es un remedio milagroso para casi todo”. Al usar demasiado aceite del árbol de té sin diluir que se compra en las farmacias para mascarillas faciales o para el tratamiento de manchas, los pacientes terminan empeorando la afección de la piel y desarrollan tiña incógnita, una infección causada por hongos que se esconde, y a menudo se exacerba, debido a la aplicación de algún agente tópico.
“Eso me dificulta todavía más diagnosticar el problema principal y resulta más complicado solucionarlo porque ahora hay que reparar la barrera de la piel que se ha visto afectada por el uso de estos aceites”, comentó Gonzalez.
Cómo experimentar sin riesgos con los cosméticos a base de ingredientes naturales
Cuando se trata de aceites esenciales, no existe un enfoque único y la respuesta no es forzosamente eliminarlos de tu rutina. “En realidad, la mayor parte de lo que usamos en la industria de la belleza está en una zona gris donde algunas personas pueden usarlo sin problema y otras no”, mencionó Gonzalez. “Siempre les digo a mis pacientes que más bien depende de la dosis, la concentración y el origen”.
Los expertos recomiendan buscar concentraciones diluidas del 0,5 al 1 por ciento o menos, de preferencia mezcladas con un aceite portador menos reactivo como el de argán o el de coco. Puesto que muchas marcas no mencionan las concentraciones, se puede hacer una sencilla prueba de olor: si el aroma es muy fuerte, hay más probabilidades de que te irrite la piel.
Gonzalez afirmó que la opción más segura es hacer una prueba en una zona de la parte interior del brazo y deja reposar, sin lavar, durante 48 horas para ver cómo reacciona la piel. Las personas que tienen enfermedades subyacentes de la piel como psoriasis, rosácea o eczema deben tener más cuidado.
Si te encuentras entre los sensibles, pero quieres experimentar con la belleza “limpia”, un número creciente de productos evita explícitamente los aceites esenciales. Drunk Elephant los incluye en su lista de “seis ingredientes sospechosos” con los que hay que tener cuidado y los mantiene fuera de sus productos.
Marie Veronique, una marca veterana en el área de la belleza limpia, vende una línea sin aceites esenciales creada en colaboración con la especialista facial de San Francisco Kristina Holey. Y la línea de cuidado de la piel Peet Rivko fue creada por Johanna Peet específicamente para hacer frente a la falta de opciones limpias para la piel sensible, la línea posicionada como la versión de alto diseño de los incondicionales suaves productos Cetaphil y CeraVe que encuentras en la farmacia.
Aunque una línea de productos calmantes sin fragancia no es muy atractiva, los consumidores (sobre todo los de la generación Z) son cada vez más conscientes de los ingredientes y de los riesgos que entrañan los productos que utilizan.
“La idea de que el hecho de que algo sea natural no es necesariamente mejor para la piel está ganando adeptos”, afirma Peet. “Pero, como ocurre con muchas cosas en la industria de la belleza, hay que repetirlo muchas veces antes de que la gente capte totalmente el mensaje”.
When Kristen Fanarakis emerged from a facial at an all-natural salon in Atlanta, her face did not have the fresh, glossy glow she had hoped for.
“My face was basically falling off,” she said, noting that the result was closer to what happens after a Fraxel laser treatment, which can leaves patients with red, shedding skin for days. “I looked Frankenstein-ish.”
It wasn’t a normal reaction for Ms. Fanarakis, the 44-year-old founder of a clothing brand. She has what she describes as “strong Greek skin” that can withstand regular chemical peels and ample retinol usage. What her skin apparently couldn’t withstand was the papaya and pumpkin essential oils used during the facial.
“Skin care is a science, so assuming that something ‘natural’ is better is risky,” she said. “There are plenty of compounds out in nature that are bad for us.”
That sentiment is growing amid an unregulated “clean” beauty boom in which many new brands position themselves as better for skin simply on the basis of their natural, nontoxic ingredients. Essential oils, often added to products for fragrance or for their antibacterial properties, have become particularly controversial as they’ve grown in popularity, with companies like doTerra and Young Living raking in billions of dollars on sales of the oils.
Dermatologists have long argued that essential oils are risky for skin, but customers are starting to catch on in the wake of unexpected and sometimes painful skin reactions. Last March, an article on the satirical website Reductress, titled “Essential Oils to Cure Your Rash From That Other Essential Oil,” offered a succinct summary of the backlash.
Dr. Annie Gonzalez, a dermatologist in Miami, has seen an uptick in essential oil reactions, calling them one of the leading causes of allergic contact dermatitis. The situation has worsened during the pandemic, she said, because people are experimenting with essential oil remedies while stuck at home.
“It’s becoming more problematic because people are using undiluted forms of these oils to make their own product,” Dr. Gonzalez said.
Lab-prepared products, however, can be just as problematic.
Last February, Gabrielle Puig, a 21-year-old student at George Washington University, decided to test out the Jet Lag mask from Summer Fridays, a much-hyped skin-care brand from the influencer Marianna Hewitt, to soothe her dry skin. Minutes after application, her face started stinging and tingling in a way that seemed counterproductive.
“I immediately took it off, and my skin was more red and irritated than ever before,” Ms. Puig said. After reviewing the ingredient list, she became convinced that the peppermint and citrus oils were the culprits.
In January, Sunday Fridays posted an apology to customers after receiving a slew of negative reviews that mentioned rashes and hives as side effects. While the brand attributed the reactions to a product batch being compromised by a third-party manufacturer, it noted that it would be working to remove essential oils from its products “to mitigate any future potential for irritation.”
Why Essential Oils Are So Risky
To understand why essential oils can be risky for skin, it helps to understand what they are and are not. Extracted from flowers, bark, stems, leaves, roots and select fruits via either distillation or cold-pressing, essential oils are highly concentrated chemical components that contain a plant’s essence or smell.
“They require a high amount of plant material for processing, so they usually have much higher active ingredient concentrations than we’re used to,” said David Petrillo, a cosmetic chemist in Los Angeles. They are much more concentrated than popular oils like coconut and argan, for instance, which are considered “carrier” oils that are milder and are often used to dilute stronger essential oils.
While inhaling certain essential oils has been shown to affect the central nervous system and stimulate the brain to release neurotransmitters like serotonin that help with mood regulation, they’ve also been shown to disrupt the normal functioning of hormones. When it comes to the skin, some experts say that in small concentrations they offer antibacterial benefits, but many believe that beyond giving a product a nice scent, they do more harm than good.
“Using them on your skin almost insures that some of it will get into your bloodstream,” Dr. Petrillo said, listing a skin-crawling list of common side effects, including redness, chemical burns, headaches, swelling and blisters. And although many brands maintain that the antibacterial properties of essential oils aid in fighting acne, they can actually worsen breakouts.
“A lot of our clients with acne are using ‘cleaner’ skin-care brands that can actually clog pores because of the oils and botanicals they’re formulated with,” said Sofie Pavitt, an aesthetician in New York.
Although it’s possible to experience an allergic reaction to any essential oil, some are known to be riskier than others. Citrus oils, including lemon, orange and bergamot, are particularly dangerous, as they can be phototoxic, meaning they react to UV light and can cause skin to burn and blister. Cinnamon bark, clove, lemongrass, oregano, peppermint and jasmine oils are also known to cause irritation.
But the essential oil that most commonly wreaks havoc is also one of the most recommended by naturopaths and natural skin-care enthusiasts.
“Tea tree oil wins the prize,” Dr. Gonzalez said. “I see so many patients with acne or fungus who are convinced that tea tree oil is a miracle remedy for pretty much everything.” Using too much undiluted tea tree oil purchased at the drugstore for face masks, or for spot treatments, patients end up worsening their skin condition and develop tinea incognito, a fungal infection that’s masked and often exacerbated by the application of a topical agent.
“It makes it even harder for me to diagnose the primary issue, and it becomes more complicated to fix because you now have to repair the skin barrier that has been compromised by the use of these oils,” Dr. Gonzalez said.
How to Experiment With Clean Beauty, Safely
There is no one-size-fits-all approach to essential oils, and blacklisting them from your routine doesn’t have to be the answer. “Most of what we use in the beauty industry is really in that gray zone, where some people can use it without a problem and other people can’t,” Dr. Gonzalez said. “I always tell patients that it really depends on the dosage, the concentration and the source.”
Experts recommend looking for diluted concentrations of 0.5 to 1 percent or lower, preferably mixed with a less reactive carrier oil like argan or coconut. Since many brands don’t list concentrations, a simple smell test will do: If it’s very fragrant, it’s more likely to irritate your skin.
Your safest bet, Dr. Gonzalez said, is to do a patch test on the inside of your arm and let it sit, unwashed, for 48 hours to see how your skin reacts. People with underlying skin conditions like psoriasis, rosacea or eczema should be particularly cautious.
If you happen to fall in the sensitive camp but still want to experiment with “clean” beauty, a growing number of products explicitly avoid essential oils. Drunk Elephant lists them in its “suspicious six” ingredients to be wary of and keeps them out of its products.
Marie Veronique, a veteran brand in the clean beauty space, sells an essential oil-free line created in partnership with the San Francisco facialist Kristina Holey. And the skin-care line Peet Rivko was created by Johanna Peet specifically to address the lack of clean options for sensitive skin, the line positioned as the high-design version of the gentle drugstore stalwarts Cetaphil and CeraVe.
While a soothing line without fragrance isn’t a sexy sell, consumers (particularly Gen Z) are getting savvier about ingredients and the risks involved in the products they use.
“The idea that, just because something is natural it’s not necessarily better for your skin, is gaining more traction,” Ms. Peet said. “But as with many things in the beauty industry, it needs to be repeated many times before people fully get the message.”
Some people are having delayed reactions to their first dose of a Covid vaccine, with their arms turning red, sore, itchy and swollen a week or so after the shot.
The reactions, though unpleasant, appear to be harmless. But the angry-looking skin condition can be mistaken for an infection, according to a letter published on Wednesday in The New England Journal of Medicine. The doctors said they wanted to share information about the cases to help prevent the needless use of antibiotics and to ease patients’ worries and reassure them that they can safely get their second vaccine shot.
“We modified our patient handout once we started seeing this,” Dr. Kimberly G. Blumenthal, an author of the letter and an allergist at Massachusetts General Hospital, said in an interview. “We had said it was normal to get redness, itching and swelling when you get the vaccine. We changed the wording to say it can also start seven to 10 days after you get the vaccine.”
The letter describes the experiences of 12 people who had “delayed large local reactions” that began four to 11 days after the first shot of the Moderna vaccine, within a median of eight days. The report is not a controlled study, but rather a series of cases that came to the doctors’ attention because the vaccine recipients were concerned and wanted to know whether they should get the second shot.
Most were vaccinated at Massachusetts General Hospital, where both the Moderna and Pfizer-BioNTech vaccines were administered. But the delayed reactions occurred only in people who had received the Moderna shot, Dr. Blumenthal said, adding, “I don’t understand why.”
Moderna reported delayed skin reactions in its large clinical trial in 0.8 percent of recipients after the first dose, and 0.2 percent after the second dose.
According to the letter by Dr. Blumenthal and 10 other physicians, all 12 people reported typical symptoms like a sore arm that often occur shortly after inoculation, and those initial symptoms had disappeared.
Then, a delayed reaction hit. In five people, big, raised skin lesions emerged that measured 10 or more centimeters in diameter near the injection site. Two had rashes in other spots, one near the elbow and one on the palm of the hand. Some also had systemic symptoms at the same time, like fatigue and achy muscles.
Most treated the skin symptoms with ice and antihistamines. But some needed steroids, in cream or pill form, and one was prescribed an antibiotic by a doctor who mistook the problem for an infection.
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The symptoms lasted a median of six days, ranging from two to 11 days. All the patients went on to get the second shot. Half did not have another delayed reaction, but three developed the same symptoms again and three had milder reactions than after the first shot.
Dr. Blumenthal said there were many unanswered questions about the reactions. Ten of the 12 patients were women, but it is not clear whether women are more prone to the problem or whether the imbalance occurred because more of the vaccinated health workers were female.
Some had allergies to drugs, wasp stings or food, but others did not.
A skin biopsy on one patient indicated that the condition was a drug reaction. But what exactly the patient’s immune system was reacting to is not known.
“I’m hoping the companies will figure it out,” Dr. Blumenthal said.
She is aware of about 30 cases now, mostly among women and all recipients of the Moderna vaccine so far, she said, and the hospital has created a registry to track them.
Every morning around 7 a.m., as she prepares to film a live workout for her 237,000 Instagram followers from her New York City apartment, Megan Roup sips on warm water with a squeeze of lemon while her French press coffee brews. It’s a ritual she has followed for years, the origin of which she can’t quite remember.
“It just get things moving and grooving in the morning,” said Ms. Roup, a fitness instructor in her 30s who founded the Sculpt Society workout beloved by many models. “Along with a probiotic, it’s really helped my overall digestion.”
Ms. Roup is one of many influential figures who swear by the drink, which counts Gwyneth Paltrow, Jennifer Aniston and Gisele Bündchen as devotees. In interviews with models and on fitness feeds, the tip has become commonplace, almost a given at this point. Melissa Wood-Tepperberg, the founder of the Pilates-centric Melissa Wood Health Method, is another believer, posting about it almost daily on social media.
The reasoning behind the ritual varies. Some share Ms. Roup’s belief that it aids digestion, lessening bloat and constipation; others point to its benefits for skin health, believing it wards off the formation of wrinkles and clears up acne. And, for the dehydrated among us, it’s simply a way to make drinking water more enticing.
“I can’t really say if I notice a difference in my skin or digestion, but I do consume more water when I put lemon in it,” said Laura Lajiness, 32, a freelance writer in New York who has been drinking two 16-ounce glasses of lukewarm water with lemon on and off for years. “Maybe there’s a placebo effect?”
The popularity of water with lemon has reached a fever pitch this year, as people stuck at home have channeled their boredom into boosting their wellness routines, hoping to emerge from quarantine with a little more glow, and more fit, than before. Google searches for “lemon and water” peaked in April and are growing overall, up 24.2 percent since this time last year, according to data from the consumer intelligence firm Spate.
Hydration in general is trending, becoming the latest lucrative frontier in the wellness boom. Liquid I.V., which sells electrolyte packets that claim to provide two to three times the hydration of one glass of water, was acquired by Unilever in September.
A company called 8Greens — its effervescent green tablets are said to promote skin elasticity — has raised $10 million in funding and has been spotted on the social feeds of Drew Barrymore and Zac Efron. Beauty Water Drops, from the meal-delivery service Sakara Life, which “transform your water and deeply hydrate your cells with 72 naturally occurring ionic trace minerals,” according to the company, have become a best seller for the brand.
But it’s best to tread lightly with what you buy into. “There’s a lot of pseudoscience out there that’s well intentioned but often misses the mark,” says Dr. Panta Rouhani Schaffer, a dermatologist in New York. Water with lemon, at least, is considered fairly harmless and, unlike the myriad branded hydration options easily accessible. A pack of 30 8Greens tablets and a two-ounce bottle of Sakara Life Beauty Water Drops each cost $39; Liquid I.V. charges $25 to $120 for packets of 16 to 96 hydration sticks.
Like many American wellness remedies, the drink is actually a repackaged ritual from another country — in this case, Italy. Known to some Italian natives as “canarino,” or canary, the drink is one of the country’s many “nonna’s remedies” that are used as a post-meal digestif, upset-stomach soother or cold killer, depending on who you ask.
Prepared by combining boiling water with a lemon peel, bay leaf and, occasionally, a drop of honey, the mixture is “an ancient remedy used by Italian grandmas to bring immediate relief to their loved ones,” said Francesco Lucatorto, a 31-year-old chef who lives in Genoa.
But in recent years, younger Italians have followed America’s footsteps and reframed it as a detox drink, often imbibed after an overindulgent night of eating and drinking. Some proponents add ginger, mint or turmeric to deepen its flavor and boost its perceived benefits.
As for what the concoction actually does … well, it’s complicated.
From a gut health standpoint, vitamin C is considered important for overall digestion and aids in the absorption of crucial vitamins like iron, said Dr. Niket Sonpal, a gastroenterologist in New York. It can also act as a laxative, meaning that if daily lemon water drinkers feel lighter, it’s probably not all in their heads.
“They’re consuming a lot of ascorbic acid and softening their stools with the hydration, so instead of going to the bathroom once every two days, they’re going every day,” Dr. Sonpal said. “Over all, that’s a good thing — better out than in.”
When it comes to skin health, there is some science to support the benefits of consuming lemon, but the details are important. Researchers are increasingly studying the impact of certain foods on glycation, a key cause of skin aging that involves sugar molecules attaching to and deteriorating proteins like collagen, according to Dr. Schaffer.
In one such study of 28 healthy Japanese subjects, 31 to 65 years old, who drank leaf balm extract in their tea, researchers found improved elasticity (which decreases with age) of the subjects’ facial skin.
Still, Dr. Schaffer said, more research needs to be done to determine what part of the lemon is beneficial. Is it the root, the leaf, the stem, the bark or the seed? While the citrus drink won’t hurt your skin, you may be better off lessening your refined sugar intake if aging is a concern, she said.
Hoping that a daily dose of lemon water will detox or clear up your skin is a lost cause, however. “There are no toxins in the skin to detox,” Dr. Schaffer said, echoing a message that many doctors have tried to get across amid the rise of juice cleanses, which are predicated on this faulty concept of detoxification.
At most, lemon’s antioxidant properties can protect against free radicals, which have been shown to speed up aging, Dr. Schaffer said. But acne sufferers would be better off drinking two cups of spearmint tea daily. The tea has been shown to have anti-androgen effects that can lessen male hormones like testosterone, which can cause acne.
One expert who won’t be signing off on the craze is your dentist. “I knew hot water and lemon had become really popular when our family dentist mentioned to us the harm of citric acid on tooth enamel,” Dr. Schaffer said. “He had seen so many patients with new onset erosion from the drink that he began to warn everyone he saw.” People with heart or kidney conditions should also hold off, according to Dr. Sonpal, the gastroenterologist, as excess fluids are often contraindicated in their treatment.
But if you can put aside visions of supermodel skin or reverse aging, incorporating water with lemon into your weekly routine is an easy, expert-approved way to raise your water intake and reap the digestive benefits without spending much money.
For now, Ms. Roup, who is quick to tell her followers that she’s not a nutritionist when sharing her dietary habits, has more faith in this route than other options on the market that make outsize claims.
“Everyone’s always trying to sell you something in the health-and-wellness world, but it doesn’t need to be complicated,” she said.
It starts in utero.
A mass of cells divides and develops, splits and stretches, and from a single layer of embryonic tissue, two seemingly separate but inherently interconnected systems are born: the brain and the skin.
They are bound for life. When one senses embarrassment, the other blushes. When one senses pain, the other processes it. And when one bears the burden of a pandemic, political unrest, systemic racism and the ever worsening effects of climate change … well, the other gets a pimple.
Or perhaps, depending on your genetic predispositions, it’s not a pimple but an eczema outbreak. A psoriasis flare-up. A bout of rosacea. A dehydrated, dull, oily or even — gasp — older-looking appearance. General blah–ness, if you will.
This is your skin on stress.
“There are two different types of stress: acute stress and chronic stress,” said Dr. Whitney Bowe, a dermatologist and the author of “The Beauty of Dirty Skin.” A quick surge of stress can be a good thing. It may heighten your senses, enhance mental clarity and help create collagen to facilitate wound repair. It’s there and it’s gone.
It’s the chronic, continuing stress, the kind that every sentient being is likely experiencing right now, that takes a toll on the skin.
It takes a toll on the entire being, of course, and a compromised complexion is the least of its consequences. But “the skin is the organ that we see,” as Dr. Loretta Ciraldo, a dermatologist and founder of the Dr Loretta skin-care line, put it. And in a society where unsustainable stress is not only the norm, but sometimes a celebrated sign of success, what better way for the subconscious to cry out than “stress skin”? (It is, after all, easier to ignore your feelings than your face.)
Here’s How Stress Affects Your Skin
Much of the skin-psyche connection comes down to the overproduction of cortisol, the primary stress hormone, and its effect on the skin barrier.
“The barrier traps moisture in and keeps allergens, irritants and pollutants out,” Dr. Bowe said. It effectively does the job of most skin-care products on the market, sans products, and needs three things in order to thrive: oil, water and the microbiome. Cortisol depletes them all.
During times of stress, cortisol slows the production of beneficial oils. “We get dry, rough and much more irritated because those healthy oils act as a protective layer for us,” Dr. Ciraldo said. Without adequate lipids to seal in hydration, the skin starts to “leak” water in a process known as transepidermal water loss (TEWL).
At the same time, cortisol stimulates the overproduction of sebum, the oil that is implicated in acne. “So for many of us, our skin seems more oily when we’re under stress, and it’s more acne prone,” she said.
All of this alters the skin’s pH, which compromises the acid mantle and creates an inhospitable environment for the one trillion symbiotic micro-organisms that exist on and in the skin barrier — a.k.a., the microbiome.
Under ideal conditions, the microbiome renders topical skin care all but superfluous. There are microbes that feed off sebum, which helps sustain healthy oil levels. There are microbes that feed off dead skin cells — the original exfoliators! There are microbes that produce peptides and ceramides, two buzzed-about beauty ingredients that keep skin firm and moisturized. There are microbes that offer protection from pollution, sunlight and invading pathogens.
“If you’re not producing enough of those healthy fats and not maintaining a healthy barrier, though, you’re altering the terrain on which these microbes grow and thrive,” Dr. Bowe said. “Imagine stripping the soil of all the nutrients and seeing if your vegetable garden is going to grow. It’s the same for the skin.”
In turn, the microbiome may experience an overgrowth of so-called bad bacteria (like C. acnes, the strain associated with acne) and a dearth of good bacteria. The microbiome becomes more prone to infection, irritation, inflammation and hyperpigmentation. It becomes more sensitive to outside aggressors, like the free radicals generated by pollution.
Stress prompts the body to produce internal free radicals, as well. “You can think of free radicals like little missiles,” Dr. Bowe said, in that they target cells for destruction and cause oxidative stress. When free radicals target DNA, it leads to skin cancer. When free radicals target elastin and collagen, it leads to fine lines and wrinkles. When free radicals target lipids, it leads to dehydration and skin barrier damage and acne.
Chronic exposure to cortisol also inhibits the production of hyaluronic acid and collagen. “These are what keep the skin plump and youthful,” Dr. Bowe said. “When you can’t make enough, the skin gets thinner.”
Sadly, hyaluronic acid serums and collagen creams can’t counteract cortisol. Topical ingredients don’t serve the same biological purpose as those produced in the body and rarely penetrate to the lower layer of the dermis, where collagen and hyaluronic acid naturally occur.
In fact, skin-care products aren’t the answer to stress skin at all.
“Most products are meant for consumers who have a healthy skin barrier,” said Ron Robinson, a cosmetic chemist and founder of BeautyStat Cosmetics. Exposing an already broken barrier to active ingredients — or too many ingredients — only exacerbates existing issues.
For this reason, Dr. Ciraldo recommends removing barrier-degrading ingredients like glycolic acid, salicylic acid, benzoyl peroxide and retinol from your stress skin routine. “They are very drying, and they really do deplete the normal, healthy barrier function,” she said.
Dr. Bowe advises that you avoid any leave-on products with essential oils in them, because they can cause irritation. “A lot of people think they’re calming and soothing, but for the skin, that’s not the case,” she said.
Exceptions can be made for barrier-boosting ingredients, like glycolipids (found in Dr Loretta Intense Replenishing Serum), fatty acids (found in Symbiome Respond Postbiomic Oil) and ceramides (found in BeautyStat Pro-Bio Moisture Boost Cream).
To Heal Stress Skin, Address the Stress. Here’s How.
Managing stress may seem nearly impossible, considering that so many modern stressors are systemic. Yet according to Dr. Heather Woolery-Lloyd, a dermatologist, “90 percent of our stress is not the stressor itself, but how we deal with that stressor.”
In other words: While meditation can’t mitigate global warming, it can, at the very least, clear your complexion.
Meditating, Dr. Woolery-Lloyd said, initiates “the relaxation response,” which activates the body’s parasympathetic nervous system and decreases cortisol and inflammation. With consistent practice, the skin barrier can stop leaking and start locking in moisture, suggesting that the fabled inner glow is less symbolic than scientific.
Dr. Ciraldo tells her patients to think of meditation as “The Life-Changing Magic of Tidying Up” for the mind. “Try to find a spot when you’re going to sit quietly for 20 minutes a day and really go through your thoughts like you would your closet,” she said. “If something comes into your mind that doesn’t give you joy, put energy into discarding that thought.”
Not into meditation? No matter. Breathing, which may beat drinking water as the most eye-rollingly simple yet undeniably effective skin-care tip, is enough. Research from Dr. Herbert Benson at Harvard Medical School shows that taking slow, deep breaths triggers the relaxation response and, Dr. Bowe said, “can stop psychological stress from being translated to physical inflammation in the skin.” Breath work classes, like those offered on the holistic healing hub ALTYR, can help with technique.
“Do not put on CNN with John King up there five minutes before bed,” Dr. Ciraldo said, which is to say, beware the blue light emitted from electronics. It interrupts your circadian rhythm and leads to lower-quality sleep, which is linked to increased cortisol, free radical damage and inflammation.
“Something as simple as sleep can change the skin barrier,” Dr. Woolery-Lloyd said.
To address and prevent free radical damage, fill your plate with antioxidants, which stabilize these unstable molecules to leave skin clearer, calmer, brighter and more even toned. Vitamins A and C (abundant in fruits and vegetables), lycopene (found in tomatoes), astaxanthin (salmon) and polyphenols (green tea, dark chocolate) are all great options, according to Dr. Bowe.
Exercise increases antioxidants, as well. (Behold, the body produces yet another popular skin-care ingredient on its own.) It lowers cortisol levels, meaning fewer breakouts and a stronger skin barrier. And if you’re exercising outdoors? Even better.
“I’m a big believer in the healing power of nature,” Dr. Woolery-Lloyd said. “People say, ‘I don’t have the time,’ but it doesn’t have to be this drawn out thing. Just going outside and seeing a tree and looking at a few birds is proven to lower inflammatory markers in our body.”
If all else fails, cry.
“Crying is a stress reliever and helps decrease cortisol levels,” said Dr. Purvisha Patel, a dermatologist and the founder of Visha Skincare. “This can result in fewer breakouts.” She notes that orgasms have a similar effect on cortisol (and are, by all accounts, more enjoyable).
“This isn’t B.S.,” Dr. Ciraldo said. “These are things we can do for our skin and ourselves that don’t cost anything, but the reward is great.”
Credit Getty Images
Summer is here, and we know we’re supposed to shield children from the sun. There’s strong evidence that early sun exposure can increase children’s risk of later skin cancer, and that’s true also for darker-skinned children who are less likely to burn. Boston and Miami Beach are providing free sunscreen in public places, and now New York is talking about it, too.
Parents have certainly gotten much more aware about sun protection, though they sometimes feel a little overwhelmed by the variety of products and by the job of keeping up with the imperatives for proper use.
And with old worries about ticks and new worries about mosquito-borne viruses, parents wonder if they should also be coating a child’s exposed skin with bug repellent.
But babies’ delicate skin is more permeable than adults’, so any chemicals we apply may be more likely to be absorbed, and their immature organs may be less able to handle those chemicals. What stays on the skin may be absorbed; but what doesn’t stay on the skin doesn’t shield. Dermatological toxicology involves considering the balance between “wash in,” the risk of absorbing potentially toxic substances through the skin, and “wash out,” the loss of protection as substances are lost by sweating or water exposure or rubbing. Both are highly complex processes, with many variables, and not necessarily well studied in young children.
With little babies, the advice is always to rely on reducing exposure, on shade and clothing for sun, and on adding screens and netting to keep the bugs off. Both the Food and Drug Administration and the American Academy of Pediatrics emphasize that babies under 6 months should be kept out of direct sunlight, protected with shade, shielded with sunhats and protective clothing when they do have to be out, rather than relying on sunscreen.
Babies’ skin surface is large in proportion to their body volume and their internal fluids, putting them at high risk for heat and dehydration. So make sure they are drinking and wetting their diapers regularly.
Adults and children alike are advised to avoid the hours of maximum exposure — to stay out of the sun between 10 and 2, and to avoid going outside at dusk in areas with lots of mosquitoes. But of course, that isn’t necessarily easy.
Sun hats and protective clothing are important for older babies and toddlers, and so is avoiding those peak hours. For children under 2, “the rule of thumb in this age group is clothing first,” said Jacqueline Thomas, an assistant professor of dermatology and surgery at Nova Southeastern University in Fort Lauderdale, who is the senior author on a commentary reviewing pediatric sunscreen and sun safety guidelines published last year in the journal Clinical Pediatrics. Dark colors and more tightly woven fabrics are more effective.
As to sunscreen, experts say not to choose by what is marketed for children or babies, and to read the label carefully. In 2011, the F.D.A. required much more information to be standardized on sunscreen labels; parents should look for products with an SPF of 30 or higher, advises the American Academy of Dermatology, and make sure they are labeled as “water resistant” (lasts 40 minutes in the water) or “very water resistant” (80 minutes), and as “broad spectrum,” meaning that they block both UVA and UVB rays, both of which do damage. There is no such thing as waterproof sunscreen.
The active agents in sunscreen can be either chemical blockers or physical blockers, and the physical blockers are safer for children because they are much less likely to be absorbed. For children ages 2 to 12, look for products with titanium or zinc as their active ingredients, rather than chemical agents, which really haven’t been studied in children.
The recommended amount for an adult-size body is variously described as a shot glass and a golf ball for the trunk and extremities; for under 12, some authorities suggest using the amount that would fill a child’s cupped hand as a rough guide. It needs to be reapplied after two hours, because the efficacy is gone, even if you can still feel the lotion on your skin, and sunscreens with higher SPFs don’t last any longer than those with lower SPFs (in fact, there is no evidence that SPFs over 50 are more protective).
Although spray-on sunscreens are popular, their efficacy has not been studied,, and there’s concern about children inhaling them. The F.D.A. has asked for more data.
What about insects? Mosquito repellents generally contain either DEET, picaridin or one of several essential plant oils, most commonly oil of lemon eucalyptus, as an active ingredient; permethrin, which is meant to be applied to clothing (or sometimes already applied by manufacturers) works to repel ticks.
There has been concern in the past about DEET toxicity, and the recommendation is to avoid DEET and picaridin for babies younger than 2 months, and to avoid oil of lemon eucalyptus for children under 3. But most pediatricians would recommend being very sparing with all of these substances on babies and young children, applying them only to exposed skin, right before going outside, and washing them off when you come back in. Don’t let young children apply the stuff themselves, and keep it away from their eyes and their mouths, and their hands if they tend to put those in their mouths. If possible, put the repellent on the clothing, or on the tent; there are also clip-on devices that can be attached to strollers.
Dr. Adelaide A. Hebert, a professor of dermatology and pediatrics at McGovern Medical School at the University of Texas Health Science Center at Houston, said she tends to recommend picaridin-based insect repellents such as Cutter Advanced and Off Clean Feel for children over those that contain DEET. “I like picaridin. I feel there’s less concern for parents using it with regard to toxicity,” she said. The strength of these insect repellents can vary as well, so again, it’s important to read the label. “We don’t recommend DEET strength above 20 percent because of concern about toxicity,” Dr. Hebert said.
Combination products are another problem, though the idea of a single lotion that protects against both sun and insects is very appealing. “I never recommend combination products,” said Dr. Hebert. “We don’t want to reapply the insect repellent as often as we may need to reapply the sunscreen.” Further, there’s evidence that the mixture may make the sunscreen less effective, and the chemicals more likely to be absorbed.
So keep babies out of the sun, be scrupulous about sun hats and protective clothing, about screens and mosquito netting. As children grow, don’t forget about protecting the eyes; think about broad-brimmed hats and sunglasses. If you need protection against insects, apply insect repellent over sunscreen, and reapply the sunscreen after two hours, on top of the insect repellent, which does not have to be reapplied so frequently.
The skin is the largest organ of the body, proportionally larger in the smallest children, and protecting it properly needs our care and attention.
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Consulting a dermatologist over the Internet may have serious drawbacks, a new study suggests.
Direct-to-consumer telemedicine, in which a patient receives an examination and treatment over the Internet, is rapidly expanding, and in 2015 attracted an estimated 1.25 million people seeking advice in the United States. And while telemedicine has substantial benefits, the researchers say — it is convenient and typically saves money – many of the websites they looked at were not providing adequate care.
For their study, published in JAMA Dermatology, the researchers submitted six simulated cases involving skin symptoms to 16 direct-to-consumer telemedicine sites and apps for diagnosis and advice. The study excluded sites that failed to respond or responded intermittently, or that delivered incomplete or inconsistent responses. In all, 62 responses were included in the analysis.
Most sites allowed patients to submit photographs, usually one to three images of the skin condition in question. In four cases, the site provided a diagnosis based only on the patient’s description.
Two thirds of the sites failed to collect a complete medical history, and only 52 percent asked female patients about pregnancy or lactation, even though such information can be essential in the diagnosis and treatment of some dermatologic disorders.
Diagnoses were sometimes missed. In one case, a 28-year-old woman presented with acne, but not a single website asked about excessive hair growth or irregular menstrual periods, symptoms that would have led to the correct diagnosis of polycystic ovarian syndrome. In another case, a woman with eczema complicated by a potentially fatal herpes infection was given a diagnosis of having an ordinary eczema flare-up in seven of nine encounters.
The lead author, Dr. Jack S. Resneck Jr., a professor of dermatology at the University of California, San Francisco, acknowledged that such misdiagnoses could occur even in a face-to-face meeting with a doctor. But, he said, none of the telemedicine sites engaged in the kind of patient-doctor discussion and “give and take” that would happen in an office and provide the information that leads to successful diagnosis.
“You could imagine a telemedicine conversation in which the patient discusses the diagnosis with the clinician,” Dr. Resneck said, “but none of that was going on. There were no instances in which the clinician discussed the problem, asked about other symptoms and so on.”
Of patients who got a diagnosis, 65 percent were given a prescription, but the risks and side effects of the medicines were mentioned only 32 percent of the time. In addition, “when people go to an office in person, they’re aware of who they’re seeing — a clinician, a doctor, a nurse practitioner,” Dr. Resneck said. “But only a minority of sites identified the person or gave information about licensure.” Only six of the 62 responses offered to send a report to a patient’s primary care doctor.
Dr. Resneck said he would like to see telemedicine succeed. “We’re inclined to support this kind of innovation,” he said, “but it needs to be done right. Our results were disappointing.”
On Thursday, we challenged Well readers to figure out the case of a 36-year-old man with a 20-year history of migrating joint pains along with other strange symptoms. Nearly 300 of you offered thoughtful suggestions of what he might have had. And one out of 10 of you were spot on.
The correct diagnosis is:
Ehlers Danlos syndrome
The first reader to correctly make this diagnosis was Bryley Williams, of New York City. She told me she knows nothing about medicine but found the answer on the Internet by investigating noninflammatory causes of joint pain and pneumothorax. All of the winners of this contest are extraordinary, but I think Ms. Williams may take the prize. She is 15 years old, a freshman in high school in New York City. Well done, Ms. Williams! Maybe you should consider a career in medicine once you graduate.
Ehlers-Danlos syndrome, or EDS, is a group of inherited disorders that affect the body’s connective tissues – the skin, muscles, tendons and ligaments that hold us together. Since the 1990s, the disease has been divided into six main types, depending on which connective tissues are most affected. Based on the gene study done in this patient, he was given a diagnosis of the least severe and most common variety, which primarily causes hypermobility of the joints as well as skin that is easily damaged and scars badly.
EDS was probably recognized as early as 400 B.C., when Hippocrates noted that the nomads and Scythians had lax joints and multiple scars. This disorder came to more modern medical attention in the 17th century when, at a medical presentation in Holland, a Spanish sailor by the name of George Albes exhibited his remarkable ability to stretch the skin on his chest out an arm’s length.
The first complete description of the condition was given by a Russian physician, Dr. A. N. Chernogubov, at the end of the 19th century. He presented a 17-year-old boy who suffered from recurrent joint dislocations and easily stretched and fragile skin. The boy had many scars resulting from minor injuries, because these patients do not heal normally. Based on these observations, Dr. Chernogubov predicted that the clinical manifestations were caused by an abnormality of the connective tissues.
That report did not come to the notice of Western Europe for many years. So while the disorder still carries Chernogubov’s name in Russia, in most places it referred to as EDS, after the two physicians who first characterized the disorder in Paris decades later: Dr. Edvard Ehlers and Dr. Henri-Alexandre Danlos.
How the Diagnosis Was Made
The patient, a 36-year-old man with a 20-year history of migrating joint pain, had been to dozens of doctors – internists, orthopedic surgeons, rheumatologists. All had examined him and seen nothing. Indeed, his last rheumatologist kept saying that she wanted to believe that he had this much pain but that she couldn’t find anything physical to cause it.
One orthopedist had asked him if his skin was particularly stretchy or if he was very flexible – obviously thinking of a diagnosis like Ehlers-Danlos syndrome, but the patient said no. He didn’t think he was particularly flexible or that his skin was unusually stretchy. Later, once he had the diagnosis, he showed one of his doctors how he could move his thumb, and the doctor told him that he was popping it in and out of joint. And the geneticist told him that his skin was stretchy enough to fit the diagnostic criteria. Still, it all seemed normal to him. Not extraordinary in any way.
Still, after 20 years of searching, the patient was finally willing to accept that he was just more prone to getting these pains. And he began keeping a list of the types of exercises or activities that seemed most likely to trigger the episodes of joint pain. His wife was unwilling to give up. She continued to search the Internet for answers.
Like Son, Like Father?
The final clue came not from the man’s doctor but from his son’s. The boy, age 11, went to see his pediatrician, Dr. Renee Brand, for his annual physical exam. He was tall and slender, like his father. He had a colt-like awkwardness about him, with arms and legs that looked just a bit too long to be well managed. And he had a stooped posture, as if he spent too much time gazing into a smartphone he didn’t even have. Could he sit up completely straight? Dr. Brand asked. He couldn’t, though he tried.
Later the doctor asked him to bend over so that she could check his spine for scoliosis. He immediately flopped down, his chest almost touching his knees and his hands lying flat on the floor in front of him. Surprised by this remarkable degree of flexibility, Dr. Brand asked another questions. Could he press his thumb down and forward so that he could touch his own forearm with his thumb? He pressed the digit down toward his wrist and, sure enough, was able to make them meet easily.
I think maybe you should take him to see an orthopedic surgeon, Dr. Brand suggested to the boy’s mother. Two weeks later the mom called Dr. Brand with a report. She’d taken the boy to see the surgeo,n and he had in turn recommended that she take him to see a geneticist.
“I thought so,” replied Dr. Brand with satisfaction. Seeing how remarkably flexible the young man was, and how hard it was for him to stand up straight, Dr. Brand thought the boy might have a disorder known as Ehlers-Danlos syndrome.
Getting a Diagnosis
After making the appointment with the geneticist, the boy’s mother sat down at the computer to read up on Ehlers-Danlos. As she read through the descriptions, she could definitely recognize her son. But in those pages she also recognized her husband. Joint pain, check; pneumothorax, check; osteoporosis, check; scoliosis, check. Ultimately this inherited disease was diagnosed in both father and son.
There’s no cure for EDS, but it’s important to know that you have it. The son sees a cardiologist every couple of years, since EDS can lead to problems with heart valves and vessels. He was found to be at risk for a dangerous stretching of his aorta that, without repair, could lead to rupture. And both father and son now understand which exercises are going to be a problem for them – possibly causing joint dislocations or other musculoskeletal injuries.
Not Just ‘Crazy’
For the father, our patient, it’s meant a sacrifice that may sound trivial, but meant a lot to him: He’s had to give up running, his favorite form of exercise. The pounding is just too hard on his joints.
“I kept hoping that I could find a kind of physical therapy that would help me run the way I used to. Now I know I just can’t,” he said. Still, it’s a relief to be able to give a name to his mysterious problems. “It’s proof that I’m not just crazy.”