Daily Skin Fix

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.

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

Top 10 Aesthetic Skin Resurfacing Tips

Here are my top 10 tips on cosmetic skin resurfacing, in no particular order. My philosophy is to err on the side of safety. You may get away with breaking the rules. You may not.

These are my opinions, your doctor may feel differently.

1. Top home treatment for skin resurfacing–hands down– are prescription retinoids (Refissa, Renova) in a high enough strength (0.05% or higher)

2. Top home treatment for skin resurfacing without a prescription is glycolic acid containing skin care in a high enough strength to do some good (8,10 or 15%)

3. Remember to stop your retinoids and glycolic acid 3-5 days before a light chemical peel, microdermabrasion, or facial waxing unless you like the scabbed up look.

4. Don’t expect more from the less aggressive treatments than you are likely to get. Fresh, glowing skin with reduced acne and some blending of pigment–yes. Removal of wrinkles and acne scars, growths–no.

5. If you are thinking of doing a deep chemical peel and have any degree of natural pigmentation, or any ancestors even 3 generations back that have any degree of natural pigmentation–think twice. And then think again.

6. When a male doctor tells you that “you will be a little crusted for a couple of days” he usually means “you won’t be comfortable going out in public for a week or more”.

7. For any aggressive skin resurfacing procedure, it is almost always better to do your whole face instead of just a segment. That way if you do get any color change it will at least blend somewhat into the other areas.

8. Be very careful with ablative CO2 laser skin resurfacing, even fractional, on the neck and chest as the risk of scarring is higher on those areas. And the scarring can involve the whole area not just a small section.

9. If you have had an ablative laser (CO2) skin resurfacing procedure, fractional or non-fractional, and are having any problems, such as increasing pain, persistent redness or sensitivity, blisters, insist that you are seen and evaluated by the doctor. Early treatment of complications can reduce scarring.

10. Take the bleaching and sun protection instructions seriously. And follow them.

Aesthetic Skin Resurfacing Treatments

• Costs
• Number of Treatments
• Recovery Time

As with any aesthetic skin procedure, you need to weigh the benefits of skin resurfacing procedures against the cost, number of treatments needed and recovery time. Of course, these vary by patient, by the severity of the problem that we are treating, and by physician.

The following are averages, your problem may require more or less treatments, your recovery time may be longer or shorter, and the cost may be greater or less than average. Many cosmetic practices offer discounts for packages of a series of treatments, or for multiple procedures performed together or on the same day. So the following are averages, your doctor may charge more or less:

Light Chemical Peels (Glycolic Acid 50-70%)

• Cost: $75/peel or package of 6 for $375
• Number treatments needed: 6
• Recovery time: 1 day of crusted pimples, mild flaking 3-4 days

Medical Microdermabrasion (SilkPeel)

• Cost: $165/treatment or package of 6 for $825
• Number treatments needed: 6
• Recovery time: none

GentleWaves LED

• Cost: $ 140-185/treatment
• Number treatments needed: 6
• Recovery time: none

Intense Pulsed Light (IPL)

• Cost: $500-700 face/treatment
• Number treatments needed: 2-3
• Recovery time: Redness for 1 day, brown spots turn darker and peel off day 5

IPL/PDT

• Cost: $1000/treatment
• Number treatments needed: 1-2
• Recovery time: Redness and light sensitivity for 3 days, crusting of pre-cancerous areas for 1-3 weeks depending on severity

Laser resurfacing results, recovery time, need for anesthesia and costs vary based on the procedure. For example Fraxel now has 3 different versions of the original Fraxel, all named Fraxel (which leads to confusion when patients don’t know which version is which–bad idea I think but no one asked me): Fraxel re:fine (used by aestheticians), Fraxel re:store (the original Fraxel) and Fraxel re:pair (fractional ablative CO2). As you go up the scale, the cost and recovery time increases and the number of treatments decrease. Fraxel re:pair may require IV anesthesia in a surgery center.

Fraxel re:fine laser resurfacing

• Cost: $750-$1000/treatment
• Number treatments needed: 4-6
• Recovery time: 1 day redness, mild flaking 3-4 days later

Fraxel re:store laser resurfacing

• Cost: $1000-$1500/treatment
• Number treatments needed: 3-5
• Recovery time: 1 day redness and swelling, 5 days bronzing skin, fine flaking day 6-7

Fraxel re:pair laser resurfacing

• Cost: $3000-$5000/treatment + possible anesthesia and facility costs
• Number treatments needed: 1-2
• Recovery time: Pinpoint bleeding  and oozing for up to 48 hours. Swelling and crusting for 1 week, redness for 1 month

Laser resurfacing results, recovery time, need for anesthesia and costs vary based on the procedure. For example Fraxel now has 3 different versions of the original Fraxel, all named Fraxel (leads to confusion when patients don’t know which version is which–bad idea I think but no one asked me): Fraxel re:fine (used by aestheticians), Fraxel re:store (the original Fraxel) and Fraxel re:pair (fractional ablative CO2). As you go up the scale, the cost and recovery time increases and the number of treatments decrease. Fractional ablative CO2 resurfacing technology may require IV sedation and ambulatory surgical facility which may increase costs.

So there you have it, as always in life, there are tradeoff’s and you just have to decide what you want, what you need, and what you are willing to do to get it.

Next: Now the fine print about skin resurfacing–risks, side effects, and other unpleasant things

How do you know which aesthetic skin resurfacing treatment is right for you?

I am often asked this question and my answer is “what do you want to accomplish, how much improvement do you want, and how much time and money do you want to devote to it?” You can start at either end–want do you want or what are you willing to do to get it, but you have to start somewhere. Cosmetic skin resurfacing procedures that are more aggressive give more results. They cost more, usually because of the technology involved.

If you expect a lot of improvement, but don’t have the time or money to get there, you are going to be disappointed. Sometimes this is a hard pill for patients to swallow. They want the kind of results that the procedures that they can afford won’t give them. I try to be honest and explain the real world results that they can expect, and then the choice is to do the less expensive, less aggressive treatments and get some improvement, do financing and pay it off over time, or save up until you can afford what you need. On the other hand, if you don’t need or want more aggressive results, then the less aggressive procedures are right for you. That’s why the prevention strategies we discussed previously are so important. But if the horse is already out of the barn, you have to do what it takes to get him back in.

Remember if you are not my patient don’t pay attention to what I tell you. Pay attention to what your doctor tells you.

If you have these changes, then these are your options:

Dull skin:

• Home treatment: exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: light chemical peels, microdermabrasion (SilkPeel), LED (GentleWaves)
• More aggressive office treatment: not needed

Flat brown spots:

• Home treatment: some improvement if mild*–exfoliants, glycolic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), skin bleach
• Less aggressive office treatment: light chemical peels, microdermabrasion, LED (GentleWaves)
• More aggressive office treatment: Intense Pulsed Light (IPL)

Raised brown spots:

• Home treatment: won’t work
• Less aggressive office treatment: lesions destruction with liquid nitrogen or electocautery
• More aggressive office treatment: lesion destruction + laser resurfacing

Fine lines

• Home treatment: glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: LED (GentleWaves), Botox, light chemical peels, microdermabrasion (SilkPeel)
• More aggressive office treatment: laser resurfacing

Skin colored bumps (milia cysts, moles, syringomas, fibromas, etc)

• Home treatment: milia only–exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin
• Less aggressive office treatment: milia only–light chemical peels. All others–lesion destruction with shaving, electrocautery
• More aggressive office treatment: laser resurfacing

Broken blood vessels

• Home treatment: won’t work
• Less aggressive office treatment: electrocautery to isolated veins
• More aggressive office treatment: Intense Pulsed Light (IPL)

Non-etched wrinkles (go away when you stretch the skin)

• Home treatment: some improvement if mild*– glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing,dermal fillers and/or Botox + laser resurfacing

Etched wrinkles (don’t go away when you stretch the skin)

• Home treatment: some improvement if mild*– tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing, dermal fillers and/or Botox + laser resurfacing

Rough spots (pre-cancerous actinic keratosis)

• Home treatment: some improvement if mild*– tretinoin, more improvement with– prescription topical fluorouracil, imiquimod, diclofenac
• Less aggressive office treatment: liquid nitrogen
• More aggressive office treatment: photodynamic therapy (IPL/PDT)

Enlarged pores

• Home treatment: if plugged only–exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin)
• Less aggressive office treatment: if plugged only–light chemical peels, microdermabrasion.
• More aggressive office treatment: if permanently enlarged–laser resurfacing

Scars

• Home treatment: some improvement in acne scars if mild*– tazarotene (Tazorac)
• Less aggressive office treatment: some improvement in acne scars if mild*–light chemical peels, microdermabrasion, dermal fillers (Juvederm, Restylane etc)
• More aggressive office treatment: laser resurfacing, surgical removal

Loss of elasticity

• Home treatment: some improvement if mild*–glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: some improvement if mild*–light chemical peels, microdermabrasion.
• More aggressive office treatment: laser resurfacing

Elastosis (yellowish, stiff, bumpy, permanently creased or cross-hatched change from long term sun damage)

• Home treatment: won’t work
• Less aggressive office treatment: won’t work
• More aggressive office treatment: laser resurfacing

Note: “some improvement if mild*”–your definition and my definition of mild may not be the same.

Next: What’s it gonna take?

Skin Resurfacing–the Overhaul
Prevent and Correct Moderate or Advanced Changes
With Dermatology Office Treatments

When you are seeing more advanced changes and look in the mirror and think “I really don’t care for these changes,” it’s time to move on to some of the moderate to advanced dermatology in-office resurfacing procedures. You are in this category of moderate to advanced changes if you are seeing one or more of the following changes: etched lines(lines that don’t totally go away when you stretch the skin), enlarged pores, loss of elasticity, the irregular bumpy slightly yellowish sallow surface that dermatologists call elastosis, and more pronounced brown spots, and worsening of old acne scars.

Options are:
Deep Chemical Peels
Traditional Dermabrasion
and Laser Resurfacing

Deep Chemical Peels

Deep chemical peels have been around for a long time. They include high strength Trichloroacetic Acid (TCA, and Phenol peels. Both will penetrate deep enough into the skin to treat at the level at which deep etched wrinkles and acne scars reside, and that is how they treat deep etched lines and acne scars. The problem that is also the drawback, that they penetrate deep enough into the skin to cause scarring. Because they are applied by hand, by a physician, they are dependent on the thickness of the skin, the preparation of the skin before the procedure and the amount of acid applied. And even in the hands of a skilled physician who has performed many deep chemical peels, there is an inherent unpredictability with the depth that the acid will penetrate. Because of this, the risk of side effects such as permanent pigmentation changes, and scarring are greater than with laser resurfacing. Also sometimes they actually cause enlarged pores. Phenol peels always cause permanent loss of pigment so that the skin turns snow white. This is acceptable if your skin type is extremely fair, but not if you have any significant natural pigment. Both require general anesthesia.

I did a fair amount of deep chemical peels under anesthesia early in my career, but have abandoned them in favor of laser resurfacing. I will say that Phenol peels remove etched lines above the upper lip more completely than any other treatment, by replacing the skin and wrinkles with what is essentially a sheet of white scar. But this requires a patient with very fair skin, and the patient will be required to wear makeup every day forever to cover the fairly marked difference in color between treated and untreated skin.

Traditional Dermabrasion

Traditional dermabrasion (not to be confused with microdermabrasion), involves using an electric medical sanding tool to sand off the skin. It is used most often for deep acne scars. The problem again is that the depth of the treatment is dependent on the skin thickness, and the skill of the physician doing the procedure. Deep acne scars are from acne cysts that occur deep enough in the skin to cause a scar. Traditional dermabrasion is performed at the level of skin where scars form. That is why traditional dermabrasion replaces acne scars with a sheet of new scar. The skin never really looks or feels normal.

Laser Resurfacing

Laser resurfacing is divided into ablative and non ablative depending on whether the surface layer of the skin is removed with treatment (ablative) or not (non-ablative). It is also divided into fractional and non-fractional.

The first skin resurfacing lasers in the 90′s were ablative and non-fractional CO2 lasers. Non-fractional ablative lasers only required one treatment but usually required general anesthesia. Patients looked like they belonged in a burn unit for 2-3 weeks, were red and sensitive for months. Although not known in the first few years of use, some patients developed permanent loss of pigment in the treated skin several years after treatment. Additionally the risk of scarring, though less than deep chemical peels and traditional dermabrasion was unacceptably high. I also did many ablative non-fractional CO2 laser treatments in the 90′s but like most physicians switched to fractional laser resurfacing when it became available.

Fractional laser resurfacing was developed to address some of these problems. Fractional means that only a fraction of the skin is treated at a time by creating thousands of tiny treated channels in the skin surrounded by untreated skin. This allows safer treatment with much less risk of scarring and permanent pigment change, but requires more than one treatment to achieve best results. Fractional lasers are either ablative (destroys the top layer of skin) or non-ablative (does not). Fraxel was the first laser to utilize the fractional technology. Fractional laser resurfacing creates microscopic “wounds” within targeted areas beneath the outer layer of skin. The natural healing process produces collagen and healthy skin cells.

The original fractional laser resurfacing treatment Fraxel, is now Fraxel:restore, and is non-ablative. Fraxel:repair is a more recent development and is ablative. Ablative lasers require less treatments, but each treatment has a longer recovery time. Ablative lasers also may require general anesthesia. Non-ablative lasers may be safely used on the neck, chest, forearms and hands. Ablative lasers carry a risk of scarring in these areas.

We use Fraxel:restore as our patients prefer more treatments with less downtime and less discomfort with each treatment. They also don’t want general anesthesia which ablative procedures may require. In the last few years, many new resurfacing lasers have emerged. All have their pros and cons, but there are now multiple choices, and each physician usually has a personal preference.

Laser resurfacing treats mild to moderate wrinkles, surface irregularities, blotchy pigment, acne scarring, large pores, and stretch marks. Skin is smoother, less wrinkled and more refined with smaller pore size.

Photos of before and after Fraxel eyelid treatment
Photos of before and after Fraxel facial treatment

Next: How to know which skin resurfacing treatment is right for you.

So you have ruined your skin with the sun. Well at least you had a good time. Now its time to fix the mess.

Our first option is to try to improve the brown spots, roughness and fine lines with skin care and prescription retinoids. But broken blood vessels, wrinkles, elastosis, pre-cancerous changes and more significant pigment changes require more significant treatment. If we can’t accomplish what we want to do to repair sun damage to the skin with at home treatments or want quicker results then we go to treatments in the office.

These anti-aging aesthetic procedures and treatments help reverse sun damage:

GentleWaves® LED Photomodulation®
Gives creamy appearance to skin

This painless light emitting diode treatment stimulates collagen and elastin production and prevents collagen breakdown.  It improves sun damaged reducing the appearance of fine lines and gives a creamy appearance to the skin.

SilkPeel®
Restores radiance and glow.

Microdermabrasion uses a controlled stream of particles to exfoliate the skin. Particle-free microdermabrasion uses a treatment tip. We perform SilkPeel® Dermalinfusion® which uses a diamond treatment head to precisely exfoliate, followed by Dermal Infusion, the application of specific dermaceutical treatment solutions at controlled intensity. It removes surface abnormalities, and allows better penetration of prescribed home skin treatments.

Chemical Peels
Improves acne and pigmentation.

A chemical peel is the application of a solution to remove skin of varying depths and to stimulate collagen production.  Depth achieved varies with strength and chemical used–superficial peels (Glycolic, Lactic, Salicylic Acids), mid level peels (lower strength Trichloracetic Acid/TCA), and deep peels (high strength TCA or Phenol). Superficial peels are effective for acne, pigmentation, fine lines and restoring glow. Mid level peels improve fine lines, some moderate lines. Deep peels improve deeper wrinkles and acne scars. The risks involved increase with the depth, with the deeper peels having much increased risk of scarring and permanent pigment change compared with superficial peels.  Deeper peels have been used less frequently since the development of lasers, as the depth of the peel is less predictable than with laser treatment.

Intense Pulsed Light (IPL®)
Improves red and brown discoloration and sun damage

Intense Pulsed Light (IPL®) reduces broken capillaries, redness, brown pigment, age spots, freckles, large pores and fine lines. Face, neck, chest, arms and hands may be treated. IPL® / PDT utilizes IPL® and a topical medication for quicker and additional results and treats pre-cancerous sun damage called actinic keratosis. IPL® gives you a clearer skin tone with reduced redness, veins, and brown spots. It improves the red and brown discoloration on the neck, chest, backs of arms, and hands from sun damage.

Fraxel® Laser Treatment
Resurfaces an entire surface area reducing wrinkles, scars, pore size and bumpy skin surface

Fraxel Laser Treatment (FLT) is a “fractional” treatment that produces thousands of deep, tiny columns in your skin, resurfacing sun damage, irregular surface changes, wrinkles and scars.

There is minimal downtime. Most patients return to routine activities the same day of treatment. Areas that improve include overall sun damage, mild to moderate wrinkles, large pores, surface irregularities, pigment abnormalities, acne scarring and stretch marks. Fraxel® increases overall smoothness of the skin.

Best choices for specific sun damage skin changes:

• Brown spots–IPL
• Broken blood vessels–IPL
• Pre-cancer–IPL/PDT or liquid nitrogen to individual spots
• Elastosis, wrinkles, enlarged pores–Fraxel

Next: My top 3 anti-aging choices for repairing sun damaged skin

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.