Daily Skin Fix

 Spider Veins On the Legs:

Why your children and mother are to blame

Its that time of year again, drag out the shorts, short skirts and sandals. Get your pedicure. And then look at your legs. OMG those ugly spider veins. Very common in women, and often very fixable. Though women frequently tell me they have varicose (or veryclose!) veins, often what they really have are spider veins. Varicose veins are usually larger than a pencil in diameter, ropy, bulging, skin colored, bluish veins that are a symptom of vein disease in the larger veins deep in the legs and pelvis. Spider veins are smaller, hair diameter to spaghetti diameter sized blue, reddish, or purple ugly lines all over your beautiful legs, ankles and feet. Reticular veins are in between sized, bluish or greenish veins that connect smaller veins to the larger ones.

Since varicose veins a symptom of deeper vein disease, they require a more in depth work up and have a whole different set of treatment options. Some women with spider veins also have varicose veins, only an exam by your physician can determine if you do. I am not going to talk about varicose veins today, only about the much more common, and much more easily treatable spider veins.

Spider veins on the legs are small dilated blood vessels, most commonly caused by pregnancy, birth control pills, hormone replacement, occupations requiring prolonged standing, pressure on surface veins from abnormal larger deeper blood vessels, weight gain, and family history.  They are very common in adult women, much less common in men due to the special and wonderful differences between men and women. Sometimes they cause aching or throbbing, especially behind the knee. They are ugly, and women hate them. Luckily, effective treatment often gives good and long lasting improvement.

What causes spider veins on the leg? In other words, why me Lord? Because you are a special and wonderful estrogen filled baby making, hard working, biological machine, that’s why.

Causes of Spider Veins On the Leg

• Pregnancy—during pregnancy hormonal influences causes your blood vessels to go into overdrive. You are making blood vessels like crazy to feed that wonderful little angel. Unfortunately you don’t just make blood vessels in your uterus; the hormonal effects cause you to make them everywhere. Your blood volume, the total amount of blood in your body, increases so that you have enough for two, or more. So you have blood vessels growing, and more volume of blood in your veins which puts pressure on the veins. And you also have that bowling ball, or watermelon sleeping right on top of where your larger, deeper veins in the legs go through your pelvis trying to reach your heart and lungs. So you can keep going. And although I often have women tell me that they didn’t have any or many spider veins with the first child or two, but only with the last one, each pregnancy stretches those veins in your legs. Just like your belly, which bounces back pretty well after the first child, less after the second and even less after the third and so on. And if you have a multiple birth, it just multiplies the fun. So don’t blame your last child, the blame should be shared equally and each should contribute equally to the cost of your treatment.
• Birth Control Pills—are really just fooling your body hormonally into thinking you are already pregnant so it doesn’t get any cute ideas.  Without the bowling ball in your pelvis.
• Hormone Replacement Therapy—ditto, but less ditto.
• Occupations— that require prolonged standing, such as teaching or hairdressing. My very “best’ spider vein removal customers are teachers and hairstylists. That’s because they stand in one place all day. The muscles in your calf are referred to as “your second heart.” When you walk, the calf muscles pump the blood in your leg veins back up to your heart, as long as the little valves in the veins are working properly. So women who are on their feet all day, but walking around, usually do better.
• Abnormal Larger Deeper Blood Vessels—the smaller veins drain into the larger, deeper blood vessels in your legs and then back to your heart. There are one way valves inside the veins that are designed to open when blood is pushed through them by the pressure of the contraction of your calf muscles, and then close to prevent the blood from falling back down from gravity. At least that is how they are supposed to work. When they don’t, varicose veins develop. Abnormal valves in the larger leg veins often run in families. Some women with spider veins also have abnormal valves in the larger veins, some don’t. Your physician will tell you if you do or not.
• Weight Gain—causes more pressure on the veins, and fat makes estrogen. Double whammy.
• Family History—yep, like a lot of things, the tendency runs in family. Another thing to put on your “blame my mother” list.

So now you know why you have spider veins. Next—how to get rid of spider veins, and how you can get your kids to pay for it.  Your mom probably thinks you should pay her.

Skin and Sin

There are sins of omission, sins of commission, and just sin.

Sins of omission, is not doing something. For hair that could be not getting enough iron intake and having hair loss as a result. For nails it might be not keeping the edges filed, and getting splits at the ends. For skin it could be not wearing sunscreen daily and using a targeted anti-aging skin care program so your skin ages faster than it needs to, or having severe acne, but not treating it, and then getting scarring.

Sins of commission are things you do that are just the result of bad decision making, that affect the skin, hair and nails, and badly. For hair it is that really unfortunate hair color, or decision to resurrect your 80’s perm. For nails it is wearing acrylics continuously, rocking the ends and super gluing the loose areas yourself. For skin it is going to the tanning bed 5 times a week.

And just sin is when you do something you know is damaging, and that serves no purpose, but you do it anyway. For hair it could be over plucking the eyebrows until you look like a silent movie star from the 1920’s. For nails it is biting them to the quick and ripping the cuticles off so that you can’t show your hands in a job interview. For skin it could be picking at that pimple 4000 times using your 15 power magnifying mirror, when you know nothing will come out of it, but you can’t stop picking. And then when it is trying to heal, picking at it again.

Of course, there is a lot of overlap, as when you don’t do something, and it is bad decision making, and it really serves no purpose but you do it anyway. Like not wearing sunscreen on your face, neck, forearms and hands every day. Yes, it does take 20 seconds to do. As opposed to the 5 minutes it takes to apply a heavy foundation to cover up the effects of sun damage. Clear cut categories of sin are sometimes in the eye of the beholder. And some of my “skin sins” are really other sins that affect your skin, but as my grandmother used to say to me: “Little missy, don’t try to talk your way out of this one, I am on to you. Just admit you are wrong, say you are sorry, and don’t do it again.” And as usual, she was right. So without further ado, here are my top 10 Skin Sins.

Top 10 Skin Sins

1. Unprotected Sun Exposure. You knew it would be #1. I am not going to go into my usual tirade about the aging and damaging effects of the sun, except to say—daily sun exposure is one of the top 2 most aging things you can do to your skin, and causes skin cancer. It causes discoloration, broken blood vessels, wrinkles, large pores, loss of elasticity and that stiff, yellow cross hatched skin that is characteristic of chronic sun exposure. You know this, so put on your sunscreen every day.
2. Smoking. Do I really have to say this? Smoking reduces blood flow in the skin, exposes you to direct toxin exposure on the skin and in the blood. And, if that’s not bad enough, the facial expressions repeated over and over etch lines in the skin. It is the other sin in the top two most aging things you can do to your skin. Whatever you do– don’t do 1 and 2 together. The effects of chronic sun exposure in smokers are much more damaging than either one alone. The results aren’t pretty.
3. Procrastination. I see this frequently. Young people in their twenties and early thirties are more worried about hair style, eye shadow, and outfit than they are about the health of their skin. That’s because they are young, and by and large have good skin. And then in their thirties and early forties they are raising a family, busy at work. Mornings are too rushed to apply sun screen, and evenings never end so active skin care is not applied. Then all of a sudden at 45, they have an “OMG what has happened to my face” moment. And end up in my office. All of the easy stuff to slow down aging of the skin work best when you do them while your skin is still good. And they are not really complicated—sun screen every day, a retinoid (tretinoin, retinol etc.) every night, a peptide lotion and a combo botanical and fruit acid serum once a day. Add a little Botox when those frown lines start showing and a little dermal filler for smile lines and you are good. Yes, those things help later too, but it is always easier to prevent than try to fix the damage.
4. Following every fad. There are patients who jump from doctor to doctor and back again. They try this new procedure, that new skin care ingredient they read about. Some may be appropriate for them, some are not and some are bogus. But they never stick with anything long enough to see the results they could see if they picked one doctor, committed to a treatment plan and then followed through.
5. Ignoring your teeth. We all lose bone structure in our face as we age. When we do there is less structure to the eyebrows, cheeks, around the mouth and at the jawline. Soft tissues and skin sag when there is less underlying structure. Tooth loss leads to loss of supporting bone structure around the mouth. Teeth wear down and become discolored over time. The result is a collapsed mouth without enough underlying structure to fill out the skin. So take care of your teeth. You need them.
6. Yo-yo weight fluctuations. The weight goes on. The weight comes off. The weight goes back on again. Repeat. Skin is pretty elastic, up to a point, when you are young, but it loses elasticity over time. At any age, too many episodes of weight gain and stretching, or too large of weight gain and skin loses its ability to shrink back. The result is sagging skin on the face, and sagging and stretch marks on the body.
7. Picking, picking, picking. One of my pet peeves. So much so I wrote a whole series on why you should step away from the magnifying mirror before someone gets hurt.
8. Accentuating asymmetry with bad eyebrows. Another of my pet peeves. Eyebrows frame your eyes and balance your face. Symmetry is the hallmark of a young face. We all get more asymmetrical over time but funky eyebrow shape accentuates it. The biggest mistakes are tweezing the brow too thin, tweezing the center margin too far outward and starting the arch too far centrally giving a comma shaped eyebrow. Hold a pencil parallel to the outside corner of your nostril through the inside corner of your eye to your eyebrow. Only tweeze center of this line. Rotate the pencil through the outside corner of your eye to your eyebrow. This is where your eyebrow should end. Rotate through the outside edge of the colored part of the eye to the brow. This is where you arch. Do it right and it will make a big difference.
9. Wearing heavy, mismatched foundation. Heavy foundation actually makes texture abnormalities like large pores, lines and wrinkles look worse. It can cover red discoloration. So lighten up on the foundation. It you want to fill in some of the texture abnormalities like lines and pores, and then use silicon based translucent foundation primer, followed by a lighter liquid foundation or mineral powder applied with a sponge.
10. Rushing around, doing too much and not getting enough sleep. During sleep many of the body’s natural repair mechanisms are more active including those that repair your skin. Sleep deprivation leads to both decreased levels of some beneficial hormones and less time to repair damage. Missing sleep for one night makes you look bad the next day and missing sleep on a routine basis can affect your appearance long term. So let everyone else do some of the work and go to bed.

It takes little or no money to correct these 10 skin sins. Just consistency and a little determination. So follow my grandmother’s “advice”—admit you are wrong, tell your skin you are sorry, and don’t do it again.

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

How to Get Rid Of Evidence of Age:
Removing Raised Brown Age or Liver Spots

So we have talked about how to tell what kind of brown spots you have in the precious post,  Out, damn’d spot! Out, I say! Get Rid of Brown Spots on the Face   so you know what needs to be done to get rid of them. Since we solved the sun damage spot problem in the last post How to Get Rid Of Your Past: Removing Brown Spots From The Sun, let’s move up the difficulty ladder to how to remove those horrible growths that come over time. They are the dreaded “age spots” or “liver spots.”

To recap, here is what you see:

• In the mirror: Tan to dark brown flat or raised growths.
• Diagnosis: Seborrehic Keratosis, which dermatologists call SK’s and you call age spots or liver spots. They often run in families, and are more common as you age.
• Treatment: First–physician evaluation to be sure they are benign, then destruction with liquid nitrogen, electric needle and curette or Fraxel Laser Treatment.
• Ease of treatment: Moderate.

People really hate these kinds of spots. The reason is that young skin is smooth, without ugly raised growths. In fact, studies have shown that people’s impression of the age of another person is primarily determined by the absence of spots and growths even more than the absence of wrinkles. In other words, a person with spots and growths but minimal wrinkles looks older than a person with few spots and more wrinkles. Sometimes the SK’s are itchy or get irritated and rubbed with clothing or things that rub up against them.

Now before we talk about how to remove them, I have to give you a disclaimer. There is another, and serious, skin growth that can be a raised brown or black growth. And that is melanoma. Melanoma is a serious skin cancer that is fatal if untreated or if treatment is delayed. It can be very hard to tell a benign non-cancerous SK from a cancerous melanoma. So hard in fact, that it is not uncommon for it to be difficult at times for a non-dermatologist physician to be sure that a particular lesion is benign. Even dermatologists, who see many tens of thousands of these lesions over a career, will need to biopsy some of them to ensure that we are not missing a melanoma. So it is very important that your brown growth is accurately diagnosed as an SK before treatment. And no, Dr. Google can’t do it and you can’t either.

So you should see a dermatologist for diagnosis and treatment. The other reason dermatologists are the best doctors to treat these are that these age spots or liver spots have to be removed by physical methods. Treatment has to be aggressive enough to remove them, but aggressive treatments can leave permanent lighter spots, permanent darker spots, or scarring.  There is a fine line between the best cosmetic result and either incomplete removal or over aggressive removal with resultant scarring or pigment change. And you don’t want to cross that line. So see your dermatologist who will be sure they are benign SK’s, not cancerous melanoma and then treat them. Lecture over.

Some families tend to grow a lot of SK’s and interestingly in each family people tend to get them either on the face, or on the trunk. They range in size from pin head size to the size of a half dollar, and can be tan, brown, and dark brown or almost black. Some are dry and scaly, or hard and rough. Some are more smooth and greasy looking, which back in the day lead to them being thought to come from oil glands.  Numbers can vary from one or two up to many hundreds, or as we in the medical field call TNTC–too numerous to count.  There is nothing you can do to prevent SK’s from coming. If they are, they are.

There is a variant of SK’s called dermatosis papulosis nigra or DPN. Dermatologists love long names, and makes us sound so smart don’t you think? Anyway, it is most often seen in skin types IV-VI, especially in people from or of origin in the African or Asian continents. It consists of hundreds of tiny pinhead sized black growths, especially in women and predominantly on the cheeks. We treat it as discussed below but it is a challenge due to the tendency of darkly pigmented skin to develop pigment change in response to trauma.

Home Treatment:

• Basically, none. These are growths that have to be physically removed. The dark color doesn’t come from increased melanin pigment; it comes from a lot of cells with normal or increased pigment stacked up on top of each other. Over the counter or prescription bleaches don’t help, although we do use them for a month or so before treatment to help stabilize pigment in patients who have a fair amount of natural pigment in order to help prevent or reduce the post-inflammatory pigmentation that often follows procedures. There are all sorts of home remedies to remove age spots that you hear about; castor oil, salt water and friction and others. They can peel off the top layer temporarily, but I have never seen them work long term.

 Office Treatment:

•  Destruction with Liquid Nitrogen: The most common way to treat age spots is by freezing then with liquid nitrogen. It is effective, relatively inexpensive and quick. The SK’s scab up, and fall off in about 7-10 days on the face, and 3-4 weeks on the body. But they have to be frozen hard enough to go through the growth, separate it from the underlying tissue. Sometimes the whole growth falls off, sometimes only part of it. Unfortunately it may leave an area that is lighter than the surrounding tissue as the pigment producing cells are killed.

•  Electric Needle and Curette:A more time consuming way to treat these brown growths is to inject a local anesthetic, cauterize the growth, and then scrape away the tissue. The nice thing about this treatment is that the growth is gone immediately. But just like freezing with liquid nitrogen, it can leave a change in pigment after healing. But if done carefully, I like this method best for dermatosis papulosis nigra, and for patients who have a lot of natural pigmentation, because it can heal with no or less pigment change.

• Fraxel Laser Treatment: Although we don’t use often Fraxel Laser Treatment as first choice of treatments, patient with age spots will often get improvement if they are undergoing Fraxel for other problems, such as wrinkles, or after one of the other treatments.

Both of the primary methods of treatment have been around for a long time. Not nearly as exciting or as lucrative for the physician as laser, but it just goes to show you that sometimes new is not better. Treatment sounds simple but it does take experience to be able to treat these with a minimum of pigment change.

Next we will be getting into much more difficult pigment problems, the bane of dermatologist’s existence—post inflammatory pigmentation and melasma.

How to Get Rid Of Your Past:
Removing Brown Spots From The Sun

In a previous post, Out Damn’d Spot, Out I Say we discussed how to tell what kind of brown spots you have, so you know what needs to be done to get rid of them. They are of very different causes and presentation, and have very different treatments. And it’s always a good idea to know what you have got, before you decide what you need to do. Let’s start with the easiest to treat, relatively speaking, brown discoloration from past sun exposure.

To recap, here is what you see:

• In the mirror: Scattered pin-head to quarter size flat brown or reddish brown spots on face, neck, chest, forearms, and hands. Some may be scaly.
• Diagnosis: Actinic damage from past sun exposure, most commonly in lighter skinned people. Freckles are small, relatively regular in size and distribution, flat and most common in redheads. There are two kinds of actinic, or “sun spots”. Actinic pigmentation are flat brown or reddish brown spots, irregular in size and distribution, but not scaly. Actinic keratoses, or AK’s, are also scaly or crusty.
• Treatment: Daily sun protection with clothing and sunscreen, prescription retinoid creams such as Retin A or Refissa, over the counter Retinol, prescription or over the counter bleaching creams, Intense Pulsed Light (IPL), Chemical Peels, Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel, LED treatments such as GentleWaves, and laser treatments such as Fraxel Laser. For pre-malignant sun damage treatments are liquid nitrogen destruction, prescription medications and photodynamic therapy such as IPL/PDT.
• Ease of treatment: Moderate.

So, now you know how you got where you are—spots, and blotches from sun damage.

• Freckles are small pinhead size brown to red to tan flat spots and are found on any part of the body that’s exposed to the sun, like the face, nose, shoulders and chest. They become darker in the summer and fade in the winter. Freckles can occur on all skin tones, but they’re more common in those with fair skin, red hair and light-colored eyes, and occur from childhood onward. Freckles give character and individuality, and many people with freckles like them and don’t desire removal, but remember the reason for them is overexposure to the sun and are a sign of sun damage.

• Sun spots are isolated discolorations appearing from prolonged sun exposure over extended periods of time. They are random in distribution, vary in size and color from tan to reddish brown, to dark brown, larger than freckles, usually flat. They’re most common on the hands, sides of the face, chest and neck, and any other part of the body that’s regularly exposed to the sun. Most common in lighter skin types, but can occur in anyone who is exposed to sun over a period of time. Sunspots usually tend to show up on the skin later than freckles, but as early as your 20’s and 30’s if you have light skin or have had significant sun exposure. Over time, as they become pre-malignant actinic keratosis they may become scaly, and accompany the crinkly texture changes, broken blood vessels and wrinkles of chronic sun damage.

Home Treatments:

• Daily Sun Protection: Of course, as with much of life, the best offense is a good defense. And the defense is sun protection started at an early age and continued though out life. And it is even more important if you have skin type I or II and live in a sunny climate such as southwestern US, southern US, the tropics or Australia; work or recreate outdoors; or grow up on the beach. I have gone over this before, and I know you don’t want the lecture again. If you do, read my previous post Quit Complaining and Wear Your Damn Sunscreen. The vitamin D issue? Topic for another day.

• Prescription Retinoid creams such as Retin A or Refissa: Retinoids are compounds which are able to penetrate the top layers of skin. Retinol is the naturally occurring form of Vitamin A and is converted to the biologically active form, retinoic acid, in the skin. Prescription retinoids are forms of retinoic acid, and are stronger than retinol. Retinoids have well documented anti-aging, sun damage reversal and acne treatment effects, and are considered the gold standard in both anti-aging and acne treatment. Prescription tretinoin, or the other prescription retinoids  include Retin-A, Retin-A Micro, Refissa, Renova, Differin, Tazorac) that come in creams and gels. I have been using one form or another of prescription tretinoin for 25 years. The key is to use the right form. I use currently use Refissa (it is the old Renova 0.05% now a branded generic), tretinoin 0.05% in an emollient base. It is much easier to tolerate than Retin-A, and even easier to tolerate than Renova 0.02%. Creams 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. When you use it, get dry and red, stop, get better and start again, your skin peels, reforms just in time to peel again when you restart it. And your skin never gets tolerant of it. You can do it every other night or even every third night to start and work up. Be very careful with exfoliants, which can cause microscopic abrasions which allow the tretinoin to penetrate and cause inflammation. Even using a washcloth or facial cloth, synthetic cotton balls (use 100% cotton), cleansing brushes, or a makeup brush to apply loose mineral powder can cause you to not tolerate it.

• Over the counter Retinol: In general, the strength of pure time-release retinol in medial grade, non-prescription products is 0.1-0.5%. The percentage may increase up to 1.5% if the product is actually a mixture of retinol, retinyl palmitate and retinyl acetate.

• Prescription or over the counter bleaching creams: Prescription hydroquinone, non-prescription hydroquinone and other over the counter bleaching creams are often helpful in addition to the other methods we are discussing. That is a complicated topic, and one which we will discuss in depth when we discuss the bane of pigment problems, melasma, later. So you will just have to stay tuned, and return later.

Office Treatments:

• Intense Pulsed Light (IPL): A series of 3-5 Intense Pulsed Light treatments (called IPL, Photofacial, or Photorejuvenation) reduces broken capillaries, redness, brown pigment, age spots, and freckles. It is ideal for those who have lighter skin, with discolorations and little or no textural problems, because it targets the pigment in cells and broken blood vessels to destroy them, while not disrupting the other, lighter parts of the skin.  Red areas get redder for 24 hours, and dark spots get darker for 5 days, and then peel off.It is absolutely essential that you use daily sunscreen, and avoid sun exposure for 3 weeks before treatment, to reduce the natural pigmentation in the surrounding normal skin. Patients with skin types III and up must be especially careful. If you don’t you are at risk of getting burned. Also it is essential that you are evaluated and treated by a physician who is trained and experienced in the skin. IPL is a great procedure when properly done, but one that takes skill to do right. We see patients who have had treatments by individuals with little training or experience and who then develop burns, more pigment, or who are given many low energy treatments with little results. IPL also can be used to improve the red and brown discoloration on the neck, chest, back of the arms, and hands from sun damage. The healing time is longer and the risk of burns higher if you don’t follow sun protection or if done by an inexperienced or untrained operator.

• Chemical Peels: At-home products with glycolic or fruit acids and 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. 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.

• Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel: Particle-free microdermabrasion uses a treatment tip to exfoliate the skin. SilkPeel Dermal Infusion uses a diamond treatment head to precisely exfoliate accompanied by application of bleaching solutions 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 such as GentleWaves: GentleWaves LED Photomodulation uses a painless light emitting diode treatment to stimulate collagen and elastin production and improve mild brown discoloration over a series of 8 or more treatments. There is no downtime, but should be used with other treatments, and improvement is variable.

• Fractional Laser Treatments 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 are candidates for fractional laser treatments such as Fraxel Laser Treatment or Active FX. Fractional lasers deliver energy deeper into the skin through thousands of deep tiny columns breaking up deeper pigment, resurfacing sun damage, irregular surface changes, wrinkles and scars. There are two main types, ablative requiring less treatments, but have a longer recovery time and discomfort during treatment and non-ablative which require more treatments, have less recovery time and discomfort during treatment.

Skin Color Does Matter

Pigment problems are one of the most frustrating things that dermatologists and their patients deal with, and I know it first hand because I have been on both sides of the exam table. To continue with our previous discussion, Out, damn’d spot! Out, I say! Get Rid of Brown Spots on the Face, let’s recap:

There are 4 main kinds of increased skin pigmentation, or brown spot problems:

• Scattered pin-head to quarter size flat brown spots on face, neck, chest, forearms, and hands from sun damage
• Tan to dark brown flat or raised growths from aging or genetic influences
• Brown or red-brown discoloration of areas from past acne or injury
• Large dark flat patches of discoloration from hormonally induced melasma

And they are easiest to hardest to treat, in that order.

The key to doing the best you can with what you’ve got, is to know what you’ve got. To some degree, you inherit the skin you’ve got. The most obvious, and one that has caused problems since our ancestors left the savannah, is skin color. Skin color is primarily determined by the amount, kind, and distribution of protective melanin pigmentation. Racial groups who were adapted to live in the tropical belt, with stronger sunlight, developed more pigmentation to protect against early death from disseminated skin cancer. Those who migrated north where sunlight is much less intense, developed reduced amount of pigmentation, and some also developed abnormal, less functional melanin, manifesting as red hair and freckles on sun exposure.  Less pigmentation allowed increased UV penetration and adequate Vitamin D synthesis to prevent rickets. All well and good, until a red headed, freckled Irishman migrates over a couple of generations, from cloudy Northern Ireland to the sunny southwest United States and takes up ranching or farming. Or as I say to patients so frequently my nurses pull their hair out, “your skin should have stayed in Ireland.”

Other kinds of abnormal pigmentation are more common in groups who may have more natural pigmentation to provide sun protection. Those ugly brown growths called seborrehic keratosis occur in many ethnic groups, but are more common in some than others. Dark pigment after injury, acne or rashes is more common in those with more natural pigmentation. The scourge of the pigment world, melasma, occurs overwhelmingly in women and is more common in those with mid or deeper pigmentation.

So the first thing you need to do is look at your ethnic ancestry. The sun is stronger near the equator and progressively less strong as you more north and south away from the equator. Since natural skin pigmentation changes based on sun exposure take many generations, it is based on your ethnic background many generations past. So we are talking about areas that were inhabited in the distant past, thousands of years ago—the Old World not the New World. For instance, with the exception of Native Americans, those in the US would base it on the area from which your ancestors emigrated.  No, you don’t need to go on Ancestors.com. Most of us have a general idea from our family narrative. Before I get angry email responses that I am trying to start the racial argument, imply superiority of one racial background over another, or correct me on my very simplistic description of the major racial groups or names based on DNA analysis or historical evidence —just stop. I’m a dermatologist discussing this in regards to how your racial or ethnic ancestry affects your risk of pigment changes, how you can prevent it, and what to do about it. Because in this situation, skin color does matter. You can’t handle the truth? Bummer. Get over it.

In a very general sense, if your ancestry is predominantly:

• Celtic (i.e. Irish and Scots) you are at high risk for sun induced pigment, moderate risk of growths and melasma and low risk of post inflammation pigment
• Northwestern European, Germanic or northern Slavic (i.e. English, Scandinavian, German, French, north-west Russian) you have moderate risk of sun induced pigment, growths, post inflammation pigment, and melasma
• Southern European, Mediterranean, or southern Slavic (i.e. Italian, Spanish, Greek, southern Baltic, southern Russian) you have low risk for sun induced pigment, moderate risk for growths, post inflammation pigment and melasma
• Northern Asian (i.e. Japanese, northern Chinese, Korean) you have low-moderate risk of sun induced pigment, and moderate to high risk of growths, post inflammation pigment and melasma
• Equatorial African or Asian, Middle Eastern, Indic; Polynesian Pacific Islander; indigenous Northern, Central or Southern American (i.e. Northern African, Arabian, Persian, Turk, East Indian, Hawaiian, Malaysian, Pakistani, Vietnamese, Native American, Mexican)  you are at low risk of sun induced pigment, moderate risk of growths, and high risk of post inflammation pigment and melasma
• Equatorial or southern African, aboriginal Pacific Islanders—you are low risk of sun induced pigment, moderate-high risk of melasma and high risk of post inflammation pigment

Because humans have been traipsing all over the earth for centuries, mixing up the gene pool, many of us are of mixed ancestry. So in addition to looking at ancestry and to simplify things the Fitzpatrick Skin Type scale was developed. The Fitzpatrick skin type scale is based on your genetic skin disposition regarding how your skin responds to the sun. You can take the full Fitzpatrick Skin Type quiz, and get specific recommendations for your skin type at the Skin Cancer Foundation website. Here it is in summary:

When exposed to sunlight, do you:

• Always burn, never tan–you are Skin Type I
• Usually burn, tan lightly–you are Skin Type II
• Sometimes burn, tan moderately–you are Skin Type III
• Rarely burn, always tan–you are Skin Type IV
• Very rarely burn, tan easily and deeply–you are Skin Type V
• Never burn, always deeply pigmented–you are Skin Type VI

Again, in general:

• Skin Type I is at very high risk of sun induced pigment, moderate risk of growths and melasma, and low risk of post inflammatory pigment
• Skin Type II is at moderate to high risk of sun induced pigment, and moderate risk of growths, post inflammatory pigment and melasma
• Skin Type III is a moderate risk of sun induced pigment, growths, post inflammatory pigment and melasma
• Skin Type IV is at low risk sun induced pigment, moderate risk of growths, and high risk post inflammatory pigment and melasma
• Skin Type V is at low risk of sun induced pigment, moderate to high risk of growths, and high risk of post inflammatory pigment and melasma
• Skin Type VI is at low risk of sun induced pigment, moderate risk of growths, moderate-high risk of melasma and high risk of post inflammatory pigment

We all have different levels of natural pigmentation, and my experience has been that almost all of us are happy with what we have got. And that is good, since we can’t change it. But, with the possible exception of freckles, most of us want to be one uniform color. We don’t want darker spots, blotches or patches of pigmentation because they take the focus away from our natural beauty. When the eye focuses on spots, it distracts from the rest of our loveliness. And makes us look older, since in youth those spots don’t occur. Subconsciously we associate uniform skin color with youth, and blotches and spots with aging. Therefore, if we want to look as young as we can, we need to reduce irregular patches of pigment.

So next: we will start with how to fix spots, blotches and irregular pigment from sun damage

How to Get Rid of Brown Spots on the Face

“Out, damn’d spot! Out, I say!”  Macbeth Act 5, scene 1

There are things that frustrate you. There are things that frustrate me. And then there is hyperpigmentation, the medical term for increased skin pigment. I can’t tell you the number of times patients have asked me in frustration–“Why can’t I get rid of these brown spots, I hate them! It can’t be so hard can it?”

Unfortunately, yes.

Melanin is the skin’s natural pigment that darkens to protect us from the sun’s skin cancer causing rays. Once sun exposure stops, skin lightens back to its natural color. At least, that’s what is supposed to happen. Damaged or abnormally functioning cells produce discoloration that does not fade. To some degree, the tendency to make abnormal pigment has a genetic basis tied to ethnic background. People with more natural pigment, such as Hispanic, Asian, American Indian, etc., respond to anything that injures or inflames the skin with increased pigmentation.

There are five triggers for abnormal pigmentation—sun exposure, inflammation, injury, hormones and aging. Each of the triggers results in a specific type of pigmentation, and each is more common among different types of patients. In medicine it’s always a good idea to start with an accurate diagnosis, before deciding on treatment and prognosis.  First, look in the mirror and see exactly what kind of pigment you want to improve.

From easiest to most difficult:

In the mirror: Scattered pin-head to quarter size flat brown spots on face, neck, chest, forearms, and hands.

• Diagnosis: Actinic damage from past sun exposure, most commonly in lighter skinned people.
• Treatment: Home skin care, prescription retinoid creams such as Retin A or Refissa, daily sun protection, Intense Pulsed Light (IPL),  GentleWaves, Fraxel Laser.
• Ease of treatment: Moderate.

In the mirror: Tan to dark brown flat or raised growths.

• Diagnosis: Seborrehic Keratosis (age spots), often familial, and more common with age.
• Treatment: First–physician evaluation to be sure they are benign, then destruction with liquid nitrogen, electric needle or Fraxel Laser.
• Ease of treatment: Moderate.

In the mirror: Brown or red-brown discoloration of areas with past acne or injury.

• Diagnosis: Post inflammatory hyperpigmentation (PIHP), most commonly occurring patients with more natural pigment.
• Treatment: Prevention by treatment of acne, not picking, and caution with procedures that can cause pigment such as chemical peels and laser hair removal. Treatment with home skin care, prescription skin bleach, prescription retinoid creams, and for some patients the very cautious use of chemical peels or microdermabrasion.
• Ease of treatment: Moderate—difficult.

In the mirror:  Large dark flat patches of discoloration, usually symmetrical, over cheeks, jawline, forehead and/or above upper lip. It is often more obvious in low light settings, such as at sunset.

• Diagnosis: Melasma or “mask of pregnancy,” is caused by a combination of hormones, predominantly estrogen from pregnancy or birth control, 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 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 are tried first.  “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.

Overall abnormal pigment, especially melasma, is one of the hardest and most frustrating skin problems that cosmetic dermatologists and their patients deal with. I know, since I have had it myself.

Though Lady Macbeth and I earned our spots in different ways, the frustration is the same.

Next: Let’s dive into the pigment pool in more depth

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.