MD. Presented by HotDoc.

Michael:

To start off, can you explain a little bit about yourself and your past, mainly related to dermatology?

Dr Weller:

Okay sure. So I’m Richard Weller. I’m an academic dermatologist in, here in Edinburgh. But before that I trained in general medicine first in Britain and then had a fantastic year in Cairns in Queensland doing internal medicine. Came back to Britain, trained as a dermatologist at the Institute of Dermatology in London, and then up here in Scotland. And I then went abroad for three years to do research training in Germany and America, and then returned to the UK. And I’ve been based in Edinburgh as an academic dermatologist now for about 20 years I think.

Michael:

And is it correct that you also take on patients every now and again. It seems like you’re more of an academic?

Dr Weller:

So my job is divided, I mean half the time I’m seeing patients. Really doing general dermatology and I have a particular interest in Eczema. And then half the time I’m doing academic, kind of research, teaching. You know, judging the various balls that are part of that life.

Michael:

Yeah sure. And in terms of what you’re looking at in the studies that you, is there studies that you’re kind of running at the moment? Any kind of interesting findings?

Dr Weller:

Yeah so really my story, I mean I suppose I’m, I have; my research has led me to an unusual direction for a dermatologist. But it’s really unexpectedly, I have found really significant health benefits to, to sun exposure. I have to say, having worked in Australia for a year has been a big influence. I mean, you guys, you Australians live three years longer than we do in Scotland. Because you know, I moved to Australia, I had a great year living there. And you’re full of how fantastic you are, great athletes, you know, great rugby players, great cricketers. As you would endlessly remind me when you were lucky so often. But you know, you’re the same bone idle, corpulent, screen watching idle buggers as we British. You’re not, you’re not any different from us really in terms of your lifestyle. And yet you live three years longer than us, which is a huge difference in public health terms. That really didn’t play a part in my thinking until you know, 20 years later I was doing research and we found this, these potential health benefits driven by sunlight. And that time in Australia certainly had an influence on my thinking. And of course, that’s a very crude measure. But I have identified this method unexpectedly. Which sunlight is good for cardiovascular disease. And what I found was that the skin contains large stores of nitric oxide. So NO is what dilates your blood vessels, it lowers pressure. On the Nobel prize for medicine back in 1998 went to the three researchers who really first found that. And the late ‘90’s was a very exciting time in nitric oxide research, with the Nobel prize arriving and trying to work out what it was doing. And I was finding NO in the skin. And I went off to Germany and the States for three years to try and work out what it was doing. And I was, I was a, I was a towing the line dermatologist at that time. So I was sure it must be something to do with skin cancer and the evils of sunlight causing skin cancer. So I was doing work on mouse models in America, trying to work out what nitric oxide was doing to skin cell behaviour. And I published some papers, looked a kind of good story. Came back to Edinburgh and thought well I better move into Mans. Where I started doing human study and I really couldn’t repeat the mouse work in man. And what that led to was a discovery that actually the skins got this big, it’s not nitric oxide being freshly formed. But stores of nitric oxide and we found through some fairly clever chemistry, driven by sunlight. That sunlight releases NO, this NO from the stores in the skin, into the circulation. There was then, and of course NO, what it was first found to do was dilate blood vessels and lower blood pressure. So we then, I ran my first series of experiments that were published. Actually published only about five or six years ago. In which we shone UV at people, ultra violet at people and we found that as it, as predicted from my previous work. This did indeed release nitric oxide from the skin into circulation. It dilated their blood vessels and it lowered blood pressure. So that was, that was pretty exciting. But it was pretty experimental, you know. This was taking an ideal condition, a bunch of medical students, slap them under a UV lamp, measuring what happens, giving it to them just once and just once is, is, it’s an experimental condition. It’s not what happens in real life. So we then set about trying to say does this actually have real life effects in people, in general? And that’s really where a lot of my research has been leading me since. That we’ve now started to do big studies of populations. So I’ve got a paper coming out, I mean in the next week or two. I just corrected the proofs. So it should be coming out pretty soon. It’ll be embargoed, I won’t be able to tell you which journal it’s in, except it will be, it will be out I suspect before this podcast. Anyway, a big study in which we looked at a third of a million Americans, dialysis patients. And the great thing about kidney dialysis patients, is they have their blood pressure measured three times a week. So fantastic, you know. They’re huge numbers of people, having huge amounts of blood pressure measurements. And these dialysis patients are being treated at 2,000 centres around America. And the great thing about that is you have different amounts of UV at each of these centres. You know, if you’re at Salt Lake City, it’s, it’s kind of hot and sunny. If you’re in Denver it’s cool and sunny. If you’re down in the, you know, so you can look at temperature, you can look at the wavelengths of UV. You can pick up on all of these things. Because we know that people have got lower blood pressure in summer than winter. But the difference is about the systolic blood pressure here in the UK. It’s about 6mm of mercury lower in summer than winter. We also know that people living closer to the equator have lower blood pressure. And these factors have been known for decades. And everyone’s always said, they’ve either said it’s vitamin D. Or they’ve said it’s temperature. Well, it’s not vitamin D. There have now been several hundred thousand people on trials of vitamin D supplementation and quite clearly what these data show are giving vitamin D to people has no effect on their blood pressure. Even though, if you go out and measure people’s vitamin D levels, people who’ve got higher levels of vitamin D in their blood have lower blood pressure. But it’s not the vitamin D causing that. The vitamin D’s a marker for something else because giving people vitamin D doesn’t effect that blood pressure. So, so we’ve got this, you know, why is it that people have got lower blood pressure, in summer and are closer to the equator? So it’s not vitamin D. Could it be temperature? Well with this big, certainly in my experiment where we where shining UV at these medical students we corrected for temperature. And this big study that’s just coming out, a third of a million people in 2,000 different centres, we were able via very clever mathematics to correct for the variations in temperature between you know, Salt Lake City and Denver. But that’s times 2,000 centres. And we, and we’ve been able to show that independently of temperature, the more UV people have, the lower blood pressure is. And the importance of that is that high blood pressure is the leading cause of death and disease in the world today. So the World Health Organisation does it’s, every five years does its global burden of disease survey. And the leading cause of premature death and disease in the world is high blood pressure. It accounts for 18% of deaths in the world. And that data is getting stronger and stronger that sunlight lowers blood pressure, the biggest killer in the world.

Michael:

And is this part of the British Heart Foundation funded clinical trial?

Dr Weller:

Yeah, so I can. Okay, so these are all observational studies, so I’ve done these. I did all sorts of basic science stuff looking at NO on the skin. I then did my initial experiments shining UV on students and saying gosh, you get a transient fall in blood pressure. We’ve then done these observational studies in masses of people in America. And I then had funding by the British Heart Foundation to give people UV as a treatment for high blood pressure. And we are just coming to the end of this study now. So what I did was, I was recruiting people with blood pressure, at the lowest level of hypertension diagnosis. So mild hypertension. And we gave them, we delivered to them at home, home phototherapy lamps. So the kind of lamps we use in dermatology to treat skin disease. Except they’re emitting UVA. Now, the study we are analysing the data at the moment. We had huge problems recruiting. I mean, I had imagined this would be easy peasey. You know, ship a lamp to someone’s home. They’d stand in front of the lamp for, you know, for 10 minutes every morning for a couple of weeks. No problem. The study was quite carefully designed that people at two weeks of the active lamp of giving out UV, they had a wash out period of two or three weeks. And then there was a control lamp, which looked the same, but gave out, but didn’t give out UV. And, and we randomised which lamp you got first. So it was a crossover randomised control study. The problem was we had enormous problems recruiting. We had huge under recruitment and the reason is that, I know in Australia you all live on your quarter acre plot. Here in Britain, here in Edinburgh we tend to live in 19^th and 18^th century tenement flats, with no lifts. Up flights of stairs. Without a great deal of space. And people don’t have room in their apartments to have a huge great lamp. And when we tried to move out into the country, outside of Edinburgh we then had the problem that it was so far out they wouldn’t come in and get the study done. So there were huge problems in recruitment. Out primary end point was to look at 24 hour ambulatory blood pressure. And we, we couldn’t show a change there because we were not, we weren’t, we just didn’t recruit enough patients. The secondary end point however was clinic blood pressure and again, we’re just analysing it now. I’m literally going through masses of Excel spreadsheets at the moment. But really excitingly, it looks like we have got a significant fall in the UV group in our secondary end point. Which is clinic blood pressure. Again not published, not presented. Working it up at the moment. But this looks really exciting. And I might say the other thing that backs this up is another group here in Scotland has just looked; so, so high blood pressure is bad for you. Because high blood pressure predisposes you to strokes, it’s the major risk factor for having a stroke. And it predisposes you to heart attacks. So if you can lower blood pressure, well when you lower people’s blood pressure you reduce their risk of a stroke or a heart attack. So you would expect that with more sunshine, people have less strokes and heart attacks. So when another group here in Scotland has actually just done a big study where they looked at all the heart attacks in Scotland over the last 10 years. And rather as I was doing this study looking at blood pressure in dialysis patients in 2,000 different centres in America. They looked at heart attacks all over Scotland and they cross referenced it for the UV. How much UV there was at that time. And again, this paper was published about three weeks ago. And they showed that independent of temperatures, the more UVA there is the less heart attacks there are. So again, more data all running along with, with our story. So this is really exciting. Look, I’m a dermatologist. Sunlight is the leading avoidable risk factor for skin cancer, absolutely. You Australian’s live three years longer than us in Britain. You have twice as much skin cancer. You know, it’s skin cancer is caused by sunlight. But at the same time, but it looks like there are health benefits too. The evidence is growing and growing for health benefits. And I suppose the question is, you know, how do we square this? How do you, what should we be advising? Sunlight is not just bad news. It’s also got a good news side to it.

Michael:

And I guess obviously it’s a hard question to answer, but how much sun is too much sun? Are there markers that we can kind of look at?

Dr Weller:

Yeah, well in the, and that, that’s really the key one. The really, for me the frustrating thing is all dermatologists have looked for, for the last 100 years. Because we shared about 100 years ago that sunlight causes skin cancer. All we’ve looked for is the harm it does. We spent 100 years chasing the harm. Well you know, orthopaedic surgeons do not say do not do exercise, look at all these new replacements I’m doing. They say do exercise it’s good for you. Yes you might twist your knee and you’re going to need cruciate’s done at some point. But exercise is good for you. Dermatologists have never got quite so advanced in their thinking as that. And it’s horrible to be out thought be an orthopaedic surgeon I have to say. So we need to be looking at the size of the benefit. I might say, and this is really striking. We know that sunlight’s a risk factor for skin cancer. We don’t know how much sunlight and that’s after 100 years, is pretty striking. We give these rather vague woolly phrases that, well for Squamous cell skin cancer there is a clear, straight line relationship. You know, the more UV you have the more Squamous cell skin cancers you get. Melanoma has a much more complex relationship with sunlight. It looks for, for superficial spreading melanoma’s. You know for common melanoma’s, it’s not so much the amount of sunlight as the nature of sunlight. Burning sunlight exposure, particularly burning sunlight exposure when you’re young is the strong risk factor for melanoma. So you know, trying to work out, you know if, if you’re looking at body mass index. We know that a BMI between 20 and 25 is the optimum. If you’re lighter than that, if your BMI is less than 20 there is increased risk from you know, cancer, malnutrition, osteoporosis, whatever. If your BMI is higher than 25, there’s increased deaths from heart disease, diabetes, blah, blah, blah. So there’s a kind of sweet spot in the middle. And I think that doctors who knew about BMI’s go around saying there’s got to be a sweet spot in the middle. This balance between the bad bits at the bottom and the bad bits at the top. I think for sunlight that is going to be harder, because we don’t have a straight line relationship for dangers from the sun. We have a straight line relationship for benefits for blood pressure lowering, and it is a straight line relationship. You know there’s, if you drop your systolic blood pressure by 10mm of mercury. That produces about a 25% reduction in cardiovascular events. If you drop it by, and, and you know half as much fall in blood pressure produces half as much benefits. That is a straight line relationship. So, but we don’t, so that’s the good side of sunlight. But we don’t have a straight line relationship for the bad side of sunlight. Now I don’t know whether that is an indictment of dermatologists who can’t produce accurate quantification of the risks of sunlight. Or whether it is the fact that there is no straight line relationship between sunlight and skin cancer. And it’s the nature of sunlight exposure, not the totality of sunlight exposure. And we’ve just not thought about this in the past. And now that we’re finding health benefits to sunshine, it starts to become important because you cannot find that sweet spot without knowing figures on which you can base it.

Michael:

And it would be dependent on the kind of person as well, I’m assuming?

Dr Weller:

Sure, absolutely. So, so if you’ve got, so you know, if you’ve got red hair. You know, here am I in Scotland. If you’re a red head celt with type one skin that burns and, and never tans sunlight is much more of a risk factor for you, than if you’re of African or Indian, or Italian extraction with type three, type four, type five skin. Those people have a lower risk of developing skin cancer. So there isn’t a one size fits all. And so you know, we need to start kind of putting that into it. I mean it’s quite interesting isn’t it? Cigarettes for instance, you know, every cigarette you smoke. I think it’s about seven minutes. Every cigarette you smoke, on average shortens your life by seven minutes. So you know, you can work out the number of cigarettes you’ve had. There was a paper in the BMJ, one of the Christmas BMJ things. You know, it’s a fairly crude measure but it’s an example of how bad cigarettes for you are for you. But that’s pretty much a straight line relationship. And that really accounts for everybody. So for everybody, smoking is bad. But there’s going to be greater inter-individual variation I suspect for the benefits of sunlight and definitely for the risks.

Michael:

And like you said you know, some people are faster to burn, are faster to feel the adverse effects. Are they, are they also, would you say that they’re generally faster to get those nitric oxides and get the benefit of sun as well?

Dr Weller:

Yeah, well that’s an interesting one. So in this paper which we’ll be having coming out in the next couple of weeks. What was very interesting about these 340,000 Americans is 100,000 were black and 240,000 were white. And the fall in blood pressure for a given increase in UV, was much more marked in white people than black people. So black people got less benefit from the sunlight in terms to their blood pressure being lowered and that is interesting. It was in America, this study was African Americans. African Americans also have higher resting blood pressure. You know, they have higher blood pressure than white Americans. And with that they have more stroke, more heart attacks, all of those cardiovascular things. So it is interesting. Is this because you know, it’s, the sunlight has less effects? Or is it, is it skin independent effects – you know, is it to do with something else? But sure that that was a very interesting one. So of course, the risks to them are far lower from UV. Maybe the benefits need more UV, you know, maybe we should be tuning. Well I’m sure we should be tuning our effects based on skin type. I mean, my children are Ethiopian. I work in Ethiopia a lot, I go there a couple of times a year working. And we have this crazy thing that in Scotland, well it’s not a crazy thing. But in, in Scotland the, if your child is in a, in a state run nursery as mine were, all children have to follow Australian rules on sunshine. If you’re out between ten and three you have to have sunscreen applied when the sun’s shining. Well, you know, this is Scotland. It may be summer, but it’s raining. My children are African. You know, this, this crazy. So every year I’d produce a letter saying that guys I understand you want the best, that’s great. But you know, I’m a dermatologist, I have an interest in UV. Can I, can I put in my tuppence worth that my kids – leave it, it’s fine. Just concentrate on somebody else. But this is, these are the kind of guideline we have for everybody and that is crazy.

Michael:

Yeah, yeah I know that we kind of talked about it briefly off air before we started this. But in terms of your, because I know that you work in collaboration with Australia. Or is it, Dr Shelley Gorman that you work?

Dr Weller:

Yeah, Shelley Gorman because I have to say it’s great speaking for an Australian podcasts. Because you Australian’s have been some of the, I thought I was the only person in the world you know, what’s your, oh my God I have a guilty secret. I’m a dermatologist who likes the sun, shhh don’t tell anyone. And then I discovered some of you Aussie’s are just the same. So yeah, so interesting I had, after I’d published my paper in which my first, this paper four or five years ago when we found, we described for the first time this nitric oxide pathway, it stores in the skin, releases the circulation in sunlight, lowers blood pressure transiently. I had an email from, well Shelley’s become one of my great sort of collaborators and colleague, and friend. She is wonderful. She is a biologist, a scientist over in the Telethon Kids Institute in Perth. The other Perth. We had, we have one in Scotland. And she has, she’s been looking at obesity and diabetes. So she’s got fantastic data. In, in Australia, over in Perth it’s interesting that people have. So, Shelley’s got work published showing that in winter, children have more impaired glucose tolerance tests that in summer. So in winter people are slightly more kind of, diabetogenic than in summer. And I might say here in Scotland, we’ve never published it but I was just talking to endocrinology colleagues here in Scotland where all our diabetes data is pooled here in Scotland. And glycosylated haemoglobin levels are much higher in winter. Glycosylated haemoglobin is a measure of long term sugar control. So glycosylated haemoglobin is much higher in winter than in summer. So just what Shelley’s finding in, down in Perth. So she then has this, she’s got this fantastic model of diabetes, type two diabetes. And again, diabetes is another condition. People with high vitamin D levels are less likely to have type two diabetes. But you give people vitamin D supplements and there’s only a very small benefit to it. Even though the observational changes are very big, so it’s got to be more than just vitamin D. So, Shelley has this great mouse model. So you overfeed mice, they get fat, they get diabetes, they get fatty livers, they get, they become a modern, modern kind of metabolic syndrome person. So she then shines UV at these mice and they don’t get so fat, they don’t get such fatty livers, they don’t get such impaired glucose tolerance tests, they get less metabolic centring. So she then gave them, she then tried this rhythm. So mice don’t make vitamin D in sunshine, you have to give them vitamin D orally. She gave these mice vitamin D, or not and found vitamin D had no effect on this. So it’s a vitamin D, sunlight independent of vitamin D stops overfed mice getting fat and getting metabolic syndrome. So she initially tried to publish this in the top diabetes journal and they said look, great, very interesting. You’re showing what it isn’t. You’ve got to tell us what it is, you know, one of those cruel rejection letters. Actually, publishing negative data is hard. And Shelley had seen my paper and literally a week or two after it was published I had an email saying hi, I’m Shelley O’Gorman in Australia. Blah, blah, blah. Do you think your NO mechanism might account for this? I went gosh really interesting. So we designed some experiments where she shone UV at her mice, the ones she was overfeeding. But we put a nitric oxide scavenging cream on the skin. So that would pop up any NO coming off. And then we also took other mice, in whom, instead of shining UV at them we put a nitric oxide releasing cream on them. And what we found was that if we shone UV at mice but you mopped up the nitic oxide, you blocked the beneficial effect of the sunlight in stopping those mice getting metabolic syndrome. And if you replaced ultra violet radiation on mice with a nitric oxide releasing cream, you reproduced the benefits of UV on stopping mice getting metabolic syndrome. So it looks like this NO pathway accounts for the reduction of metabolic syndrome in this mouse model. And with that, they published. They said fine, you’ve got a mechanism. And actually we carried on doing this for the last, we’ve got a couple more papers out. Shelley is absolutely stellar. And brilliantly, she’s coming over here to Edinburgh for a month later this year on sabbatical from, from the Telethon. And we’ve got lots of exciting things lined up. We’ve got all the data from my people we’ve been shining the UV at, we’re just sorting out some experiments to do when she comes over. Really putting together, because these are the big killers today. The big killers today are, well obviously don’t smoke, eat fruit and veg, do exercise. That aside, the other big killers are blood pressure and obesity, and diabetes. These are the big public health problems. And we’re getting, well we’ve got a lot of human data now suggesting that sunlight reduces cardiovascular disease. And we are less far down the human data track, but we’ve got this animal data from Shelley that ties up with the epidemiology in humans. Suggesting that maybe this is also an important mechanism for metabolic syndrome. It’s and it’s really exciting, and it’s really important.

Michael:

And in terms of the diabetes in itself. It’s, like you said, there’s a difference between summer and winter. How big of a difference is this? Like and are, do people who are diabetic are they finding this information?

Dr Weller:

Do you know I, I don’t feel. Like I’ve spoken to a lot of cardiologists. I spend more and more time with them. Diabetologists I, I don’t know how big the effects are and of course there is Type 2 diabetes and Type 1. I always, Type 2 diabetes is the one we’re really interested on. This is the you know, the kind of obesity related one and there’s lot of other difficult things in there. I mean, the point is in summer people do more exercise, they lose weight, you know, all of, all of these things. People are healthier in summer than in winter. But even, but, but my concern is that we dermatologists are frightening people about going outside. You know, even if the whole of the seasonal thing in diabetes turns out to be due to the fact that people do more exercise in summer, they go outside for a walk. If we dermatologists are going round saying *gasp* have you got the factor 50? No? Don’t step outside. That is not helping. You know, because we know that exercise is unbelievably good for you. And if we are going round frightening people about the outside, that is bad. Because the other thing, which is absolutely amazing is we’ve known for 100 years that sunlight, that UV causes skin cancer. There is not a single paper showing that sunlight shortens life. Now, all of these other things I’ve been talking about – smoking, high blood pressure, diabetes, diets low in fruit, air pollution which you guys have got at the moment, poverty, blah, blah, blah, blah. These things shorten life. A 100 years, they raise or cause mortality. A 100 years after we showed, the first papers in mass models that confirmed that UV is carcinogenic to the skin, published in 1928 in the Lancet. So knocking 100 years after proof that UV causes skin cancer, there are no papers showing the sunlight shortens life. That is completely different to every other risk factor we talk about. Yes sunlight leads to skin cancer. Yes exercise makes you more likely to stuff up your cruciate ligaments. But exercise is unbelievably good for you and I suspect that sunlight is also going to turn, is also turning out to be really good for your general health.

Michael:

And I know I kind of touched on it before when I asked like how much sun is too much sun. But in terms of I guess measuring UV exposure, do you recommend specific tools or techniques?

Dr Weller:

Yeah, I mean look, what I say is. This is a difficult one because my patients ask me this. I say don’t get burnt. Clearly not getting burnt is really important. That is particularly important for children. I also think that look, I am a dermatologist here in Scotland. What I’m saying, what I’m seeing is very different to what an Australian dermatologist would practice. Because of course, you have got a predominantly white skin people, in a very sunny part of the world. But you’ve not a major, you know, you guys are living three years longer than us. You know, this, you are not an unhealthy bunch. And I just, I suppose I’d just like to keep things in proportion. You haven’t got a big health problem with people dropping dead from sun exposure. Yes you’ve got more melanoma, yes you’ve got skin cancer. But you are also, you’ve got half the rate of heart disease we have in Britain. You know, and it’s not because you’re all bronzed, athletic Gods. I know, I’ve been there. There’s as many people propping up a bar, with a pint in one hand and a ciggie in the other. You know, and getting a taxi home rather than walking home in Aus as they are here in Britain, so.

Michael:

Sure. And in terms of sunscreens, because I know that you’ve actually got a sunscreen product yourself. I’m interested before we go into kind of explaining the difference between your sunscreen product and others. Is just, yeah is sunscreen good or bad for you?

Dr Weller:

Yeah, so of course you’ve done the great studies in, in, Adele Green has done the definitive study on sunscreen up in Nambour in Queensland back in the ‘90’s. I mean, an amazing study, funded by the Australian government that you know, she took was it 60-100 people up in Nambour. 800 give them sunscreen to use everyday for five years, 800 did their standard thing. And they went back and they made sure they were putting the sunscreen on. You know, 800 people for five years. Unbelievable. You know, I was trying to get you know, a few tens of people to come for my lamps. You’re taking 800 for five years. I’m just bowled over by the, what an undertaking that was. Absolutely phenomenal. And she showed that sunscreen reduces skin cancer, as you’d expect. Absolutely no effect in reducing deaths. So we no that sunscreen reduces skin cancer. And the Nambour sunscreen study is the definitive, you know, that is the kind of vertex from which we all quote. But there was absolutely no reduction in deaths with sunscreen.

Michael:

Okay, so I guess.

Dr Weller:

Stops you getting wrinkles, stops you getting skin cancer. It does not make you live longer. And actually that’s, there’s some other tremendous studies coming out of Scandinavia. Now, Scandinavia is very similar to Scotland. It’s very different to Australia. However, some studies coming out of the Caroll-Linz [36.22 spelling?] institute in Sweden. So the one here is the melanoma in Southern-Sweden study and I love the title. Because the title tells you what they were thinking. So, this was set up in 1990. And they recruited 30,000 Swedish women. And they wanted to find out how much sun do you need to cause melanoma and how does it kill you? They were trying to put some numbers of the risk of sunlight. So they asked them, they assessed at the beginning. So this was a prospective cohort study. So they asked these 30,000 Swedish women four questions basically to assess their sun exposure. Do you use sun beds? Do you sun bathe in summer? Do you sun bathe in winter? Do you go on foreign holidays? Now everybody is going to instantly jump up and down and say what about confounders? If you go on foreign holidays you’re richer, you’re less likely to smoke blah, blah. Of course. So they checked for all the confounders. They looked at you know, smoking, education level, income. So in Sweden every year, everybody’s tax return is published openly. If you want to know how much your neighbour earns, you can look it up. Your co-workers, it is a public document, the whole population. I know that after four years we still want to know what Donald Trump’s tax returns are – wouldn’t happen in Sweden. Okay, so everything was corrected for. Number of children they had, whether they were married, diabetes, exercise. All of that was corrected for. So this was 30,000 Swedish women. They went back 25 years later. So you had a score of nought to four for your sun exposure. You had a score of nought to four. Went back 25 years later. So first of all, surprise, surprise. Sunlight is a risk factor for skin cancer. I think we suspected that. That was the expected. The unexpected bit, so they were expecting to find more sunlight, more skin cancer, more death presumably. That is what they were expecting. What they found was the opposite. More sunlight, more melanoma, yes. More sunlight, the more sunlight you had, dose dependent after correcting for all of those confounders. The less likely they were to be dead. And in fact, people that had the most sunlight exposure were half as likely to be dead, as the sun avoiders. And these were all healthy people at baseline. You know, exhaustive studies. The size of the effect was as big as smoking. Just to give you an idea about how big an effect it was. There are no other studies. There’s been studies from Denmark where they have used, actually having non-melanoma skin cancer as a marker for sunlight. And they showed that when you have basal-cell skin cancers, a lot of people have shown when you have a BCC, a basal-cell skin cancer you are less likely to be dead than people without BCC’s. So when I diagnose a BCC, which even in Scotland I do a lot, the first thing I say to my patient is congratulations, you’re leaving my consulting room with a longer actuarial life expectancy than when you came in. Which, which I think is grounds for celebration but that’s probably because I’m a bad dermatologist. But I think I’m a good doctor.

Michael:

And so going back a little bit to the sunscreens themselves then, so obviously we’ll put a link to the photos.

Dr Weller:

So yeah, I mean so yeah, it is, I mean I am a dermatologist. It’s difficult, I, here am I saying well maybe sunlight causes skin cancer. And you know, I see patients with skin cancer. I don’t see people with strokes or heart attacks. But I’m going around saying actually I think it’s, it’s good for your heart. So look, we’ve developed a sun screen which releases nitric oxide. So what it does, is it contains the same nitrogen oxides within the sunscreen that are within the skin. And the various other factors that are needed, because there is some quite clever photochemistry that goes on. And when UV hits that sunscreen it releases the NO. So you know, it, it’s a sunscreen. It stops, it’s an SPF 25 sunscreen. It stops, is as effected as an SPF 25 sunscreen. But at the same time it releases NO when UV hits the skin. So we can, we can reproduce that healthy NO benefit. Now, I don’t know whether it lowers blood pressure like sunlight does. But we’re certainly moving towards being able to reduce some of those beneficial effects of sunlight, whilst at the same time giving the protection that an SPF 25 sunscreen does. So it’s, it’s an interesting, I’ve, founding that company has come late in my career and not something I expected to, and it’s been an interesting process. So I think, I think you know, I think this is going to be the norm five years from now. Because this understanding that sunlights got health benefits, it’s not just bad. So you know, how can you get the good without the bad? That’s, that’s something we should be really thinking about.

Michael:

Just to be clear, so with other sunscreens or lets say typically other sunscreens, they would actually reflect or the nitric oxides?

Dr Weller:

Yip, sunscreen prevents that NO being made in the skin because it blocks that UV getting through. So yes. Yes.

Michael:

Doing a bit of Google-ing, I found another company Relax-all? If that’s how you pronounce it?

Dr Weller:

Yeah, that’s us, that’s us. That’s our, that’s the name of the company. That’s us, yip.

Michael:

So that’s essentially, is that, maybe just describe a little bit about what it does? Is that the research arm?

Dr Weller:

Here’s the company and then we [42.15 unclear] and then I, and we then made the sunscreen that has got my name on it, that I. Initially we were going to call it sun-well sunscreen. Because I absolutely, you know, when I qualified as a doctor, you appeared in the paper on three occasions. When you were born, when you married, when you died. Your brass plaque on your door was not allowed to be bigger than four inches, by five inches. It could contain your name and your degree, and nothing else. So I grew up in the era of you absolutely keep your name out of the papers. And the marketing people said, so I thought we’ll call it sun-well because nobody will really know it’s me. And then the marketing people said they’ve got to put your name on it, because you’re the guy that’s done the research. So …

Michael:

I’m sure it’s got clout you know, Dr.

Dr Weller:

It’s got my name on it yeah, so you know, that’s what we were advised. I’m, I’m trying to move, the reality is it’s a different age from when I qualified. But yes, so relax-all is the company and Dr Weller, well sunscreen is the, is the sunscreen. So I’m kind of trying to get used to the idea of having my name plastered across tubes of stuff.

Michael:

How recent is it?

Dr Weller:

We’ve really just got going. So we, we’ve made the, we started making it. But we missed last, northern hemisphere summer so we’re really getting on sale now for the, the northern hemisphere summer up here.

Michael:

Fantastic. And I know you also mentioned at the beginning, you do a lot of research into Eczema. Yeah, is there any kind of interesting findings that you can share around some of the research on that side of things?

Dr Weller:

Well I mean, Eczema is a fast, you know. So I have, all my sunlight stuff you know, it’s slight left-field for a dermatologist. I’ve got all these, you know, dermatology patients and here I am worrying about cardiovascular disease. So yeah, I’ve got a research group here in Edinburgh and we’re looking at immunological aspects of Eczema. We’ve actually done some quite nice cross over stuff. I mean, one of the treatments of course that you can use for Eczema is UV therapy, phototherapy. I mean, phototherapy yeah, we’ve got this bizarre thing as dermatologists. We run around saying to patients for God sake, don’t go into the sun. And then we say your psoriasis, let me put you under this phototherapy lamp. And it’s fantastically effective. You know, do as I say, not as I do. What is this guys? And of course, phototherapy lamps are also, they’re not as effective for Eczema as for psoriasis. But they’re still a very useful and a very safe treatment. And we actually had a paper in JACI, the Journal of Allergy and Clinical Immunology last year. And quite, there’s a quite nice overlap there. That we found that nitric oxide, which of course is released by UV in the skin, turns naive T cells, into T regulatory, kind of anti-inflammatory T cells. Whether that relates to the mechanisms by which UV helps Eczema, I don’t know. But I mean, most of my Eczema research is much more basic science, immunology stuff actually. But of course, we’re getting very excited by the new drugs coming along. I run the Eczema service here in South East Scotland and you know, [45.33 unclear]’s coming along. There’s a lot of new drugs coming along. And I’m, we’re doing some research on IO22 pathways in Eczema, we’ve published in you know, science and JACI and some of the other big journals, and that’s all pretty exciting. But it’s all kind of basic science level still there, we’re not feeding that stuff through to the clinic yet.

Michael:

And you know, this might have. Yeah, you might know a bit about this, you might not. I’ll just throw it out there anyway. But do you know much about red light therapy and kind of like whether this has any validness in this all?

Dr Weller:

Gosh, you know. What’s interesting of course is that there are a whole, you know, sunlight has got lots of different wavelengths. And we know that you know, more sunlight equates with less blood pressure. That people’s Eczema is better in summer than in winter. That people’s psoriasis is better in summer than in winter. So when I worked in Cairns, one of my, I was a med-reg there. One of my colleagues there came from Tasmania, and he had psoriasis and he had moved to Cairns to work, because he knew his skin would be better up there where the sun shines all the time, than in Tasmania where it doesn’t. And he was absolutely right. Now, which bit of the sun? Well we know that narrow band UV-B,  you know, three ten nanometres is about 11 nanometres is fantastic. But there’s a whole series of other wavelengths and you know, people are starting to look at the red end. We’ve really concentrated on UV in the past, because you know that UV works for phototherapy. Whether it’s old fashion poover or more modern mariband UV-B. We know that UV is the carcinogenic bit of sunlight. And of course, we have all those action spectrum beautifully delineated where we know that the wavelengths that make you most red are the wavelengths that cause DNA damage, and are the wavelengths that cause skin cancer. So all of this gorgeous research over previous decades showing how sunlight causes skin cancer and that’s the UV effect. But the benefits, or you know, people are looking at blue light now. They’re looking at the infrared spectrum, there’s actually probably a lot happening at a whole series of wavelengths and that’s pretty exciting. Because they’re raising our gaze from just adverse effects. We’re raising our gaze from just UV. You know, we, we evolved under the sunlight. Humans evolved in the sun. You know, homo sapiens has been around for about 200,000 years. We lived outdoors for our entire evolutionary history until the industrial revolution about 150 years ago. So, you know, what’s that? Half a dozen, a dozen generations ago we moved indoors. And before then, we were farmers. Before then we were hunter gatherers. Our existence has been lived outdoors. You know, what is abnormal is not sunlight, but being out of the sunlight. Now, you know, Australia you’ve got a lot of north European white people living in somewhere very sunny. Aboriginals are obviously excepted. So, that’s a very unevolutionary, you know, unnatural place to be. But for me you know, white skinned in Scotland, you know my, my five great grandmother was, you know, she was a crofter in central Scotland. She would have been out on the croft all day, that was the norm.

Michael:

What about, I know you touched on this before as well. Tanning beds, and I’m sure you get it all the time. But do they have benefit or is it?

Dr Weller:

I you know, I don’t know. I mean they’ve, tanning beds are absolutely a risk factor for skin cancer and melanoma. And that’s pretty good, because that’s very unnatural. It’s very intense light, given for very short periods of time. It’s not something to which we are adapted and evolutionary times. The tanning industry is desperate to get me to come and talk to their meetings. Sort of sing their praises and all the rest of it. And you know, I’m just not interested. I, quite clear what their desires are. So I’m keeping very actively at arm’s length from them. You know they’re, tanning beds are, it’s short and intense UV. It’s a risk factor for melanoma. I, you know, there’s, I have no, I don’t think they make you live longer. I think they’re, they are probably different from natural sunlight. And of course they’re just as UV, they’re UV-A predominantly. They’re those UV-A lengths. So it looks like sunlights healthy and that’s the full spectrum, from UV through to infrared. Maybe you need it all. Maybe you need bits of IR with the UV, with the visible, I don’t know. You know, but we, knowing that sunlight’s good for you is not saying that tanning beds are good for you. They’re different animals.

Michael:

Yeah, for sure. And just before I do let you go. I kind of, you mentioned this earlier as well but, your trips to Ethiopia. Because it seems like you go about once a year. Can you maybe just describe that?

Dr Weller:

Yeah, sure. So I, I teach there and I’m doing research on Cutaneous leishmaniasis out there. So the, the teaching’s in Addis and then the research is up in Amhara. And so, I’ve been working at, Ethiopia is at, so Addis is at 2,500 metre altitude, it’s on the equator. It has shedloads of UV. I have never seen a skin cancer. So you know if, if your skin is adapted, the Ethiopian skin is adapted to Ethiopian sun. We just you know, you know, and that is shedloads of UV. More than you guys have got down at, because you’re at sea level. You know, this is up at altitude. And so there are we, certainly in Britain we take no account of skin colour with our UV advice. Oh it’s too complicated, just give out the same message to everybody. Well you know, I, I do not, I’ve been going there for 12 years now. And you know, I just don’t see melanoma. They do, they do get melanoma’s in Ethiopia but they’re, they are the melanoma, the Acral melanoma’s on the palms and the soles, which are not UV related. They’re rare in Australia, they’re rare in Ethiopia. They’re about equally rare. And they’re rare and they’re not UV related. But we don’t see the superficial spreading, the nodular, the lentigo malignas, the kind of melanoma’s that you and I, you know that you Australians and us in Britain see. And, and yet we have the same message. So you know, clearly skin type is hugely important because it affects the benefits of UV, of blood pressure and it affects the hazards of UV. So we need to tailor our message to the individual.

Michael:

Fantastic. And this is a bit of a curveball, but what is one thing that you think dermatologists could teach other specialists?

Dr Weller:

I think other specialists can teach dermatologists actually. I, I mean, it really is striking. This is, it’s slightly a hobby horse now. For me it was, you know, I went to Australia. In Britain they always think of dermatologists as quite clever, because we make you know, complicated diagnosis with long Latin names. Look, I mean, dermatology is either a skin cancer – you cut it out. Or it’s an inflammatory diagnosis and you slap a steroid on that, and that’s actually most of it. We’re not hugely clever. But I went to America and to do research, and I was in a surgical lab. And they looked on me with scorn because dermatologists in America are all thought to be beauticians, and half of them are. I mustn’t call them that. Cosmetic dermatologists. You know, they’re a branch of the beauty industry and regarded with derision. And I think dermatologists have got fixated on skin cancer. Because cancer is a kind of macho disease. You know, if you’re dealing with cancer you know, you’re a real doctor. I’m not a beautician, a real doctor. And I think we have clung onto it and we’ve clung onto our public health message which is never go in the sun, it’s dreadful stuff. Because it boosts our standing. So yes, UV causes skin cancer. But please can we think like general physicians, can we think like our orthopaedic colleagues who do not tell people to avoid exercise because of the knee joint replacements they’re doing. They say holistically in this patients life, what is good for them? Doing exercise is hugely important. They should do exercise. Let’s deal with those knee problems later. We should be taking a lesson from our colleagues in general, in other medical specialties, who treat the whole patient. Not just the organ that they deal with.