Daily Skin Fix

I Hate Melasma:
How to Prevent and Treat Melasma

Finally, the last installment in the Out Damn Spot, Out, Out, I Say series on brown spots on the face, what they are and how to get rid of them. We have discussed brown spots from sun damage, raised brown age or liver spots, brown spots after acne, cosmetic skin procedures or injury. So now, Lady Macbeth, we go on to the bane of the cosmetic dermatologist’s existence, melasma.

I hate melasma. I really hate melasma. What is that you say? “That is a bit harsh Dr. Elaine, hating on a skin disease.” True. But here is why I hate melasma: I have had it. I treat it. It is really difficult to treat. It is really difficult to treat because the factors that cause it are very hard to modify. The factors are hard to modify because they are factors that are part of life: sun exposure, hormones, and skin type. Add to that the fact that the medications that we use are really hard to get right now. Often the treatments we use to treat it cause inflammation, and inflammation worsens melasma. The women who get it often have more natural pigment, which makes them more likely to pigment with treatments for melasma. Melasma is very persistent and sneaky, it often responds to treatment, but waits patiently for a tiny sliver of opportunity to start up again. Then it does, and both patients and cosmetic dermatologists get frustrated. And that is why I hate melasma.

To recap, here is what you see with melasma:

• In the mirror:  Large dark flat patches of discoloration, usually symmetrical, over cheeks, jawline, fore head and above the upper lip. It is often more obvious in low light settings, such as at sunset. It responds almost instantly to any sun exposure. It is hard to cover up with makeup.

• Diagnosis: Melasma or “mask of pregnancy,” is caused by a combination of hormones, predominantly estrogen from pregnancy or birth control pills, and sun exposure. Once it starts, melasma tends to reoccur very easily with minimal amounts of sun exposure, even if the hormonal trigger is removed. I divide melasma into two types: “relatively easy” and “hard.” The difference is dependent on how deep in the skin the pigmentation is found, and whether both the hormonal stimulation and sun exposure can be reduced. Deeper pigment is always harder to improve.

• Treatment: Involves both removing the triggers, and using creams and procedures to reduce existing pigment. Daily, year round, broad spectrum sun protection and avoidance of sun exposure is absolutely essential. Reducing hormonal triggers is often a challenge as pregnancy eventually ends, but often the need for birth control continues. Even if the hormonal trigger is removed, the melasma remains “turned on” and even tiny amounts of sunlight cause it to reoccur. Treatment at home with skin lighteners, prescription skin bleaches, retinoid creams, and sunscreen, combined with in-office chemical peels or SilkPeel microdermabrasion are tried first.  “Relatively easy” melasma usually responds fairly well to this treatment. For more resistant cases, Intense Pulsed Light, laser, and deeper chemical peels under the supervision of a dermatologist experienced in treatment of pigment, are considered. Results are varied, and these procedures may actually make pigment worse.

• Ease of treatment: Difficult-very difficult.

Melasma is almost exclusively a skin disorder in women, though very occasionally it occurs in men. It is caused by a combination of estrogen, and to a lesser extent, progesterone, hormones, found in birth control pills or devices, naturally occurring during pregnancy or just the hormones made by the body, in combination with sun exposure. It shows up as dark patches of brown pigmentation most commonly on the sides of the face, the forehead, above the upper lip, on the chin, and on the sides of the neck.  Mild melasma appears as small faint brown splotches, but more severe melasma surfaces as patches of light brown skin pigmentation. There is a genetic susceptibility to melasma, and it is more common in women with skin that pigments easily. It is especially common in women with Asian, Hispanic or African American skin type. There are more active pigment producing cells called melanocytes, and the melanocytes are more easily triggered to produce melanin. The excess melanin is stimulated most significantly by sun exposure, but also by heat, and anything that irritates the skin like facial scrubs, brushes, irritating skin creams, medications or treatments. Once melasma is triggered on, even minimal amounts of sun exposure will cause it to darken or return after successful treatment. It is more apparent during and after periods of sun exposure and less obvious in the winter months.

Melasma can occur at either the surface level (superficial melasma) or in the deeper layers of skin (dermal or deep melasma), giving it more of a spread-out appearance. One way to determine whether your melasma is superficial or deep is to stretch the skin. If you stretch out the brown patch and it appears lighter than when the skin is not stretched, then the hyperpigmentation is superficial. If it’s darker when stretched than it is when not stretched, then the pigmentation is deeper.

I pigment moderately easily, and had a decade or so dealing with melasma. It is often in a pattern, which is why it is also called the “mask of pregnancy” and I had a delightful set of horns above my eyebrows and a brown pigment moustache. Melasma drives women crazy, and is incredibly frustrating. I was no exception. Usually it finally burns out, and mine did.

There are two reasons that melasma is so hard to treat. The first reason melasma is so hard to treat is because even minor amounts of sun exposure can darken or reactivate it. It is hard to avoid all sun exposure, especially in women in the age group most commonly affected, 25-40, who may have children with outdoor activities. The other reason is that estrogen and progesterone hormones go along with being female. And women in that age group are faced with the decision to either be on birth control pills, or be pregnant, both of which are triggers.

There is no single treatment that works for all melasma patients; therefore, we develop an individualized treatment plan for each patient. Combination therapy usually is needed and recommended. Because the melanocytes are easily irritated, and when irritated they produce more pigment, we avoid aggressive treatments that may lead to more pigmentation, white blotches, or scarring. Treatment options range from topical bleaching and prescription medications to techniques such as IPL, chemical peels and microdermabrasion as well as lasers and light sources. We plan a stepwise approach to treatment beginning with home treatment, stepping up to office procedures as needed if results to home treatment are unsuccessful. If office procedures are needed, they should only be performed by cosmetic dermatologists with extensive experience in treating pigment problems.

Because of the difficulty in reducing pigment, the ongoing hormonal issues, and the tendency for melasma to reoccur we discuss in detail the lengthy treatment times and commitment needed to success­fully treat melasma to help manage unrealistic expec­tations. We also discuss the importance of and strong commitment to the sun protection program that is central to treatment. But even in the face of our hormones and our lifestyle, we soldier on and treat it the best we can with realistic expectations for improve­ment. And here is what we do:

Home Treatment:

• Daily Sun Protection: Is absolutely essential for successful melasma treatment and should start early and continue throughout treatment and also after melasma has improved to help prevent reoccurrence. Exposure to UV radiation and even visible light activates melanocytes and causes melanin to deposit in the skin. Sun protection with a broad spectrum sunscreen which covers both UVB and UVA with a SPF of 30 or greater used every single day, year round, and reapplied every 2 hours during sun exposure is essential. And that goes for all skin types, even patients with darker skin types who do not routinely use sun protection. But you have to remember that no sunscreen will block out all UV rays, so you cannot put on sunscreen in the morning and go out all day. Patients must limit time in the sun, and wear a hat whenever possible if sun exposure cannot be avoided. As a matter of fact, it is so important, that if you are not willing to modify your sun exposure, stop reading and go play on Facebook. 

• None of the other treatments may be used during pregnancy. If you are pregnant and at risk for melasma, start immediately to protect your skin from sun exposure to prevent melasma. If you are pregnant and have melasma, scrupulous sun exposure will help keep melasma from becoming more established.

• Prescription Hydroquinone (HQ) skin bleach: Hydroquinone is skin bleach that has been used for years. It inhibits the enzyme tyrosinase which is essential in pigment production. It comes in an over the counter 2% concentration, and stronger and more effective 4% prescription concentration. It is effective for approximately 20 weeks of treatment, then the skin becomes used to it, and effectiveness decreases. If used longer than 4-5 months, rarely an irreversible darkening of pigment occurs, especially in patients with darker skin types. It is usually applied twice daily and should be applied to the entire face because bull’s-eye areas of discolor­ation can develop from localized or spot treatments. Unfortunately it is irritating to the skin and if irritation occurs it can actually cause darkening of pigment. It has been very helpful in the treatment of pigment problems, but has recently come under fire from consumer groups and the FDA because of safety testing concerns. The most effective of the prescription forms, in my opinion, was Tri-Luma cream, which is a combination of HQ, a topical steroid, and tretinoin. It can only be used for 2 months at a time because the topical steroid component can cause dilated blood vessels and thinning of the skin if used longer. Currently it is not being produced, and has been unavailable for the last year. Intermittently other prescription HQ products are available, and then they disappear. HQ at 4% concentration is a prescription product, and recently the FDA has been cracking down on products available without prescription that contain 4% HQ. Time will tell if HQ will be banned by the FDA, approved by the FDA, and if so, will a company produce it. After about three to four months, the body increases tyrosinase production and overrides the effects of HQ. Because of this, HQ is used is a pulsed manner, usually 4 months on, 2 months off, to allow it to work again. HQ cannot be used in pregnancy.

• Prescription retinoid creams such as Retin-A, Retin-A Micro, Refissa, Renova, Differin, and Tazorac: Topical HQ often is combined with a topical retinoid, such as tretinoin, which exfoliates the skin and allows for the ingredient to penetrate properly.  Unfortunately, they can be irritating, and irritation increases pigment. So they need to be used cautiously. Retinoid irritation can be reduced by titrating the dosage, changing the dosage to alternate days, and diluting the tretinoin with a moisturizer base. Creams or micro sponge formulations are much easier to tolerate than gels. The key is to have your face completely dry before you put it on at night, and use it on a regular basis, not intermittently. When your face is damp you absorb more and it is more irritating. You can apply it every other night or even every third night to start and work up. If you are having irritation, apply an oil free moisturizer first then the retinoid.

• Over the counter Retinol: The prescription retinoids discussed above are forms of retinoic acid, and are stronger than retinol. Non- prescription, over the counter retinol can be helpful in melasma treatment as long as it doesn’t cause irritation.

• Mequinol such as Solage solution (mequinol 2% and tretinoin 0.01%): If HQ causes the patient too much irritation, a deriva­tive alternative is mequinol.

• Over the counter or natural skin lighteners: include aloesin, arbutin, azelaic acid, bearberry extract, dimethylmethoxy chroman palmitate (Chromabright), ferulic acid, kojic acid, lactic acid, licorice root, lignin peroxidase, mulberry bark extract, N-acetylglucosamine, niacinamide, soy protein, various peptides, and vitamin C especially magnesium ascorbyl phosphate or L-ascorbic acid. These lighteners have various actions including inhibiting the pigment producing enzyme tyrosinase, dispersing pigment, and exfoliating pigment. They can be used for extended periods of time and can be used with other lightening ingredients to speed up the process.

• Every dermatologist and skin care company has their favorite combination. Our Antioxidant Skin Lightener contains aloesin, licorice root, bearberry, niacinamide, the form of active vitamin C magnesium ascorbyl phosphate, (Melfade-J) and dimethylmethoxy chroman palmitate (Chromabright). We use it with our Correcting Serums containing glycolic and salicylic acids, fruit acids, aloesin, and our Antioxidant Enzyme Peel containing papaya to exfoliate abnormal pigment.

Office Treatment:

Office treatments are used if topical creams don’t give enough improvement and to speed results. They must be done very carefully or they can cause increased pigmentation, especially in patients with darker skin types. They should be done very carefully, and by a physician who is experienced in treating pigment problems and skin of color, in other words by a cosmetic dermatologist.

• Chemical Peels: A series of in-office light chemical peels can improve discoloration by peeling off the top layer of pigmented skin cells, and allowing better penetration of other surface treatments. Glycolic acid peels are most commonly used but others include salicylic acid, superficial trichloracetic acid, lactic acid, tretinoin, 14% HQ, and resorcinol peels. They are best when used with home retinoids, prescription hydroquinone or other skin lighteners. Skin may be red, dry and flaky for up to 5 days.

• Intense Pulsed Light (IPL): A series of 3-5 Intense Pulsed Light treatments (IPL, Photofacial, or Photorejuvenation) at a lower intensity than is used to improve sun damage induced dilated blood vessels and age spots can be helpful.

• Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel: SilkPeel particle-free microdermabrasion uses a treatment tip to exfoliate the skin accompanied by application of the skin brightening peptide Decapeptide-12 (Lumixyl) at controlled intensity. It removes surface pigment, and allows better penetration of prescribed home skin treatments. A plus is that there is no redness or flaking after treatment.

• LED Treatments: GentleWaves LED Photomodulation uses a painless light emitting diode treatment and is used to reduce inflammation with other melasma treatments.

• Nonablative Laser Treatments: The Q switched 1064-nm Nd:YAG laser and the fractional lasers Fraxel Restore and Mosaic may be used in patients who don’t respond well to the treatments above or who also desire improvements in mild to moderate wrinkles, large pores, surface irregularities, or acne scarring.

• Ablative Lasers: Multiple treatment sessions with the Pearl 2790-nm Er:YSGG laser combined with IPL and topical treatments in carefully controlled protocols may be used in carefully chosen patients with skin types I-IV if melasma does not respond to other measures.

Sometimes things that seem that they should be easy are not. This is one of those times. With diligence and time melasma can be significantly improved or resolved. But I still hate melasma.

Your Skin Holds a Grudge:

Removing Brown Spots after Acne, Laser or Peels

Now we are getting into the more difficult stuff—getting rid of brown spots and discoloration that occurs after acne; scratches or other injuries; or chemical peels, laser or IPL treatments gone wrong. Since you know how to tell what kind of brown spots you have from the previous post,  Out Damn Spot, Out, Out, now you need to know what needs to be done to get rid of them. Since we solved the raised brown growth problem in the last post How to Get Rid Of Evidence of Age: Removing Raised Brown Age or Liver Spots, we are going further up the difficulty ladder to how to remove the brown, or reddish brown discolored spots that come after acne blemishes, scrapes, cuts, scratches, chemical peels, laser treatments or other injuries.

To recap, here is what you see:

• In the mirror: Brown, grey or red-brown discoloration of areas with past acne, cosmetic procedures, or injury.

• Diagnosis: Post inflammatory hyperpigmentation (PIHP), which most commonly occurs in patients with more natural pigment, also called “skin of color.”

• Treatment: Prevention by treatment of acne, not picking, and caution with procedures that can cause pigment such as chemical peels and laser hair removal. Strict sun protection is essential. Treatment with home skin care, prescription skin bleach, and prescription retinoid creams, and for some patients the very cautious use of SilkPeel, chemical peels, laser treatments, or microdermabrasion.

• Ease of treatment: Moderate—difficult

PIHP is best explained by a very simple skin 101 rule: skin that makes pigment makes pigment. Anything that causes injury or inflammation in the skin causes your natural pigment cells to make pigment.  That injury is seen most frequently when skin is injured—yes, I said injured—by sun exposure and you tan. Your skin really tries to protect you, and it says “if you are going on offense and throw harmful, DNA damaging UV radiation against me, I am going on defense and increase the pigment shield to try to keep it out”. And cosmetically, though not medically, an even increase in color is acceptable and often desired. The problem is that process is also turned on by other kinds of injury, and that leads to spots, patches and irregular areas of pigment that are cosmetically unacceptable. Added to that, if red blood cells are released out of blood vessels and are floating around loose in the skin, your body sends in cells to chew them up and carry them away to the trash. But the iron in red blood cells is often left behind, and iron (think rust), is reddish brown.

Although all skin has color, skin types IV, V and VI have more and are referred to as “skin of color.” It has more natural pigment, and is more efficient in making melanin. When I want to know if a patient is at risk for PIHP, I ask them one question: “When you get a scratch, what color does it turn when it heals?” Skin types I and II turns red or white. Skin type III can turn white or brown. Skin types IV, V and VI turn brown. If your scratches turn brown, you are at risk of PIHP. When your skin is injured in any way, it will turn brown or darker.

That means you must be very careful with cosmetic procedures that can injure the skin in any way, however mild. The “can injure skin in any way” list includes: waxing, plucking, picking, exfoliating, scrubbing, piercing, tattoos, acne, rashes, scratches, cuts, surgical scars, chemical peels, microdermabrasion, laser or IPL hair removal, IPL photo-rejuvenation, and laser resurfacing. Sometimes the pigment comes quickly after an injury; sometimes it is delayed for several months. Much less commonly, if the injury is severe, all pigment cells are killed, and the area turns white.

I cannot tell you the number of times I have seen patients after waxing, hair removal, chemical peels, IPL, or laser resurfacing procedures done elsewhere, who come in with pigment problems from the procedure. Dermatologists are very aware and sensitive to the issue of PIHP, and we are very proactive in preventing the problem in the first place, because prevention is much, much easier than correction. We will pretreat you with skin bleaches and strict sun protection before procedures, and send you home without the procedure if we think you have not followed instructions or have had too much sun. We act very quickly to turn off inflammation after procedures with prescription topical steroids and other inflammation reducers. Procedure settings and techniques are set very carefully to reduce risk, and sometimes we refuse to do certain procedures on certain patients if we feel the risk is too high. If an injury occurs regardless of these precautions, we work to heal the injury as quickly as possible to turn off pigment inducing inflammation. I will say without qualification, if you have skin that is at risk of pigment, you should only have cosmetic non-surgical procedures done by a cosmetic dermatologist, or a plastic surgeon that also practices proactive prevention and quick correction of pigment issues. And I mean a real board certified one, not one of the many “wannabe” practitioners holding themselves out as dermatologists. Even under the care of these qualified dermatologists or plastic surgeons, pigment problems can occur. But you have the best shot at preventing them and the best chance of successful treatment if they occur. You’ve been warned.

If you have skin of color, and you have acne, the first thing you need to do is to get effective treatment, to reduce the blemishes that pigment. And you have to stop picking. Picking at acne only increases and prolongs pigment producing inflammation and skin injury. I know it is hard, I am a picker too. I give the “stop picking” lecture all day long. Here it is: STOP PICKING!

Home Treatment:

• Don’t scrub, brush, rub, or pick: The tendency of patients with pigment problems is to try to scrub it off. But if the scrubbing causes any irritation, it will actually increase pigment production. Even using a washcloth or facial cloth, synthetic cotton balls (use 100% cotton), cleansing brushes, or a makeup brush to apply loose mineral powder a brush to apply powder can cause irritation and increased discoloration. Be very careful with exfoliants, which can cause microscopic abrasions and inflammation. Very gentle and controlled exfoliation can be helpful in removing excess pigment that has been treated with other agents, but the key phrase here is gentle and controlled. And not to belabor the point made above, but STOP PICKING.

•  Daily Sun Protection: Sun exposure produces pigment. Sun exposure on skin that has been injured or is inflamed produces even more pigment. You don’t want increased pigment in those areas, so you don’t want to expose it to something that increases pigment. So don’t. Wear a non-comedogenic sunscreen with an SPF of 30 or greater every day. Even if you don’t normally have to worry much about the skin aging and skin cancer risks of sun exposure. And I hope it goes without saying, but with me very few things go without saying, so no intentional tanning or tanning beds.

• Prescription retinoid creams such as Retin-A, Retin-A Micro, Refissa, Renova, Differin, and Tazorac: Prescription tretinoin (Retin-A, Retin-A Micro, Refissa, Renova) or the other prescription retinoids (Differin, Tazorac) that come in creams and gels help prevent and control acne and also help remove excess pigment. Unfortunately, they can be irritating, and irritation increases pigment. So they need to be used cautiously. Creams or micro sponge formulations are much easier to tolerate than gels. The key is to have your face completely dry before you put it on at night, and use it on a regular basis, not intermittently. When your face is damp you absorb more and it is more irritating. You can apply it every other night or even every third night to start and work up. If you are having irritation, apply an oil free moisturizer first then the retinoid.

• Over the counter Retinol: The prescription retinoids discussed above are forms of retinoic acid, and are stronger than retinol. Non- prescription, over the counter retinol can be a milder form of acne and pigmentation treatment as long as they don’t cause irritation.

• Prescription Hydroquinone (HQ) skin bleach: Hydroquinone is skin bleach that has been used for years. It comes in over the counter forms, and stronger and more effective prescription forms. It has been helpful in the treatment of pigment problems, but has recently come under fire from consumer groups and the FDA because of safety testing concerns. The most effective of the prescription forms, in my opinion, was Tri-Luma cream, which is a combination of HQ, a topical steroid, and tretinoin. Currently it is not being produced, and has been unavailable for the last year. Intermittently other prescription HQ products are available, and then they disappear. Time will tell if HQ will be banned by the FDA, approved by the FDA, and if so, will a company produce it.

• Over the counter or natural skin lighteners: include bearberry extract, licorice root, niacinamide, N-acetylglucosamine, forms of vitamin C especially magnesium ascorbyl phosphate, dimethylmethoxy chroman palmitate (Chromabright), arbutin, kojic acid, ferulic acid, mulberry bark extract, soy, azelaic acid, lactic acid, mequinol, aloesin, , lignin peroxidase, and various peptides. Every dermatologist and skin care company has their favorite combination. Our Antioxidant Skin Lightener contains aloesin, licorice root, bearberry, niacinamide, the form of active vitamin C magnesium ascorbyl phosphate (Melfade-J) and dimethylmethoxy chroman palmitate (Chromabright).

Office Treatment:

• Chemical Peels: Superficial chemical peels with gly­colic acid (20%–70%) and salicylic acid (20%–30%) can be effective in the treatment of PIHP, even in patients with darker skin, if used carefully.

• SilkPeel: SilkPeel combines microdermabrasion with the delivery of the skin brightening peptide Decapeptide-12 (Lumixyl).

• Laser Resurfacing: Non-ablative fractional laser resurfacing with lasers such as the 1550-nm wavelength Fraxel (Fraxel re:store) or with the Q-switched 1064-nm Nd:YAG laser can be helpful in some cases, if done under carefully controlled parameters and conditions. But before you undergo laser treatment for PIHP, remember—it can always make it worse.

Treatment of PIHP is difficult and improvement varies depending on the:

• Patient’s natural skin color
• Underlying problem causing the areas that then become discolored
• Effectiveness of the surface creams and cosmetic procedures used
• Avoidance of undesirable side effects of treatments
• Skill and experience of the treating physician
• Cooperation and involvement of the patient with the treatment plan

It’s a challenge, but results can be good. Keep the faith. And if you think PIHP is a challenge, wait till we deal with melasma.

Next: Melasma, the bane of the cosmetic dermatologist’s existence

Your skin can’t take a joke–so don’t tell it one

Hair and nails forgive and forget. But skin is something else again. It doesn’t forgive and it doesn’t forget. So, I do take care of my skin, and pretty well too. And I have for a long time. That is because skin holds a grudge. If you don’t take care of it , it goes bad on you, and at least some of the damage is irreversible. You can fry your hair, color it blue, lose it from going off birth control pills or after pregnancy and it recovers. Hair just says “whatever, and it grows out just fine. And the kind of hair problems that are really frustrating are not from anything that you do, they just happen, like alopecia areata, and the scarring hair loss diseases.  You can have chipped and damaged nails from working in the garden, you can abuse your nails from wearing acrylics and, within reason, they can recover. Unless you damage the matrix or the nail bed, then you gotta pay. But your skin remembers every unkind thing you ever said about it, did to it, or didn’t do to it (like protect it from sun damage). It really can’t take a joke.

So here is what I do. And I do it every day and every night, without fail. And yes, I use my own line of skin care products, Dr Elaine’s Advanced Skin Treatment, almost exclusively. After all, I developed them, and they are full of both high quality botanicals, marine actives, other natural actives with specific purpose, and various cosmeceuticals including alpha and beta hydroxy-acids, peptides, antioxidants, and vitamins. Since I developed them exactly the way I wanted them, this should  be no surprise to anyone.

My morning routine–First I get up, reluctantly, then:

1. Three days a week I use Dr Elaine’s Antioxidant Enzyme Peel (1 oz 38.99). You have to use it when your skin is completely dry. So I do it the very first thing, I don’t wash my hands or face, and I apply it in a very thin layer. Key word is “very thin” and then I let it sit 30 seconds with my hands in the air, without rinsing them, until the peel liquefies. Next I rub in a circular motion and exfoliate the dead skin. Then I rinse with clear water. I love this product because the papaya, grape seed, and willow extracts in it gently exfoliate without granular particles with the end result that my face reflects light well and glows, but it still allows me to use the retinoid Refissa without the increased irritation of a granular exfoliant.
2. Since I have normal-dry skin, I wash with our Facial Cleansing Lotion (6.7 oz $26.99), using my fingers only, never a washcloth. I love this cleanser–it has glycolic acid to exfoliate, it cleanses well, removes make up and the combined group of natural botanical oils leaves my skin soft and smooth rather than uncomfortably tight.
3. Then I follow with our Gentle Toner (6.7 oz $26.99) applied with a 100% cotton ball. Since I have a tendency to get eczema, and use a fairly potent retinoid every night, I need to reduce the tiny microscopic abrasions that I would get from a synthetic “cotton” pad. I don’t need a drying type of toner, so I use this one that is not drying.
4. Then Dr Elaine’s Correcting Serum (1 oz  $59.99) 2-3 pumps for my entire face and neck. The two things that I feel should be used every day as a basic program, other than sunscreen, is either an alpha hydroxy acid or fruit acid, and a retinoid. Our Correcting Serum has both 8% glycolic acid and a multiple fruit acid complex to exfoliate and promote collagen production, and hyaluronic acid to plump wrinkles and balance moisture.
5. Next I apply Dr Elaine’s Line Diminisher (1 oz $89.99). The peptides Acetyl Hexapeptide-3 and Palmitoyl-Pentapeptide 3 combined with hyaluronic acid help minimize fine lines, and antioxidant green tea calms irritation.
6. Then our Facial Moisturizing Cream ($41.99) in the winter or when I am extra dry or my skin is irritated, or our Hydrating Cream ($39.99) if it is summer or less dry weather. Moisturizers like the Facial Moisturizing Cream that are fragrance free are best if your skin has a tendency to irritation and you are using retinoids like Refissa.
7. Then I apply our Total Eye Renewal (0.5 oz $65.99) to my entire face. Yes, I know it says eyes, and I do use it on eyes,  but also on my face,  because the 3 peptides are very good, it has active Vitamin C, bunches of active botanical antioxidants and I really like the silky smooth effect from the shea butter and silicone base.
8. Then I apply DCL Super Sheer Sunscreen SPF 50 (2.5 oz $24.99) to  my face, neck, chest, forearms and backs of my hands every single day, year round, without fail. I really like this sunscreen because it covers a really broad spectrum of UV, and it is so light weight you don’t even know you have it on.

At  night, no matter how tired I am:

1. Dr Elaine’s Facial Cleansing Lotion
2. Refissa (by prescription $145) to face, neck, upper chest. I apply Refissa to back of hands and forearms every other or every third night.
3. Dr Elaine’s Total Eye Renewal ($65.99) around my eyes after Refissa.
4. Brush on Latisse to the base of the eyelashes (by Allergan–prescription $120 a 3 ml bottle) to grow eyelashes and make them darker–but I only apply it every other night or the lashes get too long and thick. That also cuts the cost, as a bottle will then go 2-3 months.
5. Dr Elaine’s Lip Therapy ($5.99) right before bed so my lips don’t get too dried out.

For Body:

1. Dr Elaine’s Calming Body Wash (12 oz $15.99) in shower which helps my dry skin.
2. Dr Elaine’s Smoothing Body Moisturizer (12 oz $37.99) every night. I am atopic, so my skin is sensitive and rashes easily. That means if I don’t apply moisturizer to my entire body I will itch all night and since I don’t want to do that I just go ahead and use body moisturizer every night. I love the scent, and also the powdery smooth feeling.
3. Then I put our Perfecting Hand and Body Moisturizer (12 oz $36.99) on my feet and heels right before bed. The glycolic acid and fruit oils, soften and repair thickened skin and cracks, and the Evening Primrose oil reduces irritation.
4. If I have been lazy and my heels are really bad I will use Ureacin-20 (4 oz $26.99)on them for a couple of nights. It works really well for thickened calloused heels, but leaves a thin white film on them, so I don’t do it in the daytime.
5. For a little color, in the summer or if I am going on vacation I will use Jergen’s Sunless Tanner ($7.99) for medium to tan skin (just means it has more DHA in it and I get color quicker) or Clarins Self Tanning Instant Gel (4.4 oz)

And that’s how I do my own skin care. I take care of my skin, and I don’t tell it any jokes.

Next: how I do cosmetics

Choose skin care like a skin doctor:

Full disclosure: I am the founder of Dr Elaine’s Advanced Skin Treatment clinical skin care line, which I formulated and developed based on my assessment of the merits of various botanical extracts and cosmeceutical advances for an optimal anti-aging, acne, sensitive skin and body skin treatment program. Dr Elaine’s skin care is sold in my cosmetic dermatology practice and online at our web site, SkinTreatment.com. Of course, I am biased toward our skin care products, and use many of them daily, especially since I developed them exactly the way I wanted.

When I talk to patients about skin care, cosmetics and hair care, they often ask “what do you use?” and “why do you use what you use?” Because I am a female cosmetic dermatologist, I am expected to have a rigorously scientific analysis of the merits of each product I use. And to a large extent I do. However, there are additional factors that I use to determine which skin care, cosmetic, nail care, hair care, beauty equipment I purchase and use.

My choices are dictated by the following factors:

• Scientific evidence favoring effectiveness in prevention of skin aging, acne, and skin cancer. Since I know preventing skin aging is easier than reversing it, I am willing to use products that may only have benefits down the road. Luckily for me, I have used a sunscreen and retinoid (first Retin-A, then Renova and now Refissa) daily for the past 27 years.

• Scientific evidence favoring effectiveness in treatment of skin aging, acne and sensitive skin. I’m not impressed by the marketing “story”–you know, “this amazingly potent antioxidant, previously unknown to the world, from the fruit of the Friscascucia plant, found only in a remote region of the Himalayas, harvested lovingly by hand by barefoot, chanting Tibetan monks, who even at 90 have beautiful, radiant, unlined skin because they apply Friscascucia fruit daily was discovered by celebrity dermatologist Dr. Special when he met the monks during the pilgrimage to Tibet that was part of his voyage of personal discovery.  And now, brought to you!”

• I want to know the actual science, even if it’s boring. It’s unfortunate that often the “story” is used and accepted as a substitute for the science. There are a lot of ingredients that have a long history of safety and effectiveness. On the other hand, some of the new discoveries, optimization of existing compounds and new uses for older therapies are exciting and backed by science. It’s just that the “story” shouldn’t trump the science.  And by science, I mean controlled, double-blind scientific studies of real effects on real live skin. As any scientist will tell you, an experiment can be designed to give any result you want. So I want the real science, not the marketing story science.

• Ease of purchase. I hate to shop. Thank God for the internet. And Walgreen’s.

• Cost/benefit ratio. I don’t mind paying more, if there is an actual benefit gained. I tend to avoid skin care products at both ends of pricing, the very cheap and the very expensive. Since we produce Dr Elaine’s clinical skin care line, I know how much it costs to include appropriate, quality ingredients in concentrations large enough to have a skin benefit, not just to include them in low concentration for their marketing value. And skin care at the very high end often uses that high price point as a selling point–”if people pay so much for this it must be worth it” without any real increase in value. However in make-up and cosmetics that is not necessarily true. For certain cosmetics, such as mascara, the inexpensive drugstore version is just as good as one that costs 10 times more.

• Sensory effects such as scent, color, texture, stickiness, etc. If I am going to pay for it and use it, I want to enjoy it.

• Persistence of result. If I take the time to put it on, I want it to stay on. I don’t want to put on lipstick more than once, twice at most, a day. I don’t want my nail polish chipping by the next morning. If I cover a pimple, it better stay covered.

I compute the above factors in a complicated mathematical formula, which remains in an undisclosed location in my brain, to determine which skin care, cosmetics, nail care, hair care, and  beauty equipment that I purchase and use on a daily basis.

Next:  My top skin, hair, nail care and cosmetic choices.

The easy way–preventative maintenance with at home treatment

Preventive maintenance, ideally beginning in your early twenties, is the easy way to resurface your skin–before you even need it. At home treatment on a daily basis can prevent many of the changes that would require more aggressive treatment later. Even if you start later, either because the options weren’t around earlier, or because you just didn’t get around to it, you can get a good amount of improvement from relatively simple home treatment.

The key to success with this option is consistent and daily treatment with anti-aging cosmeceuticals, botanicals, exfoliants, retinoids and sunscreen. I see patients who start and stop programs, don’t stick with it, and blow off many days of treatment because they are too rushed to stick to a routine or who only wear sunscreen “when I am going to get a lot of sun”. There really is no reason not to get on a program and stick with it. It will pay off in the long run.

The 5 key components are:

• Cosmeceuticals
• Botanicals
• Exfoliants
• Retinoids
• Sunscreen

Cosmeceuticals are cosmetics that have effects on the skin. The main groups are the peptides, antioxidants, growth factors, and vitamins. They improve fine lines, roughness, blotchy pigment, loss of elasticity, dullness, acne, and stimulate collagen production.

Botanicals are plant derived compounds that are used for their antioxidant, anti-inflammatory, exfoliant, moisture balancing, and collagen stimulating properties.

I will talk about skin care, cosmeceuticals, and botanicals more in a future column with specific information about the individual compounds. In the meantime, there is a complete listing of cosmeceuticals and botanicals with their historical use; scientific, botanical, and trade names; and the scientific evidence of activity on the website in our Education Center.

Retinoids include over-the-counter retinol, and the prescription synthetic vitamin A derivatives tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin).

Retinoids enhance collagen and elastin production thereby diminishing wrinkling, improve discoloration and roughness, and reduce pore size.

Retinoids do make you more sensitive to the sun, and should be used with daily sunscreen. We used to tell patients not to use them if they were going to get sun exposure but now we know that, within reason, you may use them as long as you use good sun protection. If you are going to the beach, lake, or skiing discontinue them for a few days before exposure.

They shouldn’t be used by pregnant or nursing mothers.

The current cost of Refissa (1 tube, 40 gm) $146.00; for Tazorac (1 tube, 30 gm) $170.00-180.00; Differin (1 tube, 45 gm) $260.00. One tube of either of these should last you about 4 months or more.

The biggest drawback, and the reason people discontinue them, is that they are irritating to the skin. I often start patients off on every other or every third night use and work up to every night. Another option is to start with the least irritating, Differin, and move up to the more irritating Refissa (for normal-dry skin) or Tazorac (for oily or acne prone skin). In addition you can either mix moisturizer half and half with them or apply moisturizer before (if you are having redness, itching or irritation) or after (if you are just dry) you apply them at night.

You should apply a pea size amount to the face after cleansing and toning in the evening. The skin should be completely dry before application. You should also apply it to the neck, back of the hands and forearms although most people can only apply it there every other night because of irritation. Those areas get aged from sun exposure just like your face. You don’t want to be one of those women who say “I hate the spots on my hands”. And while you are at it remember the sunscreen to neck, forearms and backs of hands. You need both.

Mild stinging, mild redness and mild peeling and flaking may occur during the first several weeks and on occasion when using Refissa, Renova, Retin-A, Differin or Tazorac.  This is normal.  Flaking is normal, soreness and irritation are not. To help reduce irritation, do not use washcloth, facial brushes, mesh scrubs, daily facial cloths, mineral powder brush or granular exfoliants on the face.

Discontinue these products to affected area 1 week before waxing or bleaching, or before other procedures (peels, microdermabrasion, facial, acne surgery, hair removal, laser treatments as directed.) You don’t want to end up like the bride who waxed three days before the wedding and disaster ensued.

I am a strong advocate of daily retinoid use, I feel that almost every patient desiring to prevent aging, or correct existing damage should use them. There is so much proven scientific data behind them they are still considered the gold standard in topical anti-aging treatment.

Daily, year round, sunscreen use is essential or you are just undoing what you are trying to do. Once again I refer you to my post “Quit complaining and wear your damn sunscreen”. Just do it.

If you start early on a home preventative anti-aging program you will have to do less later on and you will look better both today and tomorrow. It is never too late to start, you will see improvement. Stick with it. It is really a no-brainer.

Next: A tune up: In office treatment for early  or moderate changes

When I see a patient for an anti-aging skin rejuvenation evaluation, the first thing I look at is the quality of the skin. Spots, broken blood vessels, large pores, roughness, growths, milia cysts, brown discoloration, scars, acne scars, crépiness, elastosis, fine lines, wrinkles, loss of elasticity, and dullness all decrease the quality of the skin.  Most but not all of these are from chronic  sun damage.

Young skin is smooth, without blemishes, growths, cysts, brown spots, broken blood vessels, and elastosis. It has good elasticity and reflects light well giving it a luminosity. Interestingly studies have shown that people’s impression of the age of another person is primarily determined by the absence of spots, growths and the presence of luminosity. In other words a person with spots and growths but minimal wrinkles looks older than a person with few spots and more wrinkles.

That’s why it’s important in anti aging treatment to “clear the canvas and start over”.So we start with Step #1–Repair Sun Damage. Options to repair sun damage to look younger are:

At home topical surface treatments

• Cosmeceuticals and Skin Care
• Retinoids

In office aesthetic procedures:

• LED Photomodulation
• Particle Free Precision Microdermabrasion/Dermal Infusion
• Chemical Peels
• Intense Pulsed Light (IPL®)
• Fraxel® Laser Treatment

Treatments You Can Do At Home

• Cosmeceuticals and Skin Care

Antioxidants (like Green Tea, Grape Seed, Soy) help prevent and repair the damage from free radicals released by sun exposure. Hydroxy acids (glycolic and multi-fruit) exfoliate dullness and pigment, stimulate collagen production, increase elasticity. Anti-aging peptides (like  Matrixyl™ (pal-KTTKS) and Matrixyl™3000 ) reduce fine lines and increase collagen and elasticity. Stabilized vitamin C (Magnesium Ascorbyl Phosphate) reduces collagen breakdown and protects against UVB damage. To find out more about the science behind cosmeceuticals and the history and science of botanical ingredients in skin care check out our web site. And most important–Daily use of a broad spectrum sunscreen with a SPF of 30 or more is absolutely essential.

• Retinoids

Retinoids are prescription vitamin A derivatives that reverse the effects of photo aging. Over time daily use will improve fine lines, brown spots, dullness, roughness and will give some degree of improvement in pore size. There are several forms of retinoids, I find that for most adults Refissa, a 0.05 percent branded generic tretinoin formulation is the best choice. It is the same as the older 0.05 percent Renova which was discontinued when the patent ran out and replaced with a lower strength and a pump version.

Next: anti aging sun damage treatment procedures.

Antioxidant Enzyme Peel exfoliates and gives your skin a healthy glow. When our patients start using enzyme peel, many apply too much. It only takes a small amount, a very thin layer. We tell our patients “when you exfoliate the product off with your fingertips, you want to feel the granules exfoliating. If it’s gooey, you’ve used too much.” It’s very important that your hands and face are completely dry. Don’t wash your face or hands before use. Just apply (in the morning over your night treatment, or in the evening over your makeup). Let it work for 30 sec to 1 minute. Don’t wash your hands. Then massage in a circular motion to exfoliate for a daily peel. Keep tightly capped after use. Antioxidant Enzyme Peel is gentle enough to use every day, and is a must have if using a retinoid. Stop by our office for a free sample of Antioxidant Enzyme Peel. You’re going to love it!

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.