Xeomin - the new kid on the block

Competition is good.  First we had Botox.  Then Dysport came on the scene.  And now we have Xeomin.  They all are neurotoxins that work to smooth out lines in the forehead, around the eyes, improve bunny lines, fix a gummy smile, help smoker's lines, soften the jawline, and relax neck lines (although they're all only approved for the glabellar eleven lines).  So what's the difference between these three muskateers?

How They Work
All three work by temporarily inhibiting release of a chemical called acetylcholine from nerves.  Acetylcholine works as a messenger, telling the muscles to contract.  In a nutshell: no release, no signal, no contraction, no lines. 

Proteins
Botox and Dysport consist of botulinum toxin that is complexed with accessory proteins.  Once injected, the proteins separate from the toxin.  Xeomin does not have the accessory proteins.  Having no proteins may decrease the possibility of developing antibodies to the proteins, which make the injections less (or not) effective. 

How They Act
Both Botox and Xeomin start to work about a week after injection and last about 3-4 months.  Dysport may work a little faster, and may last a little longer, although the results vary.  Some reports have shown that dysport may locally diffuse further than Botox once injected.  Sometimes this means that less has to be injected to achieve a pleasing, natural result. 

Storage
Unlike Botox and Dysport, Xeomin does not need to be refrigerated -- great if we lose power in South Florida during hurricane season!

Most importantly, no matter which you choose, make sure a board certified physician in one of the core specialties: dermatology or plastic surgery is performing the treatment.  Have fun ringing in the new year wrinkle free!

Exercise and the Skin

Thanksgiving was great, right?  The turkey, gravy, mashed potatoes, stuffing, dinner rolls, pumpkin pie.  It tasted so delicious, I inhaled it all.  But by the end of the meal, we all were laying back in our chairs, too full to move.  Belts were loosed, and waistbands groaned at the force of our bloated bellies.  I decided not to wait for New Year's - my resolution was happening early.  It was time to start a running routine.

The benefits of exercise for your heart, muscles, and bones are indisputable.  As I puffed along Turnberry circle, I started thinking about how exercise benefits skin, as well.

Sweat it out
When we run, bike, box, step, zumba, or spin, we sweat.  Sweat functions to cool our body off, but it also flushes and rids the skin of toxins, such as free radicals.  The increase in blood flow delivers more oxygen and nutrients to the skin, as well.  But if sweat sits around on the skin, bacteria can follow.  For people with acne prone skin, cleaning your face/chest/back right after your workout, and removing sweaty clothing can help prevent a breakout.

Say ohm
There's no doubt about it: exercise reduces stress levels.  And if you haven't heard by now, too much stress is not a good thing.  Higher levels of cortisol (increased in stress) can worsen many medical conditions, including skin: eczema, psoriasis, acne, hives, etc.  (See my post on stress and the skin for more information).  Increased cortisol levels may also be linked to increased sebum and oil production, making acne worse.  Keeping levels low through diet, exercise, and breathing may help improve your skin's appearance and overall health.

Dimples
No, not the ones on the face.  I'm talking cellulite.  While nothing has been proven to get rid of it completely, tightening muscles and toning can improve the appearance of legs and derrier. 

But a caveat--  Exercising outside means sun exposure.  Avoiding peak hours (10 am - 3 pm), wearing a broad spectrum sunscreen, and sun protective clothing are all vital to help prevent skin cancers and sun damage. 

So who's joining me for a jog?

You look tired...

Nothing says “I’m tired,” quite like dark, hollow, undereye circles.  “I’m fine,” you insist.  “I got a full night of sleep!”  Your friend looks at your with sympathetic eyes.  “Mmm, hmmm, riiiiight.  Poor thing…” she coos. 

The truth is, sleep (or lack there of) is only one factor contributing to the appearance of hollows under the eyes.  Genetics, allergies, broken blood vessels, and volume loss all play a role.  Although this is a difficult area to treat, there are things that help.

Hollows in the “tear trough” area (the area between the eye and upper cheek) can be improved by replacing volume with filler.  Hylauronic acid fillers, such as Restylane, Juvederm, and Perlane, work well in this area because they are softer fillers.  They are injected deep to restore volume from bone and fat loss.  Deep injections prevent lumps from being seen.  These filler last about 9 months to a year.  Although they improve the hollow, filler won’t do much for the dark color.  Fillers have FDA approval to be used in naso-labial folds.

Eye creams help to hydrate the underye area and temporarily plump the area.  Hyaluronic acid creams fill in fine lines.  Creams with caffeine, like RevaleSkin Replenishing Eye Therapy, help to constrict the area, reducing puffiness.  One of my favorites is the TNS Essential Illuminating Eye Serum, which contains growth factors and antioxidants.  The growth factors have been scientifically proven to stimulate collagen.  Creams can be kept in the refrigerator and then applied; the cold helps to further constrict blood vessels.

If seasonal allergies are an issue, taking a daily non-drowsy antihistamine can help.  Sleeping propped up on two pillows helps decrease fluid accumulation beneath the eyes.  Compresses with chamomile tea can be soothing.

Finally, with any skin condition, taking care of your overall health is essential.  Sleeping a full eight hours, eating a healthy diet rich in antioxidants (green tea, vitamin C, vitamin E, resveratrol, acai, blackberry, etc), exercise, and stress relieving activites (yoga, breathing) are vital to a youthful, energized, beautiful, you!

Winter skin

Just as we change our clothing with the changes in weather, the cooler temperatures also call for changes in our skin care regimen.  Crisp outside air, blowing wind, and indoor heat can lead to chapped lips, cracked hands, and dry skin.  Keeping your skin well hydrated can help prevent these with a few easy changes to your regimen.

Moisturize, moisturize, moisturize: can’t say it enough.  Keep a tube of cream in your purse or pocket.  I like Eucerin, Cerave, and Cetaphil creams for over-the-counter brands.  For creams available in physician’s offices, Lipikar by La Roche Posay is very hydrating.  Many people use lotions, but often, the alcohol found in formulations can be drying.  Also, fragranced products can be irritating and drying, as well.  Toss the "violet lavender rose summer blossoms bouquet" scented lotion.

Harsh soaps can play a role in stripping the skin of its protective lipids.   Mild, fragrance-free cleansers, like Dove and Cetaphil are great.  Avoid using very hot water in the shower, which actually can dry the skin.  Moisturize as soon as coming out of the shower, while skin is still moist.

Fragrances are hidden in other places, too.  Strong detergents can often cause dry skin and rashes.  Perfume-free clothing detergents are a better way to go.  And avoid using dryer sheets in the dryer, which can also irritate skin.  People with sensitive skin also are often irritated by wool, so wearing a cotton shirt under the sweater, or avoiding wool all together can help.

Lips are sensitive to temperature changes.  Constantly licking lips actually dries the lips further, and saliva can be irritating to the skin surounding the lips, causing "lip licker's dermatitis."  I've said it before, and I'll say it again: forget dogs, Aquaphor is man's best friend.  It's perfect for moisturizing cracked heels, dry elbows, lips, and pretty much anywhere else.  That goes for kids' skin, too, which can be extra sensitive, especially if Junior has eczema (see the eczema post for more info on that condition).

Winter's here, folks, so pull on your Missoni for Target hats and mittens and enjoy - just make sure your skin stays hydrated and soft underneath! 

Trick or Treat

Happy Halloween! Time for candy, decorations, and cute little painted faces. Everyone has heard the urban myths of razor blades in unwrapped candies, but what could possibly be dangerous about painting a colorful butterfly on your little one’s face?

According to a 2009 report titled Pretty Scary: Could Halloween Face Paint Cause Lifelong Health Problems? by the U.S.-based Campaign for Safer Cosmetics, many kids face paint products labeled as “non-toxic” actually contained toxic products. Ten out of 10 face-paint products tested contained lead. Six of 10 contained metals such as nickel, cobalt and/or chromium at higher-than-recommended levels, which commonly cause allergic contact dermatitis. Lead poisoning, we all know, is harmful for brain and nervous system development.

Face paint may cause other skin problems, as well. For children prone to acne, thick makeup may exacerbate or trigger breakouts and clog pores. Other ingredients in the makeup may irritate the skin or cause allergic reactions.

So what’s a health conscious parent to do? Check ingredients of face paint carefully. If you’re unsure, skip it. Many websites have homemade makeup recipes using natural ingredients.

I’m planning on dressing my little girl as a butterfly princess (sans face paint). Have a safe and fun Halloween filled with treats!

Halloween Cosmetic Procedures

Halloween is that time of year when little ones get to dress up as whatever they want... animals, princesses, ghosts and goblins.  While costumes like Dr. Spock and Donald Duck are adorable on kids, adults can look downright frightening- especially when these looks result from cosmetic procedures.

Dr. Spock: you may have liked watching Star Trek on tv, but that doesn't mean you want your eyebrows to belong on the show.  The "Dr. Spock" occurs when more Botox or Dysport is injected into the middle of the forehead than the sides.  As Botox and Dysport stop muscle movement, the middle portion of the forehead doesn't move, but the sides are able to raise up, lifting the outside portions of the eyebrows with it, and Voila!  Beam me up, Scotty.  Even placement of the neurotoxin helps prevent this and results in a much more natural look.

Ducks: specifically, duck lips.  These usually occur when either too much filler is placed in the lips, and/or the filler is placed without following the natural shape and contour of the lips.  The most natural-looking enhanced lips happen when the normal anatomy of lips is respected.  The upper lip is smaller than the lower lip - usually in a ratio of 1/3 to 2/3.  The lip is not the same thickness all the way across it.  Usually, it is thinner on the sides, and has two fuller "pillows" on the top lip, and three "pillows" on the lower lip.  Some people have a more prominent cupid's bow than others.  Following these landmarks and filling with the natural shape of the lip prevents the dreaded "Donald Duck" lip. 

Thanks to modern medicine, it's easier than ever to use non-invasive cosmetic treatments like Botox/Dysport, fillers, and lasers to get subtle, natural looking results.  But make sure you see a board certified dermatologist or plastic surgeon with cosmetic experience... and leave the costumes for October 31st!
   

those hangy neck things

Almost daily, I see someone complaining of "those hangy things" on their neck, in their armpits, in the groin, on eyelids.  They're annoying - they catch on necklaces, shirt collars, and become inflamed from rubbing.  What are those things, anyway? 

They're called achrochordons, or skin tags.  They can be brown, tan, or skin-colored.   And while they may be bothersome to the patient, they're actually totally benign.  Skin tags are more common in middle-aged and older people, as well as in female and obese people - but anyone can get one. 

Pregnant ladies may notice that they become larger or get more of them - which is normal.  Since these are benign growths, they don't have to be treated - and insurance usually won't cover their removal.  They can be snipped with scissors, burned with a little cautery, or frozen with liquid nitrogen.  What treatment modality is used usually depends on location, the number of lesions, and the appearance of surrounding skin.  Usually the tag doesn't return, but it doesn't guarantee that more won't appear.  Just a caveat -  it's always important to have a dermatologist check you from head to toe- they are the experts in deciding what is benign and what needs a biopsy.  And any skin spot that changes, bleeds, or itches should be check right away!

So if those "hangy neck things" are annoying, see a dermatologist- a quick treatment can leave you "hangy neck thing" free!

Pedi Problems

Who doesn’t love a great manicure and pedicure?  The hot, bubbling water soaking your tired, overworked feet… the relaxing massage and great smelling scrubs… the fabulous new Chanel color on your nails… the boils and scars from bacteria- wait, WHAT?

Sad, but true.  Unsafe practices such as unsanitized tools and contaminated foot baths can put you at risk for fungal, bacterial, and atypical mycobacterial infections, and theoretically, hepatitis.

In October 2000, a study was performed in northern California, where the first known outbreak of Mycobacterium fortuitum skin infections were acquired from whirlpool footbaths at a nail salon.  Over 100 pedicure customers had boils on the lower legs that left scars. The bacteria was found in the area behind the screen of the recirculation inlet in each of 10 footspas at the nail salon.  Soon after, 3 cases of lower extremity infections associated with 2 different nail salons were documented from southern California.

A survey of nail salons done in different parts of California (Alameda, Sacramento, Orange, Riverside, and San Diego) was done.  A team assessed footspa equipment, cleaning solutions, cleaning techniques and frequencies, and took swab samples.  31 swabs were collected from 30 whirlpool footbaths in 18 nail salons from the 5 California counties.  Mycobacteria were isolated from all pedicure spas surveyed, except for one that had been in service for 11 days. 

Fungal and bacterial infections (such as staph) are commonly acquired from pedicures and manicures.  Unsanitized instruments, including nail files and pumice files, are often used on one client after another.  Add in a contaminated food bath that stays moist and warm, and it’s the perfect setup for fungus and other infections.  Even more worrisome is when cuticles are clipped or razors are used, causing a client to bleed.  If those instruments aren’t properly sanitized (which means placing them in a medical grade autoclave), then there is a small risk of transmission of infectious diseases like hepatitis.

Scary… so what’s a mani/pedi loving girl to do?  The best option is, of course, to do your own nails at home.  But for die hard salon fans, caution is key.  Bring your own tools and nail polishes to be used for the treatments.  Look for salons that are clean.  If the footbaths are not being cleaned between clients, walk out!  Protect your precious skin; it’s the only one you have.       

Bottom's Up

Those little baby tushies.  They’re so adorable, aren’t they?  Dimpled and sweet… but there’s nothing cute about getting red and raw from the dreaded diaper rash.  Even the most easy-going baby will fuss, cry, and try to torpedo off the changing table when it’s time to change their diaper. 

Most babies will develop a rash in the diaper area at some point in their infancy.  It’s usually caused excessive wetness and friction.  Feces, urine, fragrances, wipes, and infections with bacteria or yeast are often culprits.

Rashes can be avoided by changing diapers frequently.  The more contact the skin has with urine and feces, the more irritated it becomes.  Exposing the skin to air helps to keep it dry, and gentle cleansing with cotton balls dipped in warm water, or fragrance free wipes for sensitive skin can be used.  Protective creams like Desitin, Vaseline, and A&D ointment protect the skin barrier and help to heal the skin.  Pediatricians and dermatologists may recommend oral or topical antibiotics if there is a bacterial infection.  Yeast infections can be treated with prescription topical anti-yeast creams.  Occasionally, a mild cortisone cream is recommended for severe inflammation, but these must be used under physician’s supervision.  When the diaper occludes/covers the skin, the effects of the cortisone cream are increased.  The skin in that area is already very sensitive, and too much cortisone can cause problems. 

When is a diaper rash not a diaper rash?  Other conditions, such as psoriasis, seborrheic dermatitis, nutritional deficiencies including zinc, and other more rare conditions can present in the diaper area.  Any rash not responding to treatment needs to be evaluated by a pediatrician or dermatologist.  

We love our babies’ bottoms.  Let’s keep them dry, clean, and rash free!    

Hot Beef Fat Injection

Recently, a woman in Illinois went to the hospital complaining a burning sensation to her face.  She had injected fat into her face that she obtained after boiling beef in her house.  And reportedly, had done it several times before.  Although the autopsy ruled another finding as the cause of death, the story brings up the question - do you know what you're injecting?

Injecting foreign substances is not a new thing.  Cases of paraffinoma, where paraffin, cottonseed or sesame oil, and beeswax are injected into the skin have all been reported.  Ulcerations or red bumps can envelop these foreign substances and can show up months to years after the inital injection.  Liquid silicone has been used for the correction of scars, wrinkles, and plumping up hollowed areas of skin.  Skin reactions can include red bumps and nodules, and swelling.  While medical grade silicone (Silikon) is still used, it should be injected in very small amounts, usually as microdroplets, to avoid an inflammatory response.  Injections of mercury into the skin have been reported in the past.  It can cause red, inflamed tissue or fat necrosis (death).  Systemic toxicity can result in death. 

The intoduction of fillers to volumize the face has revolutionized the beauty industry.  With many choices of filler products, dermatologists have the opportunity to really rejuvinate and revolumize faces.  But it's so extremely important to have a board-certified physician inject FDA approved materials.  I've seen people who have received injections of unknown substances by "friends" at "house parties," or other locations.  When complications arise, the injectors have no idea what to do, or they've suddenly disappeared, and patients come to our office for treatment.  While fillers are safe and effective if injected properly, complications such as nodules, swelling, infections, and tissue necrosis may occur, and the risks increase tremendously with untrained injectors and unapproved substances. 

An article in the September issue of Journal of the American Academy of Dermatology highlighted the danger of counterfeit filler available on the internet.  The authors ordered a "permanent" filler online.  The filler was branded as Aotisei, which is a recalled product, as the producing company went out of business in 2007.  The filler was in a seemingly sterile pouch labelled with the words "STERISE" and "Deel at Comer," likely meaning "sterile" and "peel at corner."  There were Chinese symbols on the pouch.  There are also illegal, unliscensed botulinum toxin products available on the internet - on 34 different sites.  Even more sites sell unliscensed dermal fillers.

The FDA has strict regulations regarding botulinum toxins and fillers, and only FDA-approved products should be used.  Please be sure you see a board certified dermatologist or plastic surgeon experienced in cosmetic treatments.  You only have one face, and it's precious! 

Dr D's favorite things

Raindrops on roses and whiskers on kittens, botox in foreheads and aquaphor with mittens; Boxes of restylane tied up with string, these are a few of my favorite things!  I'm no Oprah, but I can still share some of my favorites...

My fav sunscreens: MD Solar Science - love the texture, the tint for the facial sunscreen, that it's chemical free, and that it's gentle on sensitive skin and those prone to acne/rosacea.  La Roche Posay Anthelios has a light texture and works well as a moisturizer, too.  SkinMedica's Enviromental Defense sunscreen is a perfect post-laser and procedure sunscreen. 

My fave face night creams: SkinMedica TNS Essential Serum is one of the best -  the Mercedes of creams.  Antioxidants and growth factors in a silky serum to help combat damage from the sun and aging.  I also love NIA 24's Intensive Recovery Complex with 5% pro-niacin to repair sun damage, brighten skin tone, and smooth fine lines.

My fave anti-aging product: Renova cream.  Available by presciption only, renova is a vitamin A cream that is applied nightly and helps improve fine lines and the texture of the skin.  With years of reseach and science behind them, vitamin A derivatives are a tried and true trick of the anti-aging trade.

My fave eye creams: Revale Eye Therapy with 1% CoffeBerry - a potent antioxidant.  The caffeine in it helps to tighten and reduce puffiness, too.  SkinMedica's Illuminating Eye Cream is great for rejuvinating the underye area.

My fave fillers: with so many options, it's hard to decide!  I love Restylane and Juvederm for lips, parentheses lines around the mouth (nasolabial folds), and hollows under the eyes; Perlane and Radiesse for cheekbones and "marionette lines" (lost volume under the corners of the lips and jaw); Sculptra for overall thin and hollowed faces; Radiesse and Sculptra for hand rejuvination; and Sculptra for wrinkled chests.  All of above fillers are only FDA approved to treat nasolabial folds.

Botox and Dysport are like your kids - they are a bit different but you still love them equally.  I use them both and think each is very effective and safe for wrinkles caused by movement.

Finally, lasers: Fraxel Dual Re:Store is amazing for brown spots and sun damage, and stimulates collagen growth.  Intense Pulsed Light treatments treats brown spots as well as blood vessels from sun and conditions like rosacea.  The Active FX/Deep FX laser dramatically improves sun damaged, wrinkled skin as well as texture and pigment irregularities.  Thermage uses radiofrequency to tighten loose skin and stimulate collagen.

When the kids cry, when the food burns, when I'm feeling sad, I simply remember to put on my creams, and then I don't feel so bad!

Stress and the skin - just say ohm

A collective sigh of relief came across the country last week.  Was it the rebounding stock market?  The avoidance of disaster from Irene?  Or the fact that Kim Kardashian is finally married?  Alas, no.  Parents everywhere are rejoicing that school has started.  And with one less thing to stress and worry about, everyone should now have clear skin. 

"What do you mean, Doc?" you may say.  "Stress can affect skin?"  You betcha!

When we're stressed, our bodies produce more of a hormone called cortisol.  We need that hormone in stressful situations- if we're in danger, about to be attacked, our body responds by saying "run!  escape!" and that cortisol kicks us into high gear.  But when constant low levels of cortisol are released, it is not a good thing. 

Stress can:
increase hair loss
make psoriasis worse
flare acne and rosacea
cause hives
precipitate a shingles outbreak
bring out cold sores
weaken the immune system, making it harder to fight infections
worsen eczema
lead to picking and pulling of skin/nails/hair

But there are ways to manage stress in our lives.  Exercising daily and eating a well balanced diet full of fruits, vegetables, and whole grains combats fatigue and stress, and increases energy levels.  Yoga, breathing exercises, and a few minutes of mediation daily help to lower cortisol levels.  Limiting alcohol and not smoking are important to keeping a healthy glow to the skin.  Spending time with family, friends, and pets builds connections and a strong emotional support system.  Hobbies, like gardening, or painting, are soothing and calming.  Find something you enjoy and look forward to, and make time for it.

As a mom, wife, daughter, friend, sister, and physician, I know how hard it is to try to balance it all.  It's important to take a moment for yourself and create calm in your day.  Stress is impossible to avoid all together - but reducing and managing it is key for a healthy mind, body, and complexion!

the dreaded "i" word

Recently, I saw a little boy for a rash on his face.  His mother, impeccably dressed and coiffed, turned to me and said, "Doctor, is it-" she paused, looked around to make sure no one was around, and continued in a hushed voice, "impetigo?!"  Her eyes were filled with horror. 

Oh, the dreaded "i" word.  It strikes fear in the hearts of parents everywhere, who know that their child will swiftly be sent home from school/daycare/camp/etc if those contagious honey crusts show up on their little angel's face.  Okay, so maybe that's a little bit of a dramatization...

What is impetigo?  It's a superficial infection of the skin caused primarily by two types of bacteria: staphylococcus aureus, streptococcus pyogenes, or both.  It tends to affect preschool children and young adults.  Usually it starts as red areas on the skin that become little blisters filled with fluid, which then burst and dry as golden, honey yellow crusts.  Sometimes kids can have fever and enlarged lymph nodes, but more often, they feel fine.  Often the face is involved, but arms, legs, buttocks, fingertips, and toes can be involved as well.

Why does this happen?  These two bacteria can live on the skin and in the nostrils of the patient and/or the patient's family members.  The bacteria then overgrow in certain areas of the skin, causing the rash and blisters. 

A dermatologist will usually culture the skin or the nose or throat, and will treat with both topical and oral antibiotics.  All the family members should be treated as well, because they may be carriers of the bacteria.  Since impetigo tends to recur, prevention with antibacterial washes can help, too.  Treatment with antibiotics is almost always sufficient.  In very rare of strep impetigo, kidney infections or scarlet fever can occur, so it's important to see a dermatologist or pediatrician for treatment.

Junior did not have impetigo.  For now, at least... 

 

the pimple that's not a pimple

It seems like a pimple on the nose.  Only it's been there for 3 months.  And sometimes it bleeds.  And when squeezed, nothing seems to come out of it.  What's up with this wierd pimple?

This "pimple" has a funny name.  It's called basal cell carcinoma.  And it's not a pimple; it's a skin cancer.  The most common type of skin cancer, in fact.  According to the Skin Cancer Foundation, an estimated 2.8 million are diagnosed annually in the US (check out http://www.skincancer.org/Skin-Cancer-Facts/ for some great info).  It tends to show up on sun exposed areas, like the nose, ears, and chest.  Although it almost always is limited to the skin, basal cell carcinoma can be locally destructive if not treated. 

Depending on the type and location of the basal cell carcinoma, different treatment options can be used.  Superficial basal cells may be treated with a cream called imiquimod that is applied 5 times a week for 6 weeks.  Or, a scraping procedure called electrodessication and curettage (ed&c) can be performed in the dermatologist's office.  Larger or infiltrative basal cells can be excised in the office under local anesthesia by the dermatologist.  Very large basal cells, or ones located on the nose, lips, ears, or close to the eyes, where there is not a lot of tissue available, may be removed by the Mohs procedure.  This is a special type of skin cancer surgery where tissue is removed and checked under the microscope while the patient is still in the office.  Once the Mohs surgeon has determined that all the skin cancer has been removed, the area is stitched up.  Mohs surgery has a very high cure rate.  Usually dermatologists who perform this procedure have an additional year of training after residency to become experts in Mohs.      

Once someone has had one basal cell carcinoma, they are 50% more likely to develop a second one.  As this type of skin cancer is directly related to sun exposure, protecting your skin from the sun is a great way to prevent their development.  Proper sunscreen use of a broad spectrum UVA/UVB sunblock is essential.  Clothing, such as hats and shirts, that are specially treated to have a UPF (ultraviolet protection factor) of 50+ can really help protect your skin from the sun.  See my recent interview on NBC6 on sunprotective clothing on our website, www.southbeachdermatology.biz for more information. 

Any "pimple" that doesn't go away, bleeds, itches, crusts, or grows needs to be seen by a dermatologist to make sure it's not a skin cancer ASAP.  Remember, one in five Americans will develop skin cancer in the course of a lifetime.  Stay on top of your skin - it's the only one you have!

Wrinkles and lines and creams?! - oh my!

Some new things are happening, and it's nothing to furrow your brows at.  A novel fighter in the war against forehead wrinkles is about to come on the market.  And studies are promising for a topical (read: CREAM) to treat forehead wrinkles.

There's Botox, there's Dysport, and now there's... Xeomin.  It was approved by the FDA in July 2010 for the treatment of blepharospasm (eyelid spasm) and cervical dystonia, but hasn't received the approval for cosmetic use just yet.  One of the main differences between Xeomin and the other two neurotoxins is that it's a "naked" toxin.  This means it doesn't have any stabilizing proteins around the toxin molecule.  Does this matter?  Maybe, maybe not.  On one hand, the less proteins, the less chance a person will develop antibodies that may make the treatment less effective.  On the other hand, studies have shown that once the powder that the toxin comes in is mixed with saline to form a liquid, 85% of the proteins separate from the toxin (before it is even injected into the patient). 

But this is America, and competition is always good.  Once Xeomin receives it's cosmetic FDA approval, it will be a welcome addition to our tool box.  But what about people that don't want injections?  Is there an option for them, too?

Currently, phase 2 trials are being conducted where a neurotoxin gel called Revance is being applied to crow's feet, and the results are promising.  In one of the studies, results lasted for 115 days.  The current plan is for the gel to be applied in doctor's offices.

The great thing about medicine is that it's constantly changing.  New products, new procedures, and new techniques are always emerging.  We're getting closer and closer to outsmarting aging. 

Ain't Nothing Rosy About It

"Are you hot?  Or embarrassed?  Why are your cheeks all red?"  If you're one of the millions of Americans suffering from rosacea, answering these questions can be a daily annoyance.  So let's set the record straight and get to the nitty gritty.

Rosacea is a chronic, inflammatory disease that usually affects the face, and sometimes the eyes.  Chronic; meaning there is no cure, but there are many treatments that can help control the disease, which I'll discuss in a minute.  Inflammatory; meaning the skin is overactive and sensitive, and has lots of white blood cells around oil glands and hair follicles, and dilated blood vessels.  Think of it acne's older cousin.

The condition can look different in each individual.  Some people have increased blood vessels on the nose and cheeks which makes them look red and flushed.  Others may have acne-like lesions: pimples and pustules.  More severe cases can have thickened tissue on the nose, making it look bulbous (think W.C. Fields).  It can affect the eyes, making them red, dry and feel "grainy."  A combination of all or none of the above can be present.

We don't know exactly what causes it.  Genetics may play a role.  A mite called Demodex folliculorum (that lives on our skin normally) may play a role.  It is clear, however, that certain factors may make it worse, although these also vary from person to person.  Alcohol, spicy foods, heat, stress, and sun exposure all can aggravate rosacea.

Luckily, a lot of treatments are available.  Oral antibiotics, especially tetracyclines, can help to decrease inflammation and calm bumps.  Topical antibiotic creams, azelaic acid creams, sulfur washes/creams are all often prescribed.  Lasers, like the intense pulsed light, can zap blood vessels and help reduce redness.  In severe cases, accutane and surgery may be used.  In all cases, sunscreen and sun avoidance should be part of a daily regimen.

So get friendly with your favorite dermatologist, and put an end to those irritating questions.

Zits and wrinkles?!

Just as the Botox starts wearing off on your forehead and the wrinkles return, you also notice you've broken out in three huge zits on your face.  Wrinkles and acne?  Weren't you supposed to outgrow those pimples?  What gives?

The fact remains that age has little to do with it.  A lot of factors are involved in acne.  One of the key players in women is hormones.  Maybe you've noticed you tend to flare right before your menstual cycle starts, and then pimples clear once it's over.  Levels of androgens, a type of hormone, fluctuate during the month.  They stimulate the sebaceous glands in our skin to produce excess oil and sebum, which contribute to the formation of blocked pores and pimples.  Some women also experience irregular menstrual cycles, hirsutism (excess hair growth), and weight gain in addition to acne.  Such symptoms may be due to a condition called PCOS, or polycystic ovarian syndrome.  This diagnosis can be made by your dermatologist or ob/gyn by checking blood tests, and sometimes an ultrasound.

There are treatments available to help decrease levels of androgens and regulate menstrual cycles, which can often help improve acne.  Oral contraceptive pills (birth control) and an anti-androgen medication called spironolactone are often used.  Oral antibiotics, and prescription topical medications: antibiotics, benzoyl peroxide, and retinoids can dramatically improve skin.  Finally, accutane is a very effective medication for severe acne that does not respond to other treatments.

What about diet and acne?  There's been a lot of discussion about dairy, sugar, and chocolate, and their effects on acne.  Although there is nothing conclusive, and more studies are needed, it makes sense that certain foods that can increase inflammation in the body.  The "white" foods: white sugar, white rice, white bread, potatos, etc are nutritionally empty foods and raise sugar and insulin levels, leading to increased inflammation, which may be harmful to cell health.  Eating a balanced diet rich in whole grains, vegetables, and fruit, with a limited amount of animal fats and sugary foods, is a good idea in general.  Foods rich in antioxidants, like berries, oranges, pomegranates, salmon, dark chocolate, red grapes, and greens help keep the skin looking healthy.  So while dairy is an important source of vitamin D and calcium for women, lowfat greek yogurt is a better choice an a vanilla milkshake (sorry!).

Makeup and products can often be the culprit in breakouts, as well.  Look for makeup that is labeled "noncomedogenic," meaning it won't clog pores.  Oily sheens for hair can often add to breakout along the forehead.  Use mild, gentle cleansers and avoid harsh, abraisive scrubs.

So, there are lots of factors to blame acne on.  Thankfully, there are lot of solutions, too.
    

Pretty Boys

I saw an attractive man in his 30's in my office yesterday.  After performing his full body skin exam to check his moles, I asked him if there was anything else I could help him with.  He pointed to his forehead and said, "Well, I really hate these lines on my forhead."  I explained to him that those could easily be improved with either Dysport or Botox.  With genuine shock he exclaimed, "Botox?!  Isn't that for chicks?"

Actually, no.  According to a recent report from the American Society of Plastic Surgeons revealed that men underwent more than 1.1 million cosmetic procedures, including both minimally invasive and surgical procedures, up 2% from 2009.  There are many reasons for this increase.  First, a practical reason: with the downturn in the economy and recent job losses have forced many to search for new positions, and men want (and maybe need?) to appear younger, fresher, and brighter to stay competitive.  And second, men are realizing what their female counterparts have known for years: that small, non-invasive changes, like Botox/Dysport, fillers, peels, and lasers, can make a BIG difference in how you look and feel.

Eating a healthy diet, exercising, safe sun practices, and a great dermatologist: the keys to the fountain of youth for both women and men!

Hairy and the Hendersons

South Florida is hot, hot, hot.  Down here, it's bikini season year 'round.  Short shorts and bikinis are in, extra body hair is not.  So what's a girl or guy to do?

There are lots of options for getting rid of excess hair.  Shaving, waxing, plucking, electrolysis, and depilatory creams are all means of hair removal.  However, they can be time consuming, painful, ineffective, and/or irritating to the skin.  Enter laser hair removal.

In laser hair removal, a laser beam of a certain wavelength targets the hair follicle and destroys it.  I like to call it permanent hair reduction, rather than permanent hair removal.  Hair growth occurs in cycles, (see my last blog post: Those Fabulous Tresses for more information), so multiple laser treatments are needed several weeks apart for best results.

Because the laser targets the hair in the follicle, the treatment won't be effective if the hairs are waxed or plucked prior to treatment.  Often, shaving is encouraged the day before the treatment.  An anesthetic gel is sometimes applied to the area prior to treatment to ensure minimal discomfort.  A cool gel, or a cooling tip on the laser is used to protect the skin.  The length of time of the treatment depends on the area being treated: an upper lip takes less time than a bikini area.

Usually, the skin will look red temporarily after the treatment.  Some crusting may occur.  It is very important to protect skin from the sun prior to and after any laser treatment.  Tanned skin is at risk for hyper or hypopigmentation (dark spots or light spots), and it's best to avoid any laser treatment on skin that is tan or recently exposed to the sun.  Similarly, darker skin types are at risk for pigment disturbances with laser hair removal.  Laser hair removal generally is not effective on blond or white hairs.

These days, lasers for hair removal can be found on every corner.  You only have one skin: it's wise to see a board certified physician for the best possible results to leave you smooth and (relatively) hairless!

Those fabulous tresses

It happens to millions of women and men.  It's so frequent, in fact, that there's a billion dollar industry of "solutions" to the problem.  We're talking hair loss, and it ain't no laughing matter.

Normally, our hair grows in a cycle.  When hairs are in their growth phase, they are called anagen hairs.  When they are resting (not growing), they are called telogen hairs.  Catagen hairs are transitioning from growth to rest.  Anagen hairs grow for about 3 years on average (the range can be between 2-6 years).  The transition phase lasts about 1-2 weeks, and then hairs rest for 3-5 months.  They shed, and the cycle starts all over again.  At any given time, if you pluck a number of hairs from the scalp, about 85% will be in the growth phase and 10-15% will be resting.  Less than 1% will be in the transition phase.  We can tell this by the shape of the hair and follicle when it's examined under the microscope.

It's normal to shed 100-150 hairs daily.  Think about it- that's a lot of hair.  And even more so on days that you shampoo.  But sometimes, that number increases, and the hair starts thinning or revealing bald patches.  So let's look at some reasons why people lose their hair.

Pregnancy.  During pregnancy, the anagen (growth) phase is often prolonged and many women enjoy thicker, fuller hair.  On delivery of the baby, however, many follicles change into the telogen phase, and then are shed simultaneously, resulting in thinning/loss of hair 3-5 months after baby comes.  This process is known as telogen effluvium.  And it's one more reason to give your mom a hug-- she brought you into this world and then endured hair loss!

Iron Deficiency.  Low iron levels (seen in a blood test), sometimes caused by mensturation or gastrointestinal blood loss, can also cause a telogen effluvium.  Nutritional deficiencies are often treated with vitamin supplements and a varied, healthy diet. 

Thyroid Deficiency.  Variations in thyroid levels can often cause telogen effluvium as well.  Levels can be checked with a simple blood test.  Thyroid medications, usually monitored by an endocrinologist (doctor who specializes in hormones) can help. 

Medications.  Lots of medications can cause hair loss.  Drug-induced telogen effluvium has been reported with amphetamines, blood pressure medications (captopril, metoprolol), antipsychotics (lithium), retinoids (etretinate), and more.  Changing/discontinuing medications can help.

Androgenetic alopecia is another term for male-pattern and female-pattern baldness.  In this condition, a hormone called dihydrotestosterone affects the androgen receptor gene to cause hair loss.  There is likely a genetic component.  Men tend to show a receeding hairline with loss of hair on the top of the scalp.  Women tend to get thinning along the middle part of the hair in a "Christmas tree pattern."  Several treatments are available, such as rogaine, and for men, finasteride (propecia) is FDA-approved. 

Other conditions that can lead to hair loss include fungal infections, autoimmune diseases (such as lupus or alopecia areata), psoriasis, bacterial infections, and syphilis.  Trauma to the hair from tight ponytails, frequent relaxer and hair color use, and overstyling can also lead to hair loss.

Often blood tests and scalp biopsies are useful to find the cause of the hair loss.  Dermatologists are expert in skin, nails, and hair, and can help!

Keeping Up with Kim and Psoriasis

Kim Kardashian has revealed she has psoriasis.  (Not ringworm, like Khloe originally thought).  She now joins the millions of other people affected with this condition.  So what is psoriasis?

Psoriasis is a common, chronic, inflammatory disease that can affect the skin and nails.  Although it's not completely clear what causes it, it is an autoimmune disease where the body's own white blood cells (T-cells) attack the skin. There is also a genetic component.  It happens equally in males and females, and usually appears when a person is in their late 20's, but it can be seen at any age, from babies to the elderly.  Severe stress tends to make it worse (i.e. the dermatologist told Kim to work less).

Typically, psoriasis looks like red patches with white silvery thick scale on top.  The patches can vary in size.  Common locations include the elbows, knees, scalp, abdomen, and loewr back.  Sometimes the patches can itch or burn.  The nails can show changes, too - pitting (which look like little indentations), oil spots (yellow areas), or can be thickened.  Patients can get arthritis which can affect the fingers and/or spine.  Sometimes psoriasis can occur after a strep throat infection, and will look like little patches the size of water droplets.

The course of psoriasis is unpredictable.  And unfortunately, currently there is no cure.  But there are a lot of great treatment options to help manage this skin disease and relieve the pain from arthritis.  A laser called the eximer laser is helpful for smaller areas or limited disease.  Light treatments in the dermatologist's office can help for more widespread disease.  Topical steroid, vitamin D, and retinoid creams and foams are often prescribed.  More more extensive disease, oral treatments are available.  The most recent class of medications are called the biologics.  These are injected by the patient every month and are extremely beneficial to relieve both the skin lesions and the arthritis.  Some names of medications you may have seen comercials for are enbrel, humira, and stellara.  They can make a huge difference in daily quality of life.

The bottom line: there's hope.

An Unwelcome Guest

We've all seen someone with it.  Or maybe you've got it yourself.  The dreaded cold sore on the corner of the lip.  It warns you it's coming with a tingling and burning feeling, then the painful blisters arrive and often outstay their welcome.  So what's the deal with these cold sores?  Where do they come from?

A virus called herpes simplex virus (HSV) is responsible for causing cold sores, also referred to as fever blisters.  It most commonly occurs in young adults, but can be seen at any age, including infancy.  Many people are infected with the virus and never develop cold sores.  Others may have sores but they aren't painful or symptomatic.  And yet others will have fever, headache, or pain associated with the blisters.

80-90% of herpes infections seen on the lips are caused by HSV type 1, and 10-20% are caused by HSV type 2.  Genital herpes is usually reversed, with 70-90% caused by HSV-2, and 10-30% caused by HSV-1.  But this is not a hard and fast rule; either type can be seen with lips or genitals.

So how is this virus spread?  Usually skin-skin contact is required.  The virus is shed in skin or secretions.  When herpes is seen in wrestlers due to skin-to-skin contact, it's called herpes gladiatorum, and is more common on the head, neck, or shoulder.

Unfortunately, once you've contracted HSV, it's there for life.  (So what happens in Vegas doesn't always stay in Vegas...).  It stays dormant in the nerves and gets reactivated later on.  About 1/3 of people with cold sores on the lips will have a recurrence.  And of these, 1/2 will have at least two recurrences annually.  Usually there is a precipitating factor to bring it out: sunburns/sun exposure, fevers/colds, stress, and altered hormones. 

Before we discuss treatment, let's talk prevention.  Avoid skin-to-skin contact with an area during an outbreak.  The outbreaks are usually treated with oral antiviral medications such as acyclovir, valcyclovir (valtrex), or famciclovir.  If the outbreaks are very frequent, daily suppressive therapy may be used.  There are topical presciption creams, as well, but they are typically not as effective as the pills.  The medications work best if they're used as soon as the tingling/burning feeling comes on.  Although there's no cure, with today's treatments, the discomfort can be minimized and sometimes prevented.

3-2-1 Contact!

Almost daily, I see someone with an itchy rash from something they came into contact with that has irritated the skin.  This condition is called, fittingly, contact dermatitis.  Figuring out what caused the rash requires a little bit of detective work.  Luckily, the location of the rash can often give some clues:

Eyelid rashes: the most common causes are nail polish (especially containing formaldehyde) and acrylic nails (the glue contains ethyl methacrylate or methyl methacrylate).  Also makeup/cosmetics (preservatives like methylchloroisothiazinolone and imidazolidinyl urea) can irritate the eyelids.  Contact solution containing thimerosal is a common culprit.

Earlobes and belly buttons/abdomen rashes are often caused by items containing nickel, the most common allergen.  This includes costume jewelery, belt buckles, and metal snaps/fasteners that rub against the skin.  Kids with eczema/atopic dermatitis (see my previous post- Itchin' An A Scratchin'- to learn about this condition) often have nickel allergy.  Parents can sew patches on the inside of pants to keep the metal parts from coming into contact with skin. Test before you wear: a chemical called dimethylglyoxime can be painted on a metal object and will turn pink if it contains nickel.

Hand contact dermatitis often varies based on profession and hobbies.  People who wear gloves often have allergies to latex and rubber.  A fun fact: people allergic to latex may also be allergic to avocado, bananas, chestnuts, and kiwi.  Dentists and surgeons can get rashes from ethyl methacralate.  Cleaning agents can contain preservatives that release formaldehyde.  (Aside from the fact that frequently wetting hands will cause irritation in general).  Hobbies, like building model planes and cars, can expose you to glues.

Foot contact dermatitis may be caused by the rubber in shoes (mercaptobenzothiazole) or the leather portion (chromates).  The rubber part along the top of socks may cause a contact dermatitis on the shins.

Scalp contact dermatitis may be due to hair dyes containing para-phenylenediamine.  This chemical is found in henna tattoos (this is what makes the tattoo have that black color instead of the traditional reddish-brown), and people can get rashes from those, too. 

One of the most common allergies is to neomycin.  This is found in topical antibiotic creams or first-aid creams, ear drops, and nose drops.  Often people are also allergic to bacitracin as well.

And the list doesn't stop there.  People can be allergic to fragrances, lanolin, tape adhesive, plants, and medications.  If the cause of the contact dermatitis isn't obvious, patch testing can be performed by the dermatologist, where the most common allergens are taped on the back and then removed a few days later to look for a reaction.  Learning what allergens to avoid can make all the difference!

Melanoma

This past weekend, The Miami Herald published a special section called skin health.  In it, they talked about two new drugs for the treatment of advanced (stage 3 and 4) melanoma.  These are the FDA approved Ipilimumab, or Yervoy, and the not-yet approved Vemufafenib.  These drugs are very promising and exciting because patients diagnosed with advanced melanoma have previously had few options for treatment, and are often facing a sentence of less than 6 months to live.  The studies, (part of which were performed at Mount Sinai in South Florida) are promising and show a lot of hope for those with advanced disease.

It's really important to realize though, that IF melanoma is caught and treated early, it can be nearly 100% curable.  Thankfully, the majority of melanomas that I see are called melanoma in situ (stage 0).  This means that the melanoma is in the very very top layer of the skin and has not penetrated deeply.  It's removed surgically, done in the office under local anesthesia.  Even melanomas that go a little bit deeper in the skin (stage 1, 2) often have a good prognosis and are treated with surgical excision.  Melanomas that measure deeper need more testing (in addition to the surgical removal), such as lymph node testing and imaging.  If a melanoma is deeper than that, then it is considered advanced and chemotherapy is added to the treatment regimen. 

Early detection is the KEY.  Any new, changing, itchy, bleeding, crusting mole needs to be evaluated asap by a dermatologist.  Don't wait to see your doctor.  With melanoma, the depth is the greatest predictor of survival.  The earlier we catch it, the better.  But once you've been diagnosed with melanoma, you're at increased risk for developing another one.  You'll need close monitoring by your dermatologist for the rest of your life. 

While genetics definitely plays a role in the development of melanoma, what you do on a daily basis makes a difference.  Of course, sunburns are a big no no, which I think pretty much everyone knows.  But any tan is a sign of sun damage, which puts you at risk for melanoma.  DON'T TAN - either in the salon or outdoors.  "Oh, don't worry, Doc, my skin is naturally tanned."  Really?  Take a look at your buttocks.  That is your real skin color.  Still think you're naturally tanned?  Slather on a physical blocker, at least an SPF 30, and reapply.  Avoid the sun between 10 am - 4 pm, when the rays are strongest.  Wear a hat, sunglasses, and sun protective clothing.  Stay in the shade.  And teach your kids to do the same. 

While we are all excited over the new developments for advanced melanoma, my hope is that with prevention and early detection, we won't have to use them.

Itchin' an a scratchin'

I see it in babies, kids, teens, and adults.  It gets itchy, sometimes infected, and often annoying to patients.  In Greek eczema means "to boil over," which refers to the blistering or weepy phase of the disease.  Eczema can start in infancy as crusted patches on the scalp, cheeks, tushies, arms, and legs.  Later, as kids get older, it often shows up on the inside of arms and backs of knees.  Adults usually develop hand and finger dryness and cracking, which is often painful. 

Although we don't know exactly what causes it, it seems to run in families and has a genetic link.  The immune system may be more sensitive to certain triggers.  Often, asthma and seasonal allergies run together with eczema.  People that have two of three of this conditions are called "atopics."  They have sensitive skin that is easily irritated.

Here are my tips for anyone with eczema or sensitive skin.  Make sure all soaps, detergents, and moisturizers are mild and fragrance free.  I like dove, cetaphil, cerave, eucerin, and vanicream.  Since I just mentioned moisturizers, let me say it again: MOISTURIZE!  You can't do it enough.  The love of my life (after my hubby and daughter) is aquaphor.  I love it for any skin area, as a lip moisturizer, for laser and peel after-care, for wound healing, on areas after biopsies and surgeries, etc.  Slather it on.  If it seems too greasy to use during the day, put it on at night and sleep with it.  For dry, cracked hands, slap on aquaphor and then cotton gloves on top.  It's amazing stuff.  Did I mention that I love it?  Make sure baths and showers use lukewarm water, not hot water.  Moisturize right after coming out of the bath, when skin is still damp.  Avoid soaking your hands in water; use gloves when doing the dishes or housework.  And certain fabrics, like wool, can be very irritating to atopic skin.

When moisturizing is just not enough, there are prescription steroid and non-steroid creams for the skin, as well as antihistamines that can be recommended by your doctor.  Also: raw, scratched areas can easily become superinfected with bacteria and viruses, so it's important to see a dermatologist regularly.  Although many kids will outgrow eczema, there are plenty of adults with it to tell you that this doesn't always happen.  Luckily, summer months are usually better for atopic skin than cold, dry winters.  And here in south Florida, we have plenty of summer!


 

The Appeal of Peels

What can brighten dark spots, improve acne, even out skin tone, and treat mild photoaging, but with minimal downtime?  Glycolic acid peels!  Of all the tools in the dermatologist's toolbox, a glycolic acid peel is a tried and true procedure for great cosmetic results and an overall improved texture of the skin. 

What is glycolic acid?  It's an AHA, alpha-hydroxy acid, which is a naturally occurring compound made from sugar.  The depth or strength of the peel depends on which concentration is used.  20-50% glycolic acid is a very superficial peel, while 50-70% is a little stronger (deeper), but still considered a superficial peel.  Superficial peels affect the very top layers of the skin, so there is little risk of scarring or hyperpigmentation (darkening after the peel).

What happens when I come for a peel?  Before the peel, the skin is cleansed with soap and water, cleansed with alcohol or acetone, and the rinsed with water.  The reason for this is to remove oil and debris from the skin.  The glycolic acid is then applied to the skin.  Usually it is left on for 2-4 minutes.  It may sting a little or feel like mild burning during this.  Often, handheld fan helps.  Then the skin is neutralized with a solution and/or washed with water.

What happens after?  Most people will have mild redness/pinkness a day or two after the peel.  If it was a deeper peel, mild crusting can be seen.  Often, vaseline is applied to help with healing.  After any peel, it's very important to avoid the sun and wear sunscreen.  Daily moisturizer should be applied.  Smoking is should be avoided (although, shouldn't it always be avoided?) because it slows healing. 

And then?  Radiant, healthier looking skin!  Peels can be done every few weeks.  Who shouldn't do peels?  Anyone who has been on accutane in the last 6 months, anyone with an active herpes infection, and anyone with a tan.  Not that you would ever be tan, though...right?! 

Leg Road Map

Children are so wonderful, aren't they?  They truly light up our lives with their shining eyes and smiling faces.  So wonderful, in fact, that we can almost overlook the changes they cause to our bodies.  Loose, sagging skin, stretch marks, and little winding leg veins are a small price to pay for the glory of motherhood, right?  Um, right?

Thankfully, we can improve those (ahem) little issues that occur after Junior is born.  Let's talk about sclerotherapy, which is a procedure performed in the dermatologist's office for small varicose veins on the legs.  After all, it's summer, and time to wear shorts and skirts!

Sclerotherapy involves injecting solutions into varicose veins to "close the veins down."  They do this by irritating or damaging the lining of the veins enough to form a small clot, which over time, will be replaced by tissue.  Different agents are injected to acheive this, including: hypertonic saline, sodium tetradecyl sulfate (STS), polidocanol, and glycerin.  Currently, STS and polidocanol (Asclera) are FDA approved for the treatment.  Which solution to use depends on the physician's preference and the size of the vein being injected.

The treatment session usually lasts 30 min-45 min.  There very minimal discomfort during the procedure, which is often dependent on which solution is injected.  Asclera tends to be more comfortable than hypertonic saline.  Compression stockings are sometimes worn after the treatment.  Usually, 2-3 sessions are recommended for best results, but veins will improve even afte the first treatment.  Pregnant or nursing women should not have sclerotherapy.

Having kids doesn't mean you're destined to hide your legs for the rest of your life.  Like I always say, "Ain't nothing vain about treating veins!"

Sweating is the Pits

Summer and 4th of July!  Hot dogs, ice cream, pools, fireworks, and for some, shirts with soaked underarms?  There's nothing fun about having to avoid wearing certain fabrics, or colors, or styles of shirts because you just know that in an hour there will be large dark circles under your arms.  And in the south Florida heat, sweating is a given.

But there are solutions for severe underarm sweating.  Both over-the-counter and prescription topical solutions, usually consisting of aluminum chloride, are often prescribed.  But when they fail, it's Botox to the rescue.

"But Doc," you may say, "isn't Botox for wrinkles?"  Yes, it is.  And it's also FDA approved for primary axillary hyperhidrosis (ie severe underarm sweating).  Dermatologists inject small amounts under the skin in the underarms.  Significant improvement and reduction of sweating is usually seen within 1 month of treatment; often sooner.  And results last approximately 6 months. 

Now, that's worth raising an arm about!

Saving face

I was looking at old pictures of my daughter the other day.  Even though she is only 17 months old, her face is already starting to transform from baby to young girl.  She is losing the chubbiness of her cheeks, the roundness of her face.  Tear - my baby is growing up!

Our face is constantly changing as we age.  But the transitions are more complex than just getting wrinkled.  Have you ever seen a person in their 50s or 60s with perfectly smooth skin, yet somehow they still look old?  The reason is because the structure of our face changes dramatically with time, not just the surface of our skin.  So what happens to our faces?

The bones of our face act as a foundation.  Just as a house sags where the foundation is weak, so does our face (nice, right?).  With time, the bones around our eye sockets receede, contributing to the hollows around our eyes.  Our temples become hollow.  Our upper and lower jaw bones atrophy, decreasing the size of our lower face, and making jowls appear.  Our chins get smaller.  This skeletal resporption changes the proportion of our face, making us look older.  Enter scrulptra and radiesse, two fillers available right now, approved by the FDA for naso-labial folds.  They are used off-label for full facial volumization, injected to help replace the bone loss.  When used properly, they can change the shape of the lower face, allowing a more youthful look.

Above our bones, we have fat.  These fat pads form our cheeks.  When they atrophy, our cheeks become hollow, making our naso-labial folds (the lines on the sides of our mouths) look deeper.  The hollows make us look tired.  Scultpra and radiesse can be used here to restore our cheekbones to their previous glory, in addition to the hylauronic acid fillers: juvederm, restylane, and perlane (all off-label uses).  Hyaluronic acid fillers also work well to fill finer lines and lips (again, off label).  I'll blog more about these separately. 

In addition to the structure of our face, there are surface changes as well.  With time, we lose collagen and make more elastin (think rubber bands....stretchy, saggy).  The more sun exposure you've had in your lifetime, the more loose your skin will be, and the less it "snaps back."  Add in lines from movement, and it equals crow's feet, pucker lines around the upper lip/lower lips, glabellar lines ("eleven lines" between the eyebrows), and forehead lines.  These are corrected with botox and dysport (although they are only FDA- approved to treat glabellar lines; all other uses are off-label).  Plus, the sun causes brown spots on the face and dilated blood vessels, especially around the nose.  For these, often a combination of lasers (like the Fraxel or Active FX, peels, and cosmeceutical creams help.  For saggy areas, Thermage, a radiofrequency device, tightens by using heat to stimulate collagen formation.   

Aging is inevitable.  I see it daily at both home and in my office.  But luckily, modern medicine can help us acheive a natural, healthy look: a volumized face and skin (almost) as soft as a baby's bottom!

Emergency!

Almost weekly, I will get a call in the office for a patient that needs to be seen for a skin emergency.  Jerry Seinfeld would joke, "What, an emergent pimple?"  (Remember the pimple popper, MD episode?)  In a word, yes.  Usually, the patient is coming in for an infected sebaceous cyst that has become an abscess.  By the time they're seeing me, it's usually because it's grown in size and become extremely painful, and they need treatment, stat!

What is a sebaceous (epidermal) cyst?  It's a closed sac under the surface of the skin that contains material called keratin, which looks like a white, cheesy material.  They can be located almost anywhere: the face, neck, trunk, and groin area are usually the most common.  They are usually caused by genetics, damage to hair follicles, and ruptured sebaceous (oil) glands, commonly seen in acne.  In general, sebaceous cysts are benign growths, and usually, don't need to be treated.

But sometimes, because of the cyst location, or trauma, or other factors, the cyst becomes inflamed: red and tender.  If it's a small cyst, and doesn't look infected, the dermatologist may treat with with a steroid injection.  But if it looks infected, then it will need to be drained.  A small opening is made in the abscess and the infection will drain out.  Often, antibiotics will be given as well for treatment.  It's very important to have an abscess treated by a dermatologist, or the infection will fester and could possibly spread into the blood. Because drained cysts tend to recur, surgical removal of the cyst may be planned once the infection has been treated.

I should point out that other things, such as skin cancers, can look like lumps or bumps under the skin.  Any growths should be checked by a dermatologist.  But Jerry Seinfeld already knew that. 

Beautiful Girls

Halle Berry.  Michelle Pfeifer.  Megan Fox.  Chances are, when you hear these names, you think of the word beauty.  But what makes us label these women as beautiful?  Many people will say that symmetry is what makes people look beautiful.  To a certain extent, this is true.  Our eye is automatically drawn to what is abnormal, or "stands out" on someone's face.  An imperfection or asymmetry on one side of the face is often considered less appealing.  Think of Austin Powers, where Mike Myers can't stop focusing on the "moley moley moley mole."  Or when you have a large pimple on your face and you feel like everyone in the world is staring right at it.  But symmetry is not the whole answer.  If you cut a photo of someone's face in half and superimpose one half on the other, you'll see that even the most "beautiful" people's faces are not perfectly symmetric.  Conversely, if you computer generate a person with both sides of their face in perfect symmetry, they actually just look...wierd.

Often we consider certain features to be more attractive.  High cheekbones, wide eyes, full lips, white, even teeth.  But what about people whose features don't conform to that?  Think of Lauren Hutton's gap in her top teeth, or Angelina Jolie's large lips, or Brooke Shield's thick, heavy eyebrows.  All considered beautiful women.

So what else?  Proportion plays a large role in shaping our perception of beauty.  Dr. Stephen Marquardt talks about the "Golden Ratio," a certain proportion found in nature (1.618:1) that describes the proportions seen in the ideal, or beautiful face.  He says that this ratio is constant in beautiful faces, regardless of culture, race, or era.  The distance between the eyes, between the nose and the upper lip, and the size of the upper lip to the lower lip have all been measured and described as what is the "ideal" distance.

I personally think that the concept of beauty is too complicated to explain with a single number, or a single answer.  I think it's a combination of facial symmetry, facial volume, proportion of features, shape of individual features, clarity and texture of skin and hair, brights of the eyes, etc.  And one important feature that can't be fixed with botox, fillers, lasers, or peels: personality!       

Best Sunscreen for Kids

Before we go any further: the best sunscreen for kids is the one you can actually get them to stay still for you to put on them!  But assuming you have a cooperative little one, what sunscreen should you choose?  An ideal sunscreen for kids should protect against both UVA and UVB rays, be gentle and non-irritating, stays on the skin, and be easy to apply. 

Both chemical and physical sunblocks (and a combination of the two) are available on the market.  There's a lot of controversy about chemical sunscreens and the possible association of cancer, particularly with oxybenzone and retinyl palmitate.  Although there is no conclusive evidence of this, I personally recommend using a chemical-free sunscreen on kids, for a few reasons.  First, as a mom, I think the less chemicals kids are exposed to, the better.  Second, many chemicals (like PABA) are irritating and cause rashes - especially for kids with sensitive skin or eczema, which many have.  And finally, chemical sunscreens need to be applied 30 minutes before going outside because they have to be absorbed by the skin to work, whereas physical blockers sit on top of the skin and start working immediately.  With any sunscreen, make sure you reapply frequently, especially when swimming or sweating.

So which do I recommend?  One brand I love is the Skinceuticals physical UV defense.  My other current favorite is the MD Solar Science line.  They carry a physical gel sunblock, and a physical cream sunblock - with and without tint.  They also carry a spray and stick sunscreen (which are great as well - especially for men who hate putting creams on), but these are not chemical-free.  Their products are recommended by The Skin Cancer Foundation. The website is http://mdsolarsciences.com/  And in case you're wondering, I do not work for the company and they are not paying me to write this! 

Other things to keep in mind: sunscreen is not recommended for babies under 6 months of age.  And even with older kids, the best defense against sunburn is limiting sun exposure during peak hours.  Remember to put hats and sun protective clothing on your kids.  One brand I love is Coolibar, but there are lots of great ones out there.  Have a fun summer, but be sun safe!

Those Pesky Mollusks

Ah, summer.  Time for kids to run around outside, swim at the pool, share toys and good times with friends, and - wait, what's that little white bump on Junior's cute little belly?  Hold on, what are ALL those little bumps on his belly, and armpit, and arm?

The dermatologist confirms it: Junior has molluscum contagiosum.  Moll-what?!

Molluscum contagiosum is a common condition caused by a type of virus called a poxvirus.  As the name implies, it's contagious.  Kids pass it on to each other by direct skin-to-skin contact.  Swimming pools are often associated with infection.  While any child can get it, kids with eczema or atopic dermatitis are at higher risk, and the mollusum often shows up in the same areas affected by eczema.

How is it treated?  Well, sometimes they're not treated at all.  Molluscum will often go away on their own, but it may take up to two years.  Applying surgical tape daily to the spots has been reported as a successful treatment in some.  Other treatments include topical retinoids, scraping (curettage) the lesions, freezing with liquid nitrogen, and applying a topical cream called imiquinod.  An often successful treatment is applying cantharadin liquid in the doctor's office, that is then washed off after 4-6 hours.  It causes blistering of the molluscum and then resolution.  It's up to the doctor and the parents to decide which treatment plan would be best. 

Oh, look, Junior's smiling again.  Oh, he's laughing, how cute.  Wait, what's on the roof of his mouth?  Hand, foot, and what?!

The Skinny on Skin Care

One of the questions I often get asked is "What should I be using as a daily routine?"  You maintain your body, your home, your car, your life - and your skin is no different.  It needs to be on a regimen to look and feel its best.  But with all those products out on the market, where do you start?

The number one most important thing you should use in your skin care is SUNSCREEN.  Wait, did I write that big enough?  Let me repeat it.  SUNSCREEEEEN!  And I don't mean a tiny little dab on each cheek so that your face can still get "a little color."  You need to coat your face (use an amount the size of a teaspoon).  The sunscreen should be at least an SPF 30, and should be labeled "broad spectrum," which means it blocks UVA (rays that cause cancer) and UVB (rays that make you sunburn).  It can contain chemicals, like oxybenzone, or physical blockers, like titanium or zinc, or both.  Some brands I like are MD Solar Science, La Roche Posay Anthelios, Skinceuticals, Neutrogena Ultrasheer with helioplex, and Cetaphil.  And for those of you who still don't believe in sunscreen or sun protection, swing by my office and I'll be happy to show you some gory skin cancer photos.   

Second, I always recommend a great moisturizer chock full of antioxidants.  Antioxidants help repair damaged tissue by blocking free radicals. Look for creams that contain vitamin C, vitamin E, coffeeberry, polyphenols (found in green tea), resveratrol (found in red wine), niacin, and coenzyme Q10.  Some brands I love are NIA24, Revale Skin, Oil of Olay ProX, and SkinMedica.  SkinMedica's TNS Essential Serum combines antioxidants with growth factors for even more anti-aging power.

Thirdly, I am a big believer in retinoids.  Retinoids are derived from vitamin A and have lots of science proving their efficacy in skin repair.  Topical retinoids diminish fine lines by stimulating collagen formation, help to even discoloration and skin tone, and unclog pores (blackheads).  Retinoids are often prescibed in pill form to treat psoriasis, prevent skin cancers in patients with weakened immune systems, and to treat severe acne (accutane).  Using a retinoid at night helps to round out a strong skin care regimen.   For people with sensitive skin, it may be too irritating to use a retinoid product every night.  And pregnant or breastfeeding women should never use retinoids.  Renova is a presciption strength retinoid; RoC Retinol Correxion Deep WrinkleNight Cream is a good over-the-counter alternative.

Before starting a regimen, see a dermatologist to fine tune products for your specific skin type to get maximum results.  It's never too early - or too late - to start taking care of your face!

Welcome

Welcome, friends.  The skin is our largest organ, and it's an amazing one at that.  Think of all it does - it encases and protects our internal organs, regulates our temperature, and protects us against harmful bacteria and viruses.  It heals when cut, stretches to different lengths, withstands heat and cold, and is constantly renewing itself.  And it withstands our abuses- sunburns, smoking, exposure to chemicals, poor diet- although often, not without consequences.  Lines, spots, blotches, hollows, rashes, bumps and lumps all seem to creep up over time, and that's where I come in. 

I love what I do.  To me, dermatology is so interesting, and in the fast paced world of medicine, there is always more information, newer technology and innovative techniques.  I decided to start this blog to share knowledge and here and there, sprinkle in my two cents on life in general.  Let's have some fun!