The Dr Louise Newson Podcast - 262 - Acne: from teen years to menopause and beyond

Episode Date: June 25, 2024

This week on the podcast with Dr Louise, Consultant Dermatologist Dr Sajjad Rajpar returns to talk about acne and its effect on women during the perimenopause and menopause, including on their self-confidence and mental health. Dr Saj explains the causes of acne and the different treatments available, including an encouraging new treatment that could make a big difference to acne sufferers in the long term. Finally, Dr Saj shares his three tips for anyone who might have acne: Keep skincare simple and targeted. Pick one of three active ingredients – retinoids, benzoyl peroxide or azelaic acid – and give it three to six months to work. Only supplement it with a very simple supporting skincare regime. Assess the impact of the acne – if it is leaving persistent blemishes, pigmentation or scars, then escalate the treatment. If the first line treatment hasn’t worked, give it three months and see a medical professional to try to get it under control because prevention of scars is so much easier than trying to reverse and cure them. Be mindful about all the different risk factors and triggers, and do not underestimate the impact of diet and stress. Where we can treat acne holistically, we should. You can follow Dr Saj on Instagram @dr.rajpar_dermatologist There is a chapter dedicated to skin and hair in menopause in Dr Louise’s bestselling book, The Definitive Guide to the Perimenopause and Menopause, which includes expert contributions by Dr Saj. Order your copy by clicking here. Click here to find out more about Newson Health

Hello, I'm Dr Louise Newsome. I'm a GP and menopause specialist and I'm also the founder of the Newsome Health Menopause and Wellbeing Centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research, bust myths on menopause symptoms and treatments and often share moving and always inspirational personal stories. This podcast is brought to you by the Newsome Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So I was super excited today to have back on the podcast a regular guest,

Dr. Saj Rajpar, who many of you would have heard before. And he is one of the leading experts, certainly the leading in my mind, about skin and hair. And so often, hair and skin are trivialized. But actually, there's two reasons why they shouldn't be, because firstly, if we have good skin, it often gives us more confidence, helps, but also the skin is a window into the rest of our body.

So if our skin isn't right, it's not just a cosmetic problem, it's often something else maybe that's going on that we can do. So Saj is very holistic with his care. It's got general medical background, which is really important when we think. about skin and it's acne awareness month in June so we've decided to dedicate this podcast on acne so welcome sadd thank you louise thank you for the very kind introduction it's really

lovely to be back and to be speaking to you about acne this month so it's interesting i think even those four letters acne there's a massive stigma and actually i hope my children don't mind me saying that you've sort of spoken to them about their acne, whereas actually when I was a teenager, acne was really, really awful spots on the skin, whereas there are different definitions, aren't there? And how would you even define what acne is before we get started? Yeah, no, that's a really good question.

And I think acne is a large spectrum of skin disorder, and it ranges from mild to severe. Now, for the definition for studies, mild refers to very few spots, moderate refers to a medium number of spots, and severe refers to a lot of spots. And that in the clinical study context is a reasonable definition because we can then group together patients who have a similar number of spots and see what different treatments help or don't help. But that is just one objective definition of acne. But we can all. also kind of try and look at the impact of acne. And I think when you just in your introduction

said that many things related to skin are often trivialized and attributed to being cosmetic. And this is where the impact of acne must not be underestimated because acne can have a very severe psychological impact on the sufferer. And in my practice, I see people on a day-to-day basis who have massive impact on their mental health because of their acne. It affects their relationships. It affects the day-to-day functioning. People who might not want to go out, might not want to meet people, friends, might not want to be photographed and are embarrassed and stigmatized about their skin. So another way of looking at acne is how much it's affecting your mental health. So somebody might have very mild acne by the study definition, but it may affect

their mental health severely. And then the third way that I look at acne, and I think that's really important, is the physical complications or impact of acne because acne can leave scarring. And there are two different types of scars. It can cause pigmentation changes or redness in the skin, or it can cause dense or elevation scars in the skin. And it's very true to say that even mild acne, so somebody might come to my clinic and say, look, doctor, I only get one, spot a month. But this spot lasts two weeks. It's massive. It leaves a red blemish for about three months and then it leaves a dent. So in the study definition, that would be mild acting because it's only one spot a month. But in our definition, between my patient and myself,

we would classify that as at least severe because it's having a massive impact on their life and it's creating a permanent scar. So it is a really broad spectrum. It is and it's really interesting. So as a GP, obviously I'd see people that were coming with all sorts of problems. And often, but always actually, I've always not been judgmental about people and not jumped to conclusions. And I remember once as a junior GP, a boy came to see me with really, it would be severe in any category acne. And he came with a cough and I helped talk to him about his cough. And he said, no, not at all. And I thought, oh, how do I bring this up? Because I was actually worried, like you're saying about the scarring, because it's not so much

looking day to day, but but future, so very pastured acne. And I said, oh, just while you're here, because I see you haven't been for a little while, just wondered if you wanted to talk about your skin at all. He goes, oh, no, it doesn't bother me at all. It's absolutely fine. He said it's just one of those things. And it was very interesting because I then realized he didn't see it as a problem, but actually he would never have made an appointment.

but then I did use it as an opportunity to say, well, do you know that there are treatments and some of the treatments that we give are only prescribable? And we then had a really lovely consultation. He did end up having something that I prescribed for him. But he would have never made the problem or made it into a problem and partly because he's surrounded by people in his year at school who had similar skin and they sort of normalised it.

And it wasn't affecting him psychologically. He was very confident, outspoken young boy. But he was actually really relieved. that I sort of brought about it in the consultation, but I had to do it in a really careful way because it was very apparent it wasn't bothering him. And conversely, you could say like your lady, oh, you know, almost trivialise it,

but actually if it is really affecting her. And so that's why anything in medicine, whether it's acne or skin problems or menopause, we shouldn't be judging people. If anyone's having any sort of suffering and they're concerned, then it's never too early to talk about what's going on and how to get help. And I think especially with skin, because often people do leave it quite later and it then can be harder to treat, can't it? I think you're absolutely right. I think we've got to take all the

opportunities that we have in healthcare to just educate our patients. And what you did there was educate him and say, look, did you know treatments are available? And also the other issue being that the acne is scarring. And we know that there's a lot of data out there about the psychological impact of scarring that people can endure and that scarring itself leads to increased rates of depression and even self-harm and suicide. So there is a massive impact consequent to acne scarring. So I think if somebody does have elements of a skin disorder, which is an inflammatory skin disorder. So in other words, if somebody had eczema on their face or cirrhosis on their face, we would probably not hesitate to say, hey, look, you've got really severe inflammation

on your face. Did you know we can treat that? And I think, you know, as healthcare professionals, we should do the same for acne as well. And I think it is trivialized a little bit in as much as, look, everybody's got it so it's okay. And also, I think often parents might say to their children, oh look, I had it when I was a teen, and I grew out of it. And so we'll just wait until you grow out of this. Now, what we know is that the longer somebody has acne for, the more likely they are to accumulate scars, which are permanent. And we know that the earlier we treat acne, the more likely we are to actually prevent some of those lesions, which might otherwise have become scars into becoming permanent scars.

So I think we do have a role in educating both parents and children to say, look, yeah, you know what, this condition may well naturally take its course and it may well burn out in three months, but actually it may take a lot longer and every time, you know, every period of time that it's left will actually leave additional scars. Absolutely. So it's a really basic question, if you don't mind. Yeah, yeah, yeah. What causes acne?

Well, that's a really good question. And I think you can break it down into five things. So genetics, hormones, stress, diet, and something else. And something else that we don't really know quite yet. And I say that because when you look at the epidemiological data for acne, the data says that the amount of acne is increasing your own. year and has been for the last two or three decades by half a percent per year. So we are seeing more people with acne. Now it could be that we're seeing people that have got milder acne

come forwards that weren't detected before. But there's probably something real going on because it's often in the high to medium income countries that we're seeing this increase in. Yes. And it's what I wonder, and I'm keen to ask your opinion, so when I was at medical school in the 80s. And when I was doing dermatology in the 90s as a junior doctor, I was always taught it's nothing to do with diet and nutrition. So don't make people feel bad. But actually that's changed. And I'm very interested, as you know, in inflammation, but also processed foods, also all those drinks that people have. Surely that has an effect on our skin, doesn't it, And you know, it's hard to say yes because we don't have any study that has a cause and

effect shown. And that's because the study hasn't been done. No, that doesn't exist. But the epidemiological data goes hand in hand that in those countries where pollution is increasing, where the ultra-processed diets are severely increasing, hey, the rates of acne appear to be increasing in wealth. So, you know, it's an observation at this stage. stage, but we know that those factors also affect our health negatively in many other ways and increase the rates of inflammation and acne is an inflammatory condition. Yeah, and it sort of makes sense as well because we always know that our skin is a reflection

of what we're eating. And I'm not saying that you won't get acne if you eat well. That's not what I'm saying this for clarification. But acne could be worsened in some people. And again, this is where there's something else thing is we don't know. Some people can eat junk food, processed foods, and their skin's fine. But there are those maybe who are genetically predisposed or there's something else that's triggering that actually changing their nutrition,

cutting back on processed foods, just drinking water rather than all the other fizzy drinks, whether they're zero calorie or not, can really make a difference to skin, can't it? In many ways, absolutely. And there are people who come to my clinic who will absolutely categorically say, every time my diet changes and my diet deteriorates, I have more of usually ultra-processed foods, my acne flares.

Now, it's a number of people who, as you quite rightly say, look, omitting those foods doesn't cure their acne, but introducing those foods does appear to aggravate their acne. and we know that there is data for foods that have a high glycine will get. So those foods that are either sugary or have very simple carbohydrates that get broken down into sugars like pizzas, like white bread and biscuits and other highly processed items. Those cause spikes in our blood glucose level, which can cause spikes in insulin, and insulin-like growth factor has been associated with aggravating acne. So there is a proposed dietary mechanism out there and there are definitely individuals who will report, you know what, every time I have a pizza, the next day, or pizza with a lot of cheese, the next day, my skin flares, you know, and they've tested it. So they've done, you know, food diaries and they've said to me,

look, every time I do this, I can see that there's a surge in my skin. So it's really important for us to not neglect that because in our conventional medical school teaching, diet, is not really emphasized as a cause for anything, yet we know it really is an important cause for so many things. Yeah. And so when we talk about acne, it's often about the face, but people can get it on their back and shoulders and sometimes that can be worse, can't it? Yeah, no, absolutely. So the face is very much the visible area, but acne can affect the chest, the shoulders, the back, sometimes the whole back and even the buttock area. And about one or two percent of people only get acne outside their face.

Sometimes acne on the body can be quite lumpy, quite inflamed and quite painful. And you often find that acne on the body can have a higher chance of scarring, especially with lumpy scars or keloid scars. And many people are quite embarrassed about things on their body, both in terms of coming forwards to their doctor to seek help, and also in terms of, you know, discussing with friends and family and relatives and partners as well. So once people, often people can diagnose it themselves, of course, by either them looking or maybe, you know, my children, I've examined my children or whatever. So what are the main treatments? What do you do? If someone came to see you, obviously you assess how it's affecting them, both psychologically and physically.

but what are the treatments? Because if you googled acne treatments, oh my goodness, my shopping basket would be full in many seconds. Yeah. Isn't that true for virtually every skin condition now? Indeed. So I think, you know, there are guidelines for acne care that are approved by the British Association of Dermatologists

and Nice, the National Institute for Clinical Excellence. So in a medical context, we would be seeking to follow those guidelines. And they certainly have utility because that means that a primary care doctor has a structure in terms of how to treat acne. And, you know, in a nutshell, we can treat acne with creams, tablets, now lasers, and a medication called isotretanone. So I would say that's our ladder for acne. So if somebody's got mild or moderate acne, they've never had a treatment before,

and it's their first sort of chance for treatment, then we'd probably start a topical treatment. And topical means it's something that we apply by cream on the skin. And the two most strong treatments, or the two most powerful treatments for acne, or ingredients, I should say, are a topical retinoid and benzoyle peroxide. The third ingredient that's worth considering is something called azaleic acid. So really, those three ingredients, or one of those three ingredients, would form part of a skincare routine. Now, what is really important is not to make a skincare routine overly complex. And we know that children are now being targeted on TikTok and Instagram by beauty influencers

and other sponsored influencers into buying heaps and heaps of skin care for potentially no skin problem or early acne. And we know that if we start putting too many products on our skin, we can actually irritate the skin, we can irritate the skin barrier and potentially even aggravate acne without actually treating it in the first place. Yeah, having three, well, two teenagers, one's only just stopped being a teenager. But actually, of the last few years, it's got worse and worse.

My 13-year-old, as you know, because I'm so bad, but I got you to talk to her because she wasn't listening to me. And suddenly there was this explosion of products in her bathroom. And I know that she's been, and her friends are exactly the same. She's not unique, and we've read a lot about it. in the papers. But it's deeply worrying, actually, because the skin is still so young, isn't it?

And they're stripping of all their natural oils as well, plus they can be quite inflammatory, plus they're really expensive. Yeah, all those reasons. Yeah. We don't really know how those ingredients all interact as well. So when I give a skincare regime, I choose one hero ingredient.

That's the ingredient that I think is going to have a biological or pharmacological effect. And in this situation, it's either going to be a topical retinoid. That means it's derived from vitamin A, benzoproxide, or azalec acid. And then any skincare that's additional to that is really supportive. It's designed to support the skin barrier and allow the skin to tolerate that active ingredient because we know all treatments for acne can be irritant. Acne is also inflammatory and causes a lot of discomfort and irritation on the skin. So we've really got to treat the skin really calmly and gently with light moisturisers

and very gentle non-foaming cleansers while we build these hero ingredients and we give them time because acne treatments take several months. And one of the things with social media is, is this immediacy of getting the product and immediacy of seeing an outcome and then changing to a new product if you haven't seen an outcome in one or two weeks. And what I see all the time now is people product hopping over a period of weeks and saying, look, I gave that three weeks and it didn't work. So I bought another £400 worth of skincare and another £1,000 worth of skincare and another,

another £400 of skincare. And so when I try and give skincare, those patients will say to me, look, I've tried everything under the sun. And it's not what you use necessarily. It's how you use it as well. We really need to take a considered approach and understand the ingredients that we're using.

We need to understand the skin. And we really need to work with all that to try and get good results. Yeah, that's so important. isn't it? Because being persistent and consistent is really crucial. And looking at, I think also when you've had changes to your skin, people think it's something that you used yesterday.

And it might be if there's an allergic reaction. But actually, sometimes it can be like a buildup of something that's not right. And so it's not necessarily just eating one wrong thing. It can be, you know, looking back in time. And actually, I know we're not talking about hair, but hair as well, people think, And actually I've seen people that say I've started HRT and next week my hair fell out and it's got to be related. No, no, let's look back three to six months ago and see what happened.

But again, with the skin, and you write really well in my book about it as well about keeping skincare really simple. And actually it's about almost what we don't use on our skin rather than what we do use, I think is important, isn't it? Oh, absolutely. And I'll give you one example, which is that many, individuals with acne and severe inflammation will react to many sunscreens. Yeah. And will come to me and say, look, every time I use a sunscreen, either my acne flares, I'm just so uncomfortable. And look, if we've tried multiple sunscreens, you know, sometimes it's really good and

it's better for the skin to just have a break from all these chemicals. And as you know, I treat a lot of skin cancer, so I don't take sun protection very lightly. But in this instance, it's better to omit products that are aggravating your skin and have essential to aggravate your skin and rely on things like wearing a hat and staying in the shade. When it comes to skincare for acne, we really need to use gentle ingredients, non-firming cleansers, light moisturisers, so that we can build up topical active ingredients that can actually have a chance in improving the skin. Yeah.

And then it's all very well doing that, but you know and I know that's not going to help everybody with acne. So there are different systemic as in putting the body treatments and different on the skin treatments that are more specialist. So can you just talk through those? Yeah, so absolutely right. So the next step conventionally would be to receive a course of oral antibiotics alongside your topical treatments. Now, this is possibly where I feel the goal. guidelines may not do necessarily a service to our patients because I'm not in favor of prescribing out loads and loads of antibiotics. And there are some issues with antibiotics.

They can work really well, but they only work while you're on them. So it's not a long-term treatment. We can use them for three to six months. But really, we don't want people on long-term antibiotics for longer than that. Now, if you consider that acne is the eighth most common condition globally of all medical conditions. Eighth. Eighth. Okay. And I don't mean just out of skin conditions, I mean of all medical conditions. And at any one time, we have 9% of the population that have got some form of acne on their skin, both adults and teenagers. And we need to talk about the fact that acne is getting more and more common in adults as well, right? Now, do we want our population on antibiotics which can cause side effects? We know that it can change

the microbiome, it can potentially upset the tummy, it can cause thrush, and this issue that we can rebound. And of course, antibiotics can have their own side effects as well, for example, some cause sun-induced rashes. However, in the guidelines, the next step would be to receive a course of antibiotics. Now, the step beyond that can be in women potentially hormonal. So if somebody's got very hormonal-driven acne and they get flares just before or during their periods in a very predictable way, then the oral contraceptive pill may help. But again, we know that that can also have side effects. And, you know, what we're doing there is we're flooding the body with estrogen and synthetic progesterone.

Now, ironically, some synthetic progesterones can aggravate acin. So it is not uncommon in my practice, Louise, to be seeing ladies who have started progesterone-only pills or even the progesterone coil and will actually get a significant aggravation of their skin. Yeah, and it's interesting. So in the clinic, we do. We see people who are on the wrong hormones for them, often when they're not body identical hormones,

as you know, the synthetic hormones can have an effect. Or it might be that their acne has flared up without any hormones, but they've become hormonal, so they've become perimenopausal. And often, as you've said before, if they've travelled with acne when they were teenagers with hormonal changes, then it can come back and haunt them, really. And so it's really important when we think about hormonal treatment as an adjuvant treatment, really, for acne,

when people say, oh, no, I can't have hormones because I've tried XYZ. And if they're synthetic hormones, actually sometimes, and I know you've seen it as well, if people are perimenopausal, when we give them the right dose and type of body identical hormones, in addition with other acne treatments that they might, or might not need, that can be really beneficial as well for their skin, can't it? Absolutely.

It can be a game changer and it is often the synthetic progesterones. Yes. That are culpable in this situation. And I think there is a lot of anxiety among women who are on the pill and want to come off it because they really do worry that their skin's just going to flare. We do have to manage that transition really well. and move on to body identical hormones if they're perimenopause. And it's really interesting that a large survey of women in the perimenopause and menopause

showed that about 10% of them suffered from acne. So that's, you know, one in ten is quite significant, isn't it? Yeah. Yeah. And if we look at women in their 20s and 30s, we think about 30 to 40% of women in that age band probably suffer from acne. and a number of those might have other hormonal issues such as something called polycystic ovarian syndrome, where potentially women might be either suffering from slightly higher

level of androgens or be sensitive to their own levels of androgens. Yeah, so really important. So we're thinking about maybe, maybe not antibiotics if they help, but need to think about that, thinking about hormones, then you mentioned before about roacutane. Yeah. Well, before we talk about rachetane, just while we're talking about hormones, there is another treatment called spironolactone, which effectively blocks the effect of testosterone and androgens on the skin and can help hormonal acne. It's not licensed in the UK, but it is something

that we use quite a lot where we are trying to get the hormonal component of acne in women under control. And the other main medication is something called isotretinoin and the brand name. The famous brand name for that is Roacutane. And it's the strongest treatment that there is available for acne. It's given as a five to seven month course. And it is very effective. It certainly can help reduce acne by 90%, but it can have a number of side effects. And potentially it dries the skin, it dries the lips, it can give aches and pains, it can increase the cholesterol and triglyceride levels in the blood, it can strain the liver, it damages a baby, so one can get pregnant on that, and potentially it has been associated with low mood and self-harm and even

suicide. So when somebody might have any issues with their mental health, it's something that might not necessarily be the best treatment to be prescribed. No, and it's certainly a treatment that has to be done by an experienced dermatologist. I don't think it should just be a dermatologist. I think certainly an experienced dermatologist having blood tests regularly, being really, you know, being checked in, sometimes using a psychologist as well. But it can be very useful. It absolutely can help with some people.

But some people still have problems or they might have scarring or they might have acne. So we might be, you know, people might be listening here who've had acne before and then had acne scars. So they don't need any of these treatments. But what else can they do? One of the latest advances in treating acne, and I think actually this is probably the most significant advance that there's been in the last 25 years in acne care is the development of targeted lasers for active acne. So one laser is called aviclear. and what this laser does, it actually emits light that heats and damages the sebaceous glands. So roacetateinermin medically shrinks the sebaceous glands and dries the skin.

But this is a non-drug way of actually targeting the sebaceous glands and shrinking them. And the benefit with this laser treatment is that it's only three treatments. So it's once a month for three treatments. and the benefits of acne reduction can last at least two years. So finally, we've got something that's one drug related and actually has a long-term benefit. So it's not something that somebody needs to keep coming into the clinic for, for example, like with chemical peels or with other lasers

where they work really well. But again, the rate at which the acne comes back can be quite high. But presumably that's not available on the NHS yet. It's not available on the NHS yet, and it's just become available in the UK in the last three or four months, and it's something that we're offering at my clinic. And the hope is that as we get more and more experience with this, that this will be something that will be available earlier and earlier and earlier on in people's journeys, because ultimately, wouldn't it be nice that we would be able to treat acne for the long term? And we wouldn't need to use medications such as antibiotics for these long term periods,

or potentially medicines that might have other side effects like isotretinoin. So I do think that the direction of travel now is to look at other ways of treating acne, treating it early and for the long term. I think it could be transformation. I'm really keen to sort of have you back and talk about, you know, more experience in time to come as you and others uses acne, having had two children who have used her acutane. One did, as you know, very well,

but she had very, very dry skin. And the other one, I had the most dreadful psychological reaction to it. It was really scary to witness, actually. And you were amazing helping her. So she had to stop, but she absolutely couldn't continue. I'm a third daughter who, you know, it's genetic, as you've said, that she's going to head into some sort of treatment. And I'm really scared of her starting, rare cutane,

seeing what happened to my oldest daughter. So having an option that isn't systemic, when it is, we've already said it is sort of a systemic condition, but also it's so much more on the skin than some other conditions, that looking at anything that we can give on top, and then also addressing nutrition, good skin care as well, you know, everything together is actually, but to avoid any potentially toxic systemic medication,

I think is going to be a game changer for acne, isn't it? Oh, definitely. And I think the future, is going to be increasingly bright as more and more technologies come about and we can start offering these things on a day-to-day basis. Yeah, and it's really important. And I think just before we finish,

just to mention there are lasers and there are lasers and there are all sorts of lasers that are available now. And I know you've got quite a few different lasers we've talked in the past about treatments for things like rosacea or malasma. it's really important before anyone actually has any laser treatment to make sure that they are talking to someone who does understand the difference and I know some lasers are used cosmetically, but they're all different machines, aren't they, in different techniques?

And that's really important that we understand that. Yeah, no, you're absolutely right. And I think the landscape is really confusing because the same lasers may well be used for aesthetic indications and those who might be using it for aesthetic indications, try and translate those protocols for acne indications. And acne is actually a completely different ballgame altogether. And it's really, really important, A, to get the acne under really good control

and keep it under good control and then start concurrently managing the impact of acne that it might have had on the skin, whether it's red marks and blemishes, which can be treated with vascular lasers, pigmentation, which can sometimes last years, in fact, following acne, which can be treated with creams and pigment-specific lasers, and then scars, which can be treated with resurfacing lasers. So great advice, as for usual.

I could keep talking, but in the interest of time, we will bring it to a close and I have to invite you back in because there's so much to talk about with skin. And there really is. And, you know, the more we see skin changes, the more we hear about skin changes. We know is so important not just doing perimenopause and menopause, but with women with PMS, PMDD, postpartum after having a baby, all stages of life. And men too, actually, having a husband who has kindly given his acne gene to our three children.

He's still struggling now. So really great to have your knowledge and experience shared with us on the podcast. So before I end, three take-home tips. So three things, and I'm going to put it not just for the people who might be having acne. So if your mother and your daughter is having problems with her skin, what three things would you say we should be doing for ourselves or our children or someone we know to try and get the right treatment? Right. Well, the first thing would be to keep skincare simple and targeted.

Yeah. I mentioned those three active ingredients, retinoids, benzoproxide or azalec acid. Pick one of those and work with it, give it three to six months, and have a very simple supporting skincare regime. The second would be to assess the impact of the acne. If the acne is leaving persistent blemishes, pigmentation or scars, then escorts. the treatment. If the first line treatment hasn't worked, then give it three months and see a medical professional and try and address that and try and get that acne under control because

prevention of scars is so much easier than trying to reverse them and cure them. And the third would be to be mindful about all the different risk factors and triggers that we talked about and do not underestimate the impact of diet and stress and where we can treat acne holistically, we should. And I think we should address those factors as much as we can as well. Very important. So we have got information on free balance app and on our website and obviously, as I've already said in my book as well,

and sadly as a mindful of knowledge and always sharing things on his Instagram, which we'll share links to as well. So thank you so much again for giving you. up time I'd hasten to try it on a Sunday to record this. So thanks again. Pleasure, Louise. Thanks for the invite. You can find out more about Newsome Health Group by visiting www.newsonhealth.com.uk. And you can download the free balance app on the App Store or Google Play.