Of Fitness, Friction, Fillers, and Fat: Pearls for Managing Active Patients

As dermatologists, we increasingly field questions about diet relative to acne or skin aging, heart health and psoriasis, and, in the age of body contouring devices, physical fitness and weight management. We don’t necessarily have all the answers, but we know from both years of data and ongoing study that physical activity has positive impacts on patients’ cardiovascular health and reduces risks for heart disease.¹ Specific to the field of dermatology, recent research has revealed a significant association between low cardiorespiratory fitness at an early age and incident psoriasis and psoriatic arthritis in later life.²

We can and should advise our patients to exercise in order to improve their overall health and to provide both direct and indirect benefits for their cutaneous health. Paradoxically, however, we must also recognize that physical activity can lead to some unintended negative effects on the skin. Thankfully, we can be prepared to offer effective interventions to minimize any long-term negative impact that an active lifestyle can have on the skin.

Fitness, Friction, and PIH

Anyone who has run, participated in a strength training routine, or had to wear sports gear like pads, chin straps, etc. knows the potential consequences of friction: blisters, callouses, and in some cases post-inflammatory hyperpigmentation (PIH). PIH can be particularly worrisome, since it can be persistent and may occur in highly visible areas of the body.

Those who spend time exercising outdoors also face the potential for irksome bug bites that, if scratched or otherwise inflamed, can lead to PIH. Additionally, shaving can lead to PIH whether or not the patient develops shaving folliculitis.

The best approach to PIH is to minimize its occurrence in the first place. Often shoes, shin guards, shoulder pads, and chin straps simply need adjustments to improve the fit and reduce friction. Certain protective pads can be used to reduce friction and inserts in the shoes can reduce slipping and rubbing. When possible, breathable and stretchable materials are preferred over rigid or non-breathable materials for straps and bindings.

The effects of clothing on the skin and the risk for PIH cannot be overlooked. Women in general may complain of “bra-burn” developing on the shoulders and back from the daily friction of bra straps. Sports bras, which are intended to be tight fitting, can also be a source of bra burn. Similarly, leotards, swim apparel, and singlets can be very tight-fitting; a too-tight fit may lead to excess friction. A proper fit is key, and individuals may need to visit a specialty store for help in fitting their exercise clothing.

Once friction is minimized or eliminated, the focus can shift to treating PIH. Sunscreen is a must for all patients and is especially important for those prone to dyspigmentation. Daily use and reapplication of sunblock with SPF 30 or higher is fundamental.

In the case of bug bites, it is important to discourage scratching or picking. Holding ice on a fresh or already inflamed bug, ant, or bee sting can reduce inflammation significantly. A topical corticosteroid used in the acute phase can help to reduce inflammation and associated itch. Other remedies to consider include topical aloe vera gel and manuka honey. Patients very prone to bite-associated PIH may benefit from a prescription anti-inflammatory to be used as needed on particularly inflamed areas. I prescribe topical tacrolimus for many of my patients for this use.

For other forms of PIH discussed above, I recommend topical agents along with in-office procedures. Topically, I recommend the Obagi-C Rx System, which features Vitamin C and prescription-strength hydroquinone 4% in a kit that supports clearance of PIH and helps prevent its recurrence. I also commonly recommend Cyspera (cysteamine, Scientis), which is a naturally occurring, biological compound that has been shown to be an effective, non-toxic pigment corrector.

In the office, I find that chemical peels (I recommend the VI Peel from Vitality Aesthetics) and fractional ablative treatment (I use Fraxel laser and/or Lutronic LASEMD) can speed the resolution of PIH. Importantly, care must be taken to administer treatments safely and appropriately, as patients prone to dyspigmentation can experience worsening of the condition from aggressive treatments.

Patients who develop shaving-associated PIH may find the use of lubricating shave gels and sharp razors reduces inflammation. Aveeno shave gel is one of the thickest, richest shave gels on the market. I recommend shaving with either a single or a double edge razor, nothing more. Patients should never use toners. They just dry out the skin and can lead to more PIH.

Those prone to folliculitis may benefit from the daily use of topical azelaic acid, dapsone, antimicrobials like benzoyl peroxide, and/or retinoids. Alternatively, energy-based devices may be used to permanently reduce unwanted hair and obviate the need to shave.

Keep an eye out for distinctive patterns of PIH and be prepared to do some sleuthing. Patients may not realize that clothing or equipment is causing inflammation and creating PIH, so they may neglect to share relevant information.

Fat Loss and Fillers

Excessive facial volume depletion is not always associated with a high level of physical activity, but it is not uncommon to see extreme volume depletion in distance runners and others with high levels of activity and low body fat indices. For many of these patients, most traditional hyaluronic acid-based fillers alone will either provide insufficient benefit or would require such a volume of filler as to make them not cost-effective. Therefore, I generally use a combination of poly-L-lactic acid (Sculptra, Galderma) and hyaluronic acid-based filler with Vycross technology (Juvederm Voluma XC, Allergan) for optimal improvement. I tell my patients that after age 30 we lose, on average, one teaspoon of volume per year from our face. One teaspoon equals 4.9 syringes of filler! Juvederm Voluma XC offers a rapid improvement for immediate improvement in terms of facial volume.

Encourage Fitness: Be a Resource

As experts in the skin, nails, and hair, dermatologists may play an important role in reducing barriers to physical fitness in African American women. A recent survey by McMichael, et al revealed that 80 percent of African American women had less than 150 minutes of exercise per week (Skin Appendage Disord. 2020 Jun;6(3):147-150). And more than a third indicated that they modified their hairstyle to accommodate exercise. These findings are concerning, as data indicate that African American women are disproportionately affected by obesity. The HHS Office of Minority Health reports that four out of five African American women are overweight or obese and are 60 percent more likely to have high blood pressure compared to non-Hispanic white women. Strokes in young women are more likely among black women (BMC Womens Health. 2021 Apr 17;21(1):160). The HHS also says that non-Hispanic blacks are twice as likely as non-Hispanic whites to die from diabetes.

Dermatologists can help. The McMichael survey found that African American women were largely pleased with their hair before exercise and displeased after. We have the tools and knowledge to help patients manage their hair concerns as they pursue fitness.

I tell patients they should work out four to five times per week. And I tell them there are ways to do it so that they don’t sweat out their hairstyle or their blow out. It’s not a question of achieving a desired hairstyle or being physically active. Patients can do both, and we must be prepared to help them!

As a collagen stimulating injectable, Sculptra takes several months to achieve significant improvement in facial volume. I also use it in the upper arms to decrease crepiness, as well as above the knees.

I explain to patients that because of their body physiology, they can expect to need more frequent injection with filler than most other patients require. To enhance and protect the effects of injectables, I advise all patients to use and reapply sunblock SPF 30 or higher every day. I also recommend that they use SkinMedica TNS Advanced Plus and Obagi Elastiderm topically to support collagen and promote healthy skin.

The single most important thing patients can do to prolong injectable treatment benefits is to avoid smoking. This means no vaping and no smoking tobacco or marijuana. Do not assume that a “fitness nut” won’t smoke; tell all patients to avoid smoking. Advise patients to avoid tanning, emphasize the need to reapply sunblock frequently, and advise them to sleep on their back all the time.

In my practice, I have discovered a treatment pearl that appeals to many women who are active. Ballet dancers, runners, gymnasts, and women who love high heels all like a little filler placed in the ball of their foot. The initial injection causes significant but temporary discomfort; provide treatment when the patient can rest for two days after. It is well worth it, as the results last for a minimum of two years.

It is also worth noting that many of my patients with mild to moderate arthritis feel their pain is decreased after receiving Voluma injections in the hands. When they lift weights, jump rope, or use their hands for yoga poses, they feel strongly that the constant discomfort of their arthritis is minimized.

A Perfect Fit

Being physically fit is a key aspect of human health, including cutaneous health. Yet, getting and remaining fit can come with some risks to the skin, hair, and nails. Dermatologists who are attentive to the needs of active patients can help them to overcome some of the more visible effects of exercise so that they can look as good as they feel.

1. Kosendiak A, Felińczak A, Szymańska-Chabowska A. The role of physical training in the prevention of cardiovascular disease in a population of healthy people. J Sports Med Phys Fitness. 2021 Jun;61(6):844-850.

2. Laskowski M, Schiöler L, Gustafsson H, Wennberg AM, Åberg M, Torén K. Cardiorespiratory fitness in late adolescence and long-term risk of psoriasis and psoriatic arthritis among Swedish men. PLoS One. 2021 Jan 11;16(1):e0243348.