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I Hate Melasma:
How to Prevent and Treat Melasma

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

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

To recap, here is what you see with melasma:

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

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

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

• Ease of treatment: Difficult-very difficult.

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

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

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

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

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

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

Home Treatment:

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

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

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

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

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

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

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

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

Office Treatment:

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

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

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

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

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

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

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

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

Your Skin Holds a Grudge:

Removing Brown Spots after Acne, Laser or Peels

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

To recap, here is what you see:

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

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

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

• Ease of treatment: Moderate—difficult

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

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

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

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

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

Home Treatment:

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

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

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

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

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

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

Office Treatment:

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

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

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

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

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

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

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

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.

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.

The fine print about skin resurfacing–risks, side effects, and other unpleasant things

So here is the fine print on risks and side effects of the skin resurfacing procedures we talked about. The risks and side effects are similar with all resurfacing procedures: infection, scarring, pigment problems and redness. This differs from the expected post treatment course such as crusting, flaking etc that we discussed previously, because the risks and side effects are things that, thankfully, don’t usually happen, and ones we don’t want to happen.  The incidence and severity of these reactions vary among with the procedure, with the patient, and with the physician.

Infection: Infection risk can be viral, bacterial or yeast. Viral risk is from the cold sore virus with a post procedure outbreak occurring in someone with a history of frequent cold sores. The virus can then spread into the treated area causing scarring. It can occur with any of the procedures but is more common after the more aggressive procedures. Anyone with a history of cold sore infections should receive preventative treatment with Valtrex. Bacterial infection can occur after picking with any of the procedures. Without picking it is very rare in the less aggressive procedures, more common but still unusual in the more aggressive procedures. Fungal infection, usually with Candida yeast only occurs after the more aggressive procedures.

Scarring: Can occur with any of the procedures, but in the absence of picking, or infection, should not occur in the less aggressive procedures. Much more common after deep chemical peels and traditional dermabrasion.

Pigment problems: Patients with any degree of natural pigment are at increased risk for permanent pigment change, usually darker but sometimes lighter skin, after all resurfacing procedures. The risk rises rather steeply as you move from the less aggressive to more aggressive procedures. At risk skin types include: Hispanic, Asian, American Indian, Middle Eastern, East Indian, Black, including those with these skin types in their genetic makeup several generations back. Caucasians who tan easily and those who get sun exposure are also at risk.  Careful patient selection, not treating irritated skin and reducing post treatment sun exposure are important.

So here are my assessments of the degree of risk for each procedure:

Light Chemical Peels

• Infection: Occasional viral infection if not pretreated.
• Scarring: Very rare unless picking.
• Pigment problems: Uncommon if proper patient selection and patient follows sun exposure precautions. More common if they don’t.

SilkPeel (medical microdermabrasion)

• Infection: Very rare viral infection, unless pretreated.
• Scarring: Very rare
• Pigment problems: Rare

Deep Chemical Peels

• Infection: Moderately common, less if pretreated
• Scarring: Moderately common
• Pigment problems: Uncommon if very fair skin, moderately common if darker skin

Traditional Dermabrasion

• Infection: Moderately common
• Scarring: Common
• Pigment problems: Uncommon if very fair skin, moderately common if darker skin

Non-Ablative Fractional (Fraxel re:store)  Laser Resurfacing

• Infection: Uncommon viral infection, unless pretreated. Very rare bacterial or fungal
• Scarring: Uncommon
• Pigment problems: Uncommon if fair skin, moderately common if darker skin

Ablative Fractional CO2 (Fraxel re:pair and others) Laser Resurfacing

• Infection: Uncommon viral infection, unless pretreated. Rare bacterial or fungal
• Scarring: Relatively uncommon on the face, occasional on neck, chest, arms
• Pigment problems: Uncommon if fair skin, moderately common if darker skin

Who are the highest risk patients?: Patients with a fair amount of natural pigment (darker skin types, or those with darker skin types in their genetic background), smokers, pickers, thin skin, those with tendency to form scars, those with undisclosed recurrent cold sores, and those who don’t take the sun precautions seriously.
Disclose all medical information, follow instructions–what a concept

Who are the highest risk physicians?: Physicians without an in depth, formal training in the skin in health and disease, those who aren’t willing to not treat inappropriate patients because of a profit motive, those who aren’t willing to take the time to be sure the patient understands and follows instructions.
Training, experience and ethical standards–what a concept

What are the highest risk procedures?: From highest to lowest–Traditional dermabrasion and deep chemical peels, then fractional ablative laser resurfacing, fractional non-ablative laser resurfacing, light chemical peels, SilkPeel.
Deep chemical peels, and traditional dermabrasion are the most risky procedures. If you are going to proceed with these, be sure the physician is trained, experienced and does a lot of them.

Remember, these are my opinions and what I tell my patients. Your doctor may feel differently. Don’t make your decision regarding procedures on what I tell you, unless you are my patient. Make your decision based on what your doctor tells you.

Next: Aesthetic skin resurfacing tips