The Dr Louise Newson Podcast - 268 - Skin, hair and nail changes in menopause: a dermatologist’s guide

Episode Date: August 6, 2024

This week, Dr Louise is joined by Dr Claudia DeGiovanni, a consultant dermatologist with a keen interest in the menopause. Dr Claudia has published a four-part review on the effect of menopause on skin and hair and has carried out research into the effect of menopausal skin issues on quality of life. Here she talks about the prevalence of skin issues in menopause and their causes, the significance of oestrogen and what to look out for in products and what to avoid. Finally, she shares three tips for menopausal skin: If you have got significant skin problems, if it's affecting your quality of life, seek help, see your GP, see a dermatologist, get a diagnosis and find some accurate treatments because we will take you seriously. Look at your skincare routine and be aware of how your skin is changing. It’s likely to become more sensitive so avoid harsh exfoliants or anything that strips the skin of moisture, and include a good quality SPF into your regime. When choosing products it’s more important to look at the ingredients list, and choose quality ingredients such as ceramides and hyaluronic acid, than buying those labelled for menopause. You can follow Dr Claudia on Instagram @dr.degiovanni_dermatology and read her paper on menopause and skin disorders here. 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. Order your copy by clicking here. Click here for more about Newson Health.

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom 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, 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 today on the podcast, by popular demand, I'm going to be talking with a consultant dermatologist

about skin, hair and nails. So I've got with me in front of me, Claudia DiGivani, who is a consultant, dermatologist in Brighton. And she also, by coincidence, knows Dr. Saj Rajpah, the dermatologist who has been on this podcast before and written some articles with us. And also Dr. Sarah Glynn, who is an academic with us, who's also a menopause specialist, who's also been on my podcast and written with us. So life is connections and I love it when people can, we can join the dots. And so Claudia wrote a great paper recently about skin changes during

menopause but also perimenopause. So I'm going to have her here to quiz her and get as much information as possible to share. So thanks Claudia for coming today. Oh, you're welcome. It's pleasure to be here. Thank you. So it's really interesting because some people, even people who are doing a lot of menopause work, say, oh, people just take HRT because they want nice skin. And I have a bit of an issue with that for two reasons. Firstly, is that that's not correct. People take it for lots of reasons. But the other thing is it's quite disparaging about skin because I think people think skin is just like something that protects our internal organs. But when I say to people, actually, it's a really important organ that's biologically active. And if our skin is healthy,

then our internal organs are more likely to be healthy. I presume you agree with that. Absolutely. So the skin is the largest organ in the body. It's incredibly important and it's really sad that it is so dismissed. When you have symptomatic skin, it has a massive impact on your quality of life. And it influences everything from your day-to-day interactions with people, your self-esteem, your confidence. So it's really important that we take management of skin seriously in all walks of life, you know, but also importantly through the menopause. To actually emphasise that fact, I've done some work recently, which we haven't yet published, but it links in nicely to this, which is asking women going through the menopause

about skin symptoms, but also importantly, I've asked them to do the DLQI score. This is your Dermatology Quality of Life School to mark how much your skin symptoms are impacting your life. And it's coming out at about six out of 30, which indicates a moderate impact on your quality of life. And this was a wide range of women. Some of them had DLQI. scores up to 17, 18, which is a severe impact on quality of life. So it's significant. Yeah. And it doesn't surprise me at all. But the other thing about skin, I think there's so much more now, even than when I qualified many years ago, about skin and cosmetic. So people do various things to their faces or bodies to improve or to try and reduce their aid or whatever.

And then you forget that actually a lot of skin changes is because there's things happening within. And a good dermatologist has excellent general medicine training. It's not like seeing a cosmetic person who isn't medically trained, who's only going to look at the odd wrinkle or something very cosmetic. Dermatologists do have medical training. And I think sometimes even people in the public forget that, because if you scroll on Instagram, you just think it's all about Botox and fillers, which I'm sure frustrates you as much as it does me because when you see a dermatologist,

they're not just going to look at your skin, they're going to ask lots of questions about what else because there's many diseases that we can diagnose from the skin as well, aren't there? It's really fascinating. I mean, I love it, obviously. It's my passion. But you're right, it's hard to get to become a consultant dermatologist. It's years and years of training. We do all of our medical specialty exams. And then, you know, it's one of the most competitive areas of medicine to get into. And unfortunately, you do get a bit of a skewed view on social media because obviously a lot of cosmetic practices are advertising. It is an advertising platform. And sometimes we do forget that when we're on social media because we are all a bit new to it. But absolutely,

it's important that dermatologists will assess your skin properly, thoroughly, all aspects of it. And it's important to also understand that when you go through the menopause, your skin becomes more sensitive. We know that loss of estrogen has an impact on a technical level. It impairs the skin barrier so that your skin can't protect yourself as much as it used to. So a lot of cases, women are finding that they can't tolerate products that they used to. Their skin is suddenly more sensitive than they were aware of. And when you're in that situation, and particularly if you've got skin condition, it's really important that you see a specialist who can take that into account as well.

And like you said, won't just look at the wrinkles or, you know, just look at you from a cosmetic point of view, but we'll take all of you holistically and have a more holistic view and approach to your skincare. Yeah, and it's something that I hadn't realized. I don't know how much menopause training you had as an undergraduate or postgraduate, but it was probably similar amount to me, which was vanishingly small. But it's only because I see more people and I, this pattern recognition in medicine, but we also did a survey of nearly 6,000 women before the launch of my book, the definitive guide, and we found that it was quite staggering, but not surprising, that 64%, so nearly two-thirds of women who answered, had experienced dry skin, and 56% had itchy

skin, and that's a lot. That is, you know, a significant number, and I shudder to think about how many emolients I prescribed to women when I was a GP and didn't think beyond their dry, itchy skin. So I presume those stats don't surprise you. No, so that actually reflects quite nicely the data that I've collected as well. I am hoping to develop another research study looking again in more detail about those sort of skin symptoms women are getting. The other thing that I've found from speaking to women is we found that about two-thirds of women are trying to manage skin symptoms without seeking help or advice from a healthcare

professional. And often they are getting advice from friends, from colleagues, they're trialling loads of different things on their skin. Some of them are too harsh and the combination, for example, of lots of exfoliants and cleansers and retinoids, the combination of that on dry, irritated, sensitive skin can be really very damaging and ultimately make things worse. you know, so absolutely. And again, I agree, I probably was a bit, I don't think I understood when I started my training how important the skin can be in the menopause. And I think also people are a little bit concerned about asking. There's a bit of a worry about raising the menopause in case you offend women. Actually, I found in my experience now, people don't mind at all. You know, if you ask them how you're having any changes, if they are having changes, they go, well, yes, I hadn't really noticed this might be associated. with the skin, but even if they aren't having changes yet, they're still grateful because they know what to look out for and that it might be an issue for them. Absolutely. It's really important. I remember just before I left general practice, there was a patient I've known for many years,

really lovely lady and she was 54 when I last saw her and her skin had become really inflamed and she had a history of eczema that flared actually in her teenage years and then she'd been fine and it got really worse and she'd tried all sorts of treatments. And I said to her, sorry to ask, And hear me out, but I just want to ask you a question which you might not think is related, but when did your period stop? She was like, Dr. Newsom, I don't understand why you're asking me. And she'd actually just, she was fortunate in that she'd only just stopped her periods aged like 53. So when did your skin get a lot worse?

And then she said, and she went out actually with some HRT, nothing for her skin. And then came back and really thanked me. And we had a bit of a laugh, actually, that how unusual. because then it was, this was like nine years ago, so people really not talking about menopause at all then. But actually then I think it's a lot easier when you understand what's going on. So you've already said that the barrier of the skin isn't as good, but also people might or might not realize that our skin is fed by our blood vessels.

We've got a massive supply, haven't we, of blood vessels that get smaller and smaller and smaller as they feed the skin and get to the surface. And our blood provides nutrients to the skin. but also importantly takes away any toxins or anything that our cells build up any waste products, if you like. But what we do know is that their blood supply to any organ is not as good as inflammation that occurs. The endothelium, the lining of blood vessels gets inflamed. And so this network of blood supply is not as good.

We also know that the collagen, the building sort of protein, becomes reduced as well. So there's lots of reasons why skin texture. type changes, even people often, if they cut themselves, they say it takes longer to heal, don't they? Yeah, it's very well recognised. And your collagen, you lose about a third of your collagen in that perimenopause period and then it slowly declines a little bit more following that as well. That's a lot, a third, isn't it? It's a lot. Yes. And you can understand then why people are noticing that their skin is changing so dramatically during that perimenopause stage. There is some evidence that estrogen can improve the collagen a little bit. Clearly it is not

licensed for that and I wouldn't recommend it for that at all. But it's just helpful to know that that is a normal, natural thing that happens during the menopausal period. Yes. And quite a few people actually through social media often contact me and say, oh, I've just been, there's an advert because of the algorithms that come up on social media for a collagen supplement. And I'm not aware of any good quality, data, but it feels a bit weird that you can take something orally that will suddenly build your collagen. So I think the problem with collagen supplements is that they are made of the building blocks of amino acids, which are in proteins. And for them to be absorbed through the gut, they have to be really small blocks of tissue. So most of the collagen would have to either

be broken down, or you would have to have really tiny, tiny, tiny, tiny fragments of collagen to be absorbed. And I struggle to see medicine. and scientifically how that would then translate to thicker collagen in the skin. I think obviously if you've got a diet which may be slightly deficient, then that might be a slightly different picture. But I haven't seen convincing evidence that collagen supplements orally are that beneficial. No, no. It's always difficult.

I mean, lack of evidence doesn't mean they're not good, but it's looking at why they might work. And I think that's where it's an interesting perspective. And it's the same with using topical treatments to help reduce itchy skin or dry skin. There are lots of things that will work. There are some things that won't work. And there are some things that are marketed more for menopausal dry skin. But actually, they'll help any dry skin as well. So you have to be very careful what's in it.

And sometimes when you strip back the ingredients, they can sometimes cause more irritation as well, can't they? Yeah. And I have to say, I'm a little bit disappointed, I think, I would say. about the amount of products that have been flooded on the market because they've got the word menopause on them. And unfortunately, it is a situation where in some cases there are quite basic ingredients in them, but the price tag is slightly higher because they've got menopause on the front

of the packaging. So I'm afraid it does involve a little bit of research looking into the kind of products which are beneficial and good and moisturising for the skin. and you do have to look at the back of the packet and see exactly what's going on. That ingredient list is far more important than necessarily the advertising on the front. And you were quite right that actually products that are good for Exma skin, you know, can equally be good for menopausal skin. It doesn't have to have menopause on it for it to be good for your skin.

No, and just for complete transparency, I don't do any paid work with any of these products. And I know you don't either. and I often get asked to be a face or a name behind them. And I've not seen any scientific evidence to show that they're more beneficial on menopausal skin than, you know, my husband's skin, for example. They might help both of our skin. But also, we need to be thinking of our skin of what it is. You've already said it's an organ. It's the biggest organ in our body.

So slapping some cream on is not always going to help if there's an internal reason for it. A lot of people also find that their skin. flares. So acne can be very common. Often, rosacea can be more common. Even psoriasis can be more common as well, can't it during the perimenopause, especially actually more than the menopause. And again, with all of those, it's not just what's happening in the skin. We're now then moving down into that systemic elements. So we know that the hormones you have premenopause, estrogen and progesterone, reduce inflammation a little bit. So, in that peri and postmenopausal period, actually there are more inflammatory cytokines going around the

body and that can increase inflammatory skin conditions. So things like psoriasis may well flare because of the reduction in skin barrier, eczema might flare. Acne is multifactorial. We think it's hormonal, possibly inflammation, possibly a bit of the skin barrier that's involved there as well. And rosacea can be affected by flushes and hot flushing and obviously the sensitivity of the skin. For me now, if I'm seeing women with these sorts of issues, I always ask about menopausal symptoms and I do raise it. And again, that's part of the reason why I want to get involved in this podcast and I want to circulate that information both to patients but also to healthcare professionals so that if they're seeing a woman with a skin condition at this part in their life, they are also thinking,

could this also be related to the menopause and not just treating that skin in isolation necessarily? Yeah, it's so important. So we've got estrogen progesterone, but actually testosterone can be very beneficial for the skin as well. Very limited research, but certainly anecdotally seeing thousands of women over the last 10 years and giving testosterone, people find that their texture of their skin actually improves.

A lot of people think that they're going to grow beers and have acne, but actually they don't But also testosterone can, for some women or many women, actually, improve hair growth and hair quality as well, which always people think if they take testosterone, they're going to lose hair and be bald. But it's about the right dose for the right person often. Yeah, I think that's right. So hair issues are also a big issue for women going through the menopause. Part of that is estrogen problems. So we see how sensitive hair is when we go through pregnancy, you know, when estrogen levels are high, hair becomes thicker, and then in the post-pregnancy period, you end up with a phase where the hair sheds, and that's because of the

drop in estrogen levels. Similar sort of picture happens in the menopause, whereas estrogen levels drop, you do end up with more hair thinning and shedding, which can be further upsetting for women. You know, often it's not to a degree that other people would necessarily notice, but as a women, you yourself do notice it. You can also get hormonally related issues with your hair. So there's a condition called female pattern hair loss, and that is hormonally active. And I think for women like that, testosterone may not be that helpful because it is a reaction to those androgenic hormones. And we do find that sometimes medication that act against androgenic hormones seems to help in those conditions. So I think the key thing is, if you do have hair thinning or hair loss, do see somebody, do go and get an expert opinion because you need to know exactly what the cause of it is because the treatment might be slightly different.

And it's crucially important because I see some women who've literally tried either HRT or testosterone or both. And literally two days later they have some hair thinning and they say it's due to the hormones. And often, as you know, it can take quite a few months, can't it, for her to change. And then they might have seen a trachologist or someone who's making them have some sort of different treatment. But actually, I'm really, I think it's very important to have a proper diagnosis because it can change your treatment and pathway. And you don't want to be blaming something and then find that maybe you've got iron deficiency or maybe there's some inherited condition or something else. Because often with hair changes, you want to get on sooner rather than later as well, it if you need some treatment. Yeah, I completely agree. And, you know, many hair things do improve.

You know, if you've got, say, telogen ophluvium is when you get hair loss related to stress or, you know, if you've got low iron levels or, you know, thorough problems. And they will regrow, the hair will we grow with those. But if, say, you have got a scarring condition, you really do want that diagnosed as early as possible so that you don't end up with that progressing. So, yeah, the key is seek help. if you're worried to get an opinion. And, you know, doctors do want to help. You know, yes, people are busy, but you do matter and you are important and we want you to be better. Yeah, and I think like you were saying, it's sad in your survey showing that so many people are not going to help.

Because I think there is this thing, oh, it's only the skin. It's not my liver or my heart. But actually, it is still a really important organ. And often, if it's due to a systemic condition, you know, or like menopause is a, multi-organ disorder really. If you've got increased inflammation in your skin, you've got increased inflammation throughout your body as well. And that's where looking at the whole person, as dermatologists do with that massive training behind them, is crucially important. And so it can't, the importance can't be ignored. The other thing about skin that I find really interesting

is looking at venous ulcers. So we know that ulcers in legs are a lot more common in older women and when I was a GP we had a district nurse that literally went round most days and her job was to do different dressings for women with these venous ulcers which can really affect them in so many ways and their quality of life but we know that actually they're less common in women who take hormones and I think it's really interesting when we think about the circulation effects of having hormones properly and you know if it really did make sense of such a difference. I mean, Elsa's cost the NHS, you probably know the figures, but it's a heck of a lot of money because of all the dressings and the time, you know, the staff time, the nursing time to go

and do these dressings as well. And it's something that I think a lot of people don't connect the two together. No. They don't. And the other issue is HRT is not licensed for any skin condition. And based on the review articles that I did, I would have to agree with that at the moment, there is not enough good evidence. You need to have that robust evidence to confirm a benefit, but also to weigh up those side effect profile and just demonstrate that it is actually beneficial. And that is where we are seriously lacking in dermatology at the moment. And that's why. But isn't it ridiculous? It's so ridiculous when we know skin problems are so common. And, you know, I don't prescribe HRT for a skin condition, but we know it improves because we see it all the

time because women reporting their skin as well as their other symptoms and they improve. And it's really interesting. There's this bit of work, but not much looking at actually using topical estrogen as well, which is really safe. Like we use vaginal estrogen a lot and it could be transformational, can't it? For dermatitis, I can see a lot of women that have peri-anel dermatitis and flares, even of psoriasis in the perineum, that can really improve with localized hormones. So you wonder people with localised skin problems like ulcers even, is there a role for using topical hormones?

But we don't know the answer, don't. No, we don't. And actually, this is why I'm trying to start developing some provisional background research, because I think before anybody goes to any funders wanting to look into a specific area, there's still a massive gap in the research. We need to see what the actual issue is in menopause. And then we can pick out the top areas to look at in terms of. of the impact of HRT, but it is going to take a while before we're there.

Interesting in terms of topical versus systemic HRT, because with a leg ulcers, for example, it may be that systemic, because it may be tied in with the cardiovascular impact of menopause, which then is a more systemic issue. So, yes, it would be great to do a study, have a look and see whether topical works, but that may be one of those indications where actually systemic HRT might be more beneficial. Yes.

But we don't know at this point, unfortunately. There's a lot we don't know, and we really need to move the agenda forward. So also the other thing, we've talked about skin and hair, but also nails. So whenever I put out any, if people want to ask any questions, it's a lot about nails. And it's interesting, lots of people actually talk about the nail ridges. So they talk about their nails becoming easy to break. They don't grow as well. They're weaker.

But often they have ridges. And in my clinical experience, that can improve. the hormones, but especially testosterone, actually, can make a big difference to those nail ridges. So I just wondered if you can explain why our nails might change with our menopause. Okay, so yeah, nails are very, very sensitive areas of the body, even though you don't necessarily think about it. But the really important bit of your nail is the nail bed, which is the new growth area, and that's the bit where the new nail grows from. And that is what's going to impact on what your nails look like and how they grow. Now, there are lots of elements of the menopause

which would impact on that growing part of your nail. So first of all, things like a poor skin barrier, increased inflammation, poor blood flow, those blood vessels not growing as well, all of that is going to affect your nail bed's ability to create and produce really good quality nail. And when nail growth isn't as good as it used to be, the actual nail growth slows down a little bit. So that's, I think, why you probably get a little bit more ridging of the nails, because the nails are growing more slowly, so they're then a little bit more thicker. And they are then more brittle because they're not as good quality nails as they were before. In terms of what you can do to manage it, I mean, I also have noted anecdotally, again, there's very poor evidence in the literature. But anecdotally, I I've seen that women's nails do grow more healthy with the hormonal treatments. The other things you could do is things like making sure you've got well-moisturised hands, making sure that the skin barrier is very good. And maybe even things like massaging around the nail beds,

just to increase and encourage that blood flow, wearing warm gloves and things as well. So in the colder weather, making sure you're really protecting your hands from the cold weather. Those are sort of more simple conservative measures that you could try and adopt to help. Because it's interesting because I think lots of people think that, well, even our hair, but especially our nails, they're just protection. They're not actually growing, living that need looking after. But also it's not just putting things on.

It's looking within, like you say, even any ways to improve the blood supply, because there's a good blood supply to the nail bed and the nails as well, which often people don't realize. Because by the time we cut them, we don't feel them and you think, oh, there's no sensation, there's no blood. But actually, it's really important, isn't it? And nails can be a marker of changing health as well. Many people, if you get admitted to hospital, one of the first things we do is doctors is look at nails. And often people are like, I've got a heart problem, why are you looking at my nails? But it's a window, isn't it, sometimes into people's health? Yeah, it is.

In medical school, you learn about all the changes to look for. And it is absolutely, for some reason, it is the first thing that we've been taught to look at. But yes, you know, things like iron deficiency can show up in nails with white spots. On a colitis, you can get. lifting of the nails as well. So it is one of the windows into the systemic world. Yeah. And it's natural. At the moment as well, having really good nails is so important on social media. Lots of people have got really good quality nails. So again, if you are feeling that your nails aren't growing in the way that you're used to, then that is also going to impact on your

self-esteem as well. So it's not surprising. There are lots of questions about it. Absolutely. So really important and I'm very grateful for your advice and there's so much more that we need to explore and talk about but I think it's just given people again just more information so they can try and understand why the skin is so important for all of us and changes that can occur during perimenopause and menopause and ways that we can improve them even if we haven't got all the evidence we can still start so before we finish I always ask for three take-home tips so three things that you think would be really easy, cheap, not going to say evidence-based because we don't have evidence for everything, for women who are really played with dry, itchy skin, what are three things

that most of us could just go and do easily? Okay, I think the first thing, and this really has to be important, is that if you have got significant skin problems, if it's affecting your quality of life, seek help, see your GP, see your dermatologist, get a diagnosis and find some accurate treatments because we will take you seriously. We do want you to get better. And it's important you have the right diagnosis and then the right management and treatment for it. I think the second thing that everybody can do is look at your skincare routine and your regime. Your skin is changing. It's becoming more dry. It's becoming more sensitive. Make sure you're not using lots of, you know, harsh exfoliants and different PHAs and BHAs and all things that together are going to end up

stripping the skin of moisture even more. And make sure you're using. You're using. a really good sunblock. We didn't talk about sunblock, but I do recommend that for all my ladies. High UVA, high UVB, and get that into your routine regularly. And then the final thing has to be what I said before about, you know, what's on the back of the packet is far more important than the advertising on the front. Look for good quality ingredients, seramides, hyluronic acids. Those are really good moisturizing ingredients, which are really helpful to look for. Products like vitamin C and retinoids can be helpful, they're more expensive. But yeah, just look at that ingredient list

and just do a bit of research to make sure what you're putting on is right for your skin. Great advice. Thank you so much for your time. I've really enjoyed it. Thanks, Claudia. I've enjoyed it too. Thank you. You can find out more about Newsome Health Group

by visiting www.newsonhealth.com. And you can download the free balance app on the app store or Google Play.