Daily Skin Fix

How to pick like a dermatologist

My lawyer won’t leave me alone unless I remind you of my medical-legal disclaimer so here goes, again:

Electronic message exchanges to, from, or with Dr. Cook do not constitute medical advice, an evaluation, or consultation and must not be considered a replacement or substitute for a formal evaluation in the office. Information and correspondence in this blog does not form and will not result in a doctor-patient relationship. If you desire an evaluation or consultation, contact our office for an appointment. Recommended changes to your present treatment plan or therapy must be approved by your physician. Explanation and/or discussion of off-label services and/or products, if mentioned, do not reflect endorsement or promotion by Dr. Cook and must not be construed as such.

Let’s finish our review of   “Dr. Elaine’s so you think you can dermatology quiz”!!

When should I pull the flaky crust off?

• This instant
• When I want it gone so my makeup will go on smoothly
• When I can rip it off with tweezers and get good, fresh blood
• When the edges are lifted but the center is still stuck down
• When it completely lifts off by itself
• Never

When skin heals, it heals from underneath and the tissue rises up from the depth of the hole to the surface. When it get absolutely flush with the surrounding skin the cells from the surrounding normal skin start to migrate centrally into and cover the central defect. Epithelial or surface skin cells are really smart and they only want to migrate when they can do so absolutely horizontally. They don’t like to climb down into valleys or climb up hills. If you pick off a scab or crust before the tissue underneath has risen to be absolutely flush with the surrounding skin, the surface cells often won’t go ahead and move centrally to cover the hole. If you keep picking the scab off, they finally give up and say “OMG, alright already I will climb down that hole but you will be sorry because now you are going to have a divot, a depressed scar”. Once the surface cells close over a hole, the base stops rising, so it will never be flush with the skin.

Once the skin cells start migrating centrally under the scab, the crust starts to lift up at the edges as a flake. And yes, makeup makes it look worse. If you pick it off when the center is still stuck down you will see either an oozing hole in the center, or it will be shiny and red. Then your skin sends in more healing factors and it gets redder, and just tries to make another flake or crust. And you have put yourself behind another couple of days.

If you want to try to remove the edges that are lifting up, take a soft washcloth soaked in tap water (no not toner or alcohol or what have you) and gently press it on the crust. Do not rub or scrub. Leave it there 5 minutes and then let the area air dry. Often the edges that are ready to come off will lift off by themselves. Then apply a bland (meaning no glycolic, salicylic, etc.) plain moisturizer dot over it and let it soak in. Gently blot off excess.  Then apply your foundation and the flake will be less noticeable.

To cover a pimple or crust/flaky area, do not use concealer. Use a liquid foundation. Apply foundation to your entire face first, if you use foundation. Then put a small dot on your index finger and pat, pat, pat it on the spot. Do not rub. Then, press powder with a sponge over it. Do not rub. The key is to not rub but to press or pat only. If you rub over a healing spot, the foundation comes right back off.

Answer is: When it completely lifts off by itself.

What is the best way to remove those little white beads under the skin?

• Apply Retin-A 37 times over 24 hours
• Squeeze them until they pop through the skin like “Aliens”
• Scrape them off with a fingernail
• Prick the top with a clean, sharp straight pen and squeeze gently.  Once
• Do a reverse osmosis high colonic

Those little white beads are usually milia. Milia are little hard cysts under the skin that look like round white beads when they are removed. Usually they just happen, there is no particular reason.  Some people get them when they use heavy moisturizers, all day wear foundations, waterproof sunscreens, or apply mineral powder with a brush. Milia don’t have a pore so squeezing them won’t make them come out unless you squeeze hard enough to rupture the skin.

The best way to remove them is to gently prick the surface with a clean, sharp straight pin and gently squeeze them. The ones around the eyes and on the eyelids are often very hard to get out, even for me.

Answer is: Prick the top with a clean, sharp straight pen and squeeze gently.  Once. If they don’t come out easily or for those on the eyelids, come in and we will get them out.

 What are the possible complications from picking?

• Scarring
• Permanent pigmentation changes
• Infection
• Delaying treatment of a skin cancer
• Continual harassment from my husband
• All of the above

I can’t tell you how often I see women with bad scars simply from picking. The most common are on the lower face, and are depressed white gouge marks. If you keep picking you will get scars. Often the pigment cells won’t recover and you will be left with a permanent white, depressed scar that doesn’t hold makeup well because there are no pores in the scar. If you have a lot of natural pigment, you may have a depressed scar that is darker than the surrounding skin. If you have a tendency to make keloids or thick scars, it may be raised and thick. None of these is your desired outcome.

Answer is: All of the above.  So stop.

How do I know I am picking too much?

• When I have to use medical makeup meant to cover birthmarks and severe burn scars
• When I spot the Intervention production crew talking to my husband
• I keep a 10x magnifying mirror and tweezers at my side 24/7/356
• I keep picking when I know there no chance that it will help
• When Dr. Elaine tells me so
• All of the above

Women are pickers. Some women are major pickers. Every single woman I tell to stop picking already knows they are picking too much and is causing permanent damage. It’s a weird phenomenon. About half the time they are picking because they want to cover it up with makeup and think it looks worse if they don’t pick the scab off.  The rest are picking because it is there, or pick when they are stressed or anxious. It is an extremely hard habit to break and I wish I had the answer.

Only two things seem to work. The most effective and best solution is to see your dermatologist and get whatever it is you are picking at treated so there won’t be anything to pick at. Usually it is adult acne. We can treat that. The other is to pick one spot, preferably up in your scalp so the scar won’t be visible and pick at that and then leave the others alone.  Good luck with that one.

Answer is: All of the above. We see this all day long, and will commiserate and not judge (though I do tease quite a bit) because we are pickers too. But we are trained, licensed, professional pickers, who know how to do it right and know when to stop, even if it is hard for us to stop picking on ourselves. Come in and we will help you. The best solution is to get what you are picking at treated so you won’t have anything to pick on. Except your husband or significant other.

When should I stop playing junior dermatologist and see a real one?

• When I see scarring
• When I see increased redness, pain, bleeding, or pigment
• When it is not getting better within one week
• For any brown, black, growing, bleeding, or tender growth or persistent sore
• Any growth that I am not absolutely sure is not skin cancer
• When I want the best result possible
• All of the above

Answer is: Hello, all of the above. Class is dismissed. Have a good weekend.

Next: Don’t know. Will have to see what kind of a mood I am in.

If you must pick, do it like a dermatologist

My lawyer is standing over my shoulder again reminding me to remind you of my medical-legal disclaimer so here goes:

Electronic message exchanges to, from, or with Dr. Cook do not constitute medical advice, an evaluation, or consultation and must not be considered a replacement or substitute for a formal evaluation in the office. Information and correspondence in this blog does not form and will not result in a doctor-patient relationship. If you desire an evaluation or consultation, contact our office for an appointment. Recommended changes to your present treatment plan or therapy must be approved by your physician. Explanation and/or discussion of off-label services and/or products, if mentioned, do not reflect endorsement or promotion by Dr. Cook and must not be construed as such.

Let’s review “Dr. Elaine’s so you think you can dermatology quiz”!!

What is a good reason to pick at a skin spot or pop a pimple?

• It is there
• It hurts
• I really think I can get it better
• Makeup makes it look worse
• I have a date tonight
• I am stressed

Women pick.  For all of the above reasons.  It is an interesting psychological issue, because men rarely pick just because something is there. Sometimes, if it hurts or itches, but not because it is there. Very commonly I see women who pick at a lesion every morning even though they know it will make things worse, because foundation makes it look worse and it is easier to cover without the flaking or scabbing (read: healing).  And when under stress, they do it even more.

Answer is: I really think I can get it better. The only reason to pick at a pimple or spot is if you really think you are going to make it better.

How many times should I try to pick at a pimple or something on my skin before I give up?

• One
• Three
• Ten
• Thirty-seven
• Four Hundred
• Never give up

Often women pick at a pimple that they either know is “not ready,” or that they know won’t respond to picking. Like running for president, you only get so many tries before your chances of success approaches zero. It’s extremely common for women to squeeze and pick at a pimple before the white blood cells have finally consolidated into a collection of pus. The white blood cells are dispersed throughout the tissue and squeezing too early just causes them to take the path of least physical resistance and that is down and out in the tissue, not rupturing through the skin at the top of the pimple.  This causes inflammation, and inflammation brings more white blood cells, swelling, and all sorts of inflammatory chemicals into the area. Which then just gets worse.

The key to popping a pimple in a way that will actually cause it to resolve is to wait until it is ready. Leave it alone, let your body consolidate the white blood cells into a drop of pus, let it rise to the surface and then pop it. Once.  If you are not sure it is “ready,” it’s not. Wait.

Answer is: three.  But the real answer is: one. Wait like a lioness at a watering hole until the situation is perfect. Pick your time. Pounce. do it once and do it right. And get the gazelle.

What is a good indicator that a pimple will respond to picking by getting better?

• I want it to be gone
• It is deep and painful
• It is red
• I can see pus at the top
• It is draining
• I have a date tonight

Deep and painful pimples are by definition—deep. Which means that picking at the surface won’t get you to the collection of pus that needs to be drained for the pimple to resolve. It is either: not a consolidated pus collection that will “pop” and/or too deep in the skin for the pressure of a squeeze to rupture the skin above it so it can drain. Instead it will rupture down and into the tissues. And get worse.

Answer is: I can see pus at the top.

When you see a definite collection of pus at the top, that means the pimple is high enough in the skin and the thickness of the skin between the pus drop and the outside is thin enough that the pressure of a squeeze has a good chance of rupturing the pus drop outward.

What is a good indicator that a pimple will respond to picking by getting worse?

• I want it to be gone
• It is deep and painful
• It is red
• I can see pus at the top
• It is draining
• I have a date tonight

As above a deep and painful lesion is either: not a pimple that is ready to pop, or, not a pimple. If it is draining that is a sign that it has already consolidated into a pus drop and drained, or, you have been picking at it. In any of these situations picking at it won’t help. And will probably make it worse.

The answers “I want it to be gone” and “I have a date tonight” are examples of what we in the medical profession call “magical thinking.” As in, “if wishes were fishes, we would all be fishermen.”

Answer is: It is draining. But the real answer is: anything other than “I can see pus at the top.”

I am deep enough in the skin to cause scarring when I see?

• Redness
• Pus
• Blood
• Muscle
• China

The skin has 3 layers: the epidermis (surface), the dermis (containing blood vessels,  collagen, elastic fibers and tiny nerves), and the subcutaneous fat(which is…fat).  Underlying that is muscle. You will see blood as soon as you are into the dermis. Scars are made of collagen fibers and are the body’s response to injury. Collagen is made in the dermis in response to injury. When you are picking at a spot you are causing injury. So if you see blood you are deep enough in the skin to cause injury that the body responds to by forming scars. If you are deeper than that you will certainly get scarring.

Answer is: Blood

What things should I not pick at?

• Red bump filled with pus
• Deep tender pimple that I feel but can’t see
• Little white beads under the skin
• Moles
• The spot I have been picking at for 6 months
• Growths

In life there are things you can probably do, things you might get away with and things you shouldn’t do. Try to stay within the first, and only do the second if the downside is limited. “Red bump filled with pus” is in the first category, if you do it right. “Deep tender pimple that I feel but can’t see”  and “little white beads under the skin” is in the second category. “Moles,” “the spot I have been picking at for 6 months,” and “growths” are in the third group.

Moles and most growths are deep enough in the skin, you won’t be able to remove them, or if you are a masochist, you will remove them with scarring. The spot you have been picking at for 6 months isn’t going to suddenly give up and go away quietly.  And do I even need to say it—it may be a skin cancer, and even a serious one.

Answer is: Deep tender pimple that I feel but can’t see, moles, the spot I have been picking at for 6 months, growths.

Go to the dermatologist.

All right, class is out for the day.  Come prepared to finish the quiz review next time.

We all hate acne. It’s frustrating and many of our patients deal with it every day.

If you have mainly “small junky stuff” which consist of blackheads, whiteheads, pustules and under the skin, never come to a head, painful, cystic acne, then glycolic acid chemical peel treatments are for you.  You may look a little “ratty” for a day with small crusts where the pimples were, but then you will clear up rapidly.

If you have red acne, sensitive skin, or pustules, or want a acne treatment with absolutely no down-time,  then blue-light ClearLight treatments are what you need. ClearLight is absolutely pain free. You come into the office, lay down under the blue light, fall asleep, get up and go home.

These are two very different treatments that we do here in the office.  Once you see Dr Cook for an acne consult, she can determine which treatment is right for you. We are here to help.

As a part of this blog I will be posting some permanent pages about common cosmetic dermatology problems, aesthetic procedures, skin care and other topics. They will be based on what we commonly see, and common patient questions in our cosmetic dermatology clinic.  You can find them on the right navigation under 411.

Check out the first one–Acne Treatment Tips

Let me know if there is particular topic you would like to hear about.

Elaine Cook MD

Welcome to the SkinTreatment.com blog, opinions and observations of board certified cosmetic dermatologist and creator of  Dr Elaine’s Advanced Skin Treatment skin care line, Elaine Cook M.D.  I’ve been specializing in Dermatology for 27 years, the last 15 of which have been devoted to the practice of cosmetic dermatology, the development of my own skin care  line, and running SkinTreatment.com. This blog represents the summation of the knowledge and experience I have gathered over the years seeing countless patients and developing multiple prototypes for our skin care products. Some of the medical stories happen over and over again, some are more unusual. Some are purely cosmetic. Some are symptoms of underlying medical disease. All are important. All affect peoples lives.

I plan on discussing a variety of topics. Among them: the so-called “cosmetic” skin problems–acne, melasma, rosacea, aging skin, wrinkles, spider veins, cellulite, stretch marks, hair loss, age spots, sun spots, discoloration and more. I will also discuss the cosmetic procedures used to remedy these problems: Botox, Juvederm, Restylane, Sculptra, Laser, Fraxel  Laser, Intense Pulse Light Photorejuvenation (IPL), Thermage, Therma-Frax (also called Fraxage), Sclerotherapy, Chemical
Peels and the various other light-based treatments such as LED and blue light. Finally, I will be using my understanding of the skin in health and disease and my experience developing my own skin care line as a basis to discuss anything and everything about skin care products.

Basically, I will be discussing whatever I want on any given day.