Daily Skin Fix

How To Use Retinoids Without Your Face Peeling Off

As many of you know, I am a strong advocate of daily retinoid use for most patients to prevent aging and correct existing damage. There is so much proven scientific data behind them that they are still the gold standard in topical anti-aging treatment. I have been using prescription retinoids and daily sunscreen for 25 years. If you come to see me as a patient, I will likely recommend that you start one of them as part of your anti-aging skin care program. And, of course, if I recommend it, you will do it.

Retinoids are vitamin A derivatives and include over-the-counter retinol, prescription Retin-A, Renova, Refissa, Tazorac, and Differin. Originally developed for acne, they were found to also increase collagen and elastic fiber production, diminish wrinkling, improve brown discoloration, and reduce both roughness and pore size. Retinoids can be applied to the face, neck, back of hands and forearms as these areas also show aging changes from chronic sun exposure.  Apply a pea size amount to each area on completely dry skin in the evening. Most people can only apply it to skin that is off the face every other night because of irritation.

The biggest drawback, and the reason people discontinue retinoids, is that early on they cause peeling and some redness, a process called retinization. The key to success is to use the right form and to use it correctly on a regular basis, not intermittently. Most people do it this way: they use the retinoid; they get dry and peel so they stop until it gets better and then start again. In the meantime the top layer of skin builds up, just in time to peel again when you restart treatment. That is the wrong way to do it. If you do it that way your skin never adjusts and you will keep peeling every time you start treatment again. If you use it regularly without starting and stopping, after about 2 months your skin will stop peeling. You may have occasional episodes of peeling after an environmental insult to the skin, but much of that can be prevented.

Most, but not all, people who have had problems using a retinoid are able to use it successfully if they do it the right way. I often start patients off every other or every third night and work up to every night, but consistently. You can start with the least irritating retinoid and move up to the more irritating product. Gels are more drying and irritating than creams. Refissa and Renova are the least irritating, then Differin, then Retin A, and finally Tazorac is the most irritating. On the other hand, Tazorac gives the most improvement in pore size and acne scars. Another strategy when you are starting treatment is to mix them with moisturizer to dilute them, apply moisturizer before application (if you are having redness, itching or irritation), or after (if you are just dry). And if you have an episode of dryness and peeling later in treatment, you can always dilute them again for a few days. Our Antioxidant Enzyme Peel is great for removing the peeling skin without abrasion.

Mild stinging, redness, peeling and flaking may occur during the first several months and on occasion. This is normal, soreness and irritation are not. Anything that you use on your skin that abrades the skin will cause more redness and peeling. The most common culprits are washcloths, synthetic cotton balls, makeup brushes, or a granular exfoliant. The infomercial technique of applying mineral powder in a circular scrubbing motion with a special brush is the most common cause retinoid intolerance in my clinic.

Discontinue retinoids 5-7 days before waxing, bleaching, peels, microdermabrasion, acne surgery, hair removal, and laser treatments or you will be sorry. If you wax an area that has been treated with a retinoid, strips of skin will come off with the wax when it is ripped off. Other procedures may burn the skin if you don’t stop retinoid use prior to the procedure. That is why the instructions we give with the prescription goes over this. If you didn’t read your instructions, and have an “unfortunate accident” start with a non-fragranced moisturizer and apply it 3-4 times a day to the area where the skin was ripped off.  I like Aquaphor, or Cetaphil cream. Don’t put any toner or active skin care products (glycolic acid, salicylic acid etc.) on it until it has healed. Don’t scrub or pick. As soon as the skin has healed, (pink, not open, crusted or oozing) wear broad spectrum UVA/UVB sunscreen with an SPF of 20 or higher every single day, whether you normally do or not. Avoid sun exposure over the next several months to help keep the area from darkening over time.

Retinoids do make you more sensitive to the sun and you should use sunscreen every day, year round or you are just undoing what you are trying to do. We used to tell patients that they could not use retinoids if they were in the sun, but now we know that, within reason, you may use them if you use sun protection. Of course, I know you are already wearing your sunscreen every day, because you know that it is an essential part of an anti-aging skin care program.  If you are going to the beach, lake, or skiing, discontinue retinoids for a few days before exposure.

To recap:

How to reduce peeling and irritation with Refissa, Retin A, Differin, Tazorac and retinol

• Use it on a consistent schedule—every day, every other day, every third day, not on and off. Work up to every day.

• Choose a cream not a gel.

• Start with Refissa unless you have oily skin and acne. Refissa is in a moisturizing base, is stronger than Renova, and usually the easiest to tolerate. I use Refissa.

• Apply moisturizer underneath to reduce redness and irritation.

• Apply moisturizer over retinoids to reduce dryness.

• Don’t use mineral powder with a brush, use a sponge.

• Don’t use a washcloth or granular exfoliant.

• Stop retinoids 5-7 days before waxing or laser hair removal, chemical peels.

• Wear sunscreen.

Retinoids are very effective as part of your anti-aging skin rejuvenation program. It is worth working with them to be able to use them successfully.

To the consternation of the tanning industry, dermatologists lecture you all the time about the medical and cosmetic dangers of tanning, especially indoor tanning. That is because UV exposure is the single most cosmetically damaging thing you can do to your skin, as well as the major cause of skin cancer. No matter what the tanning industry says.

I know you get tired of hearing it from me. Too bad. But, I am going to cut you some slack. I am going to let someone else lecture you. So listen to our guest blogger, Jourdan Miller, on some of the interesting recent findings that tanning is similar to drug addiction.

I am loaning her my bulletproof vest.

 

More than Skin Deep
by Jourdan Miller

The prototypical American beauty is typically portrayed as blonde, thin, tall and most importantly: tan. While achieving this California dime look may seem harmless, new research from The Archives of Dermatology reveal that tanning is another form of addiction and as physically detrimental as cocaine abuse.

New York Times author Tara Parker-Pope writes about these shocking findings in her article, Is Indoor Tanning Addictive? “In the study, 78 percent of the most frequent tanners said they had tried to cut down on indoor tanning but had been unable to,” Pope writes. “Frequent tanners reported missing scheduled plans because they had opted to use a tanning bed instead.”

Frequent exposure to UV light produces opioids in the brain, more commonly referred to as endorphins. Indoor tanners report feeling happy, calm and relaxed and brain scans prove that the body is at a heightened state of contentment, writes Parker.

Dermatologist Dr. Robert McDonald says he sees tanning addiction all too often in his patients.

“The problem is only getting worse as affluence increases,” McDonald said of this affliction. “People have more money so their going on beach vacations to [places like] Cancun.”

As the media glamorize beauty, they often make it synonymous with bronzed skin and a youthful, carefree attitude.  Unfortunately, such ideas have a damaging effect on health.

“The threat is so far removed people aren’t paying attention to it right now,” McDonald said. “It’s like saving for retirement, it’s something you should do but if you don’t you might be ok, it’s also like telling a 20 year old ‘you better stop smoking now or you might get cancer in 30 years’; it’s hard to see yourself down the road.”

The human brain responds to UV light and almost immediately a bio chemical reaction triggers an addictive response, McDonald says. With nearly 30 million Americans tanning indoors every year, the habit isn’t going anywhere soon.

“We have 20 times more melanoma than in the 1920s,” McDonald said about the increased frequency of skin cancer. “It’s the kind of thing that happens when you’re young, before 25. It a cycle between the beach and the tanning bed.”

UW-Madison student Kayla Gross’ bronzed-skin-bliss took taken a turn for the worse last May. After developing a strange growth on her leg, dermatologists confirmed that Gross had skin cancer.

“I loved the warmth. If I didn’t go I wouldn’t feel right,” Gross said when asked why she continued the unhealthy habit.

An avid tanner throughout high school, Gross tanned for 20 minutes every other day. No eye goggles, no sunscreen, and no worries.

“I used to say ‘skin cancer isn’t a big deal, they just cut it off and remove it.’” Gross said about her outlook on cancer in high school. “I’ve had basil cell three times now, and I have the scars to prove it.”

While Gross had a wake-up call early in life, many of America’s youth aren’t so lucky.

“There’s a long time before this goes away,” McDonald said. “It’s an addictive behavior that’s only going to get worse.”

Jourdan Miller is a student at the University of Wisconsin-Madison in the School of Journalism and Mass Communication. When she’s not reading the latest article on beauty, fitness or skincare, you’ll find her running along the lake and dining out at the trendy restaurants in Madison. 

 Check out her blog http://jourdanmiller.wordpress.com/

 

 

 

 

How to pick like a dermatologist

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

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

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

When should I pull the flaky crust off?

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

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

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

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

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

Answer is: When it completely lifts off by itself.

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

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

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

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

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

 What are the possible complications from picking?

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

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

Answer is: All of the above.  So stop.

How do I know I am picking too much?

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

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

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

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

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

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

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

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

If you must pick, do it like a dermatologist

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Answer is: I can see pus at the top.

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

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

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

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

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

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

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

• Redness
• Pus
• Blood
• Muscle
• China

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

Answer is: Blood

What things should I not pick at?

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

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

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

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

Go to the dermatologist.

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

So you want to be a junior dermatologist?

Women pick at skin lesions, growths, cysts and spots. It is hard wired into our DNA. The first rule in medicine is to know what you know, know what you don’t know, and know that you know the difference.

So junior dermatologist, let’s take a pre-test.

 

 

 

Dr. Elaine’s “So you think you can dermatology?” Quiz

What is a good reason to pick at a skin spot?

1. It is there
2. It hurts
3. I really think I can get it better
4. Makeup makes it look worse
5. I have a date tonight
6. I am stressed

How many times should I try to pick at something before I give up?

1. One
2. Three
3. Ten
4. Thirty-seven
5. Four Hundred
6. Never give up

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

1. I want it to be gone
2. It is deep and painful
3. It is red
4. I can see pus at the top
5. It is draining
6. I have a date tonight

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

1. I want it to be gone
2. It is deep and painful
3. It is red
4. I can see pus at the top
5. It is draining
6. I have a date tonight

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

1. Redness
2. Pus
3. Blood
4. Muscle
5. China
6. 4 or 5
7. 3, 4, or 5

What things should I not pick at?

1. Red bump filled with pus
2. Deep tender pimple that I feel but can’t see
3. Little white beads under the skin
4. Moles
5. The spot I have been picking at for 6 months
6. Growths
7. 2 and 4
8. 2, 4, 5, and 6

When should I pull the flaky crust off?

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

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

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

 What are the possible complications from picking?

1. Scarring
2. Permanent pigmentation changes
3. Infection
4. Delaying treatment of a skin cancer
5. Continual harassment from my husband
6. All of the above

How do I know I am picking too much?

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

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

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

 

Answers: Give yourself one point for each correct answer

1. 3
2. 2
3. 4
4. 5
5. 6
6. 8
7. 5
8. 4
9. 6
10. 6
11. 7

Score

1-3     Surrender your magnifying mirror, tweezers, and surgical instruments

4-6     Return to Google Medical School

7-9     You may proceed, but you are on academic probation

10-11   Apprentice junior dermatologist–proceed

12      Grab your white coat and join me in clinic

Note: maximum score is 11

Next: Review of test answers

 

Do you have a license for that thing?

I was recently talking with a patient whose face had markedly improved since her last visit. When I asked her what had changed she said, “You were right, and I finally took your advice. That made all the difference.” Gratified that my clinical skills had once again been validated, I asked her which specific and wonderful piece of advice she had taken, since I give quite a bit of wonderful advice.

“I had my husband hide my magnifying mirror.”

So here we are at yet another of my pet peeves—magnifying mirrors.  Specifically, magnifying mirrors that are owned and operated by women who also own several pair of devilishly sharp tweezers, assorted safety and straight pins (cleaned with alcohol of course!), and their very own monogrammed comedome extractor  (pimple popper) complete  with loop on one end and scalpel  blade on the other.

Before my gentlemen readers get too smug, at least the women don’t tell me “I didn’t know what that growth on my arm was, but it was bugging me, so I just took out my pocket knife and cut it off. See this scab right here? What do you think it was doc? You don’t think it was something serious do you?” To which I answer “I don’t have a clue.”

When women have a magnifying mirror, at-home surgical instruments, and the stubbornness of a mule, bad things can happen.  

For instance:

• Eyebrow shape becomes very peculiar, with the eyebrow starting centrally too far apart over the pupil, and the natural arch obliterated.
• Milia, those small white balls under the surface of the skin that the nurses and I remove through tiny pricks in the skin with sterile instruments, are excavated through incisions in the skin that most doctors would close with stitches.
• Hair on the chin is plucked, in-grows, is dug out with tweezers and needle, tweezed, in-grows again.  The cycle is repeated until permanent brown and red pigmentation, and scarring occur. And then the hair, ingrown skin, red and brown discoloration, and scar are picked again. Repeat.
• Pimples are popped and picked at before they are ready. Even when the picker knows they are not ready. Because they are there, and they are gross.  So they must be picked, mustn’t they? Of course if one squeeze doesn’t remove the pimple and all signs of its existence, then 200 squeezes must be applied. Because that will make it disappear without a trace. By morning.
• Scabs, flakes of skin, acne pimples that are trying valiantly to heal, are picked off every morning because the dry flaky top looks unsightly with makeup accentuating it. Unfortunately, the trauma of picking at it causes the lesion to make more protective flakey skin and scab, to thicken and pigment. It is in effect saying “please stop so I can heal.” Usually no one listens, and the cycle can literally go on for years.

Sarcasm aside, I commonly see women (and I hate to be sexist, but it is almost exclusively women, unless meth is involved) who have caused permanent and unnecessary scars to themselves by picking.

Am I any better? No. As my husband once said to me “I think you went into dermatology just so you could pick legally.” Partially true.  But be that as it may, I am a licensed and trained professional who knows what the lesion is, how to remove it, how much I can destroy without a permanent scar, and when to stop. Even if I don’t always do it.

Magnifying mirrors should be available by prescription only.  Or at least any magnifying mirror over 3x power. If I can’t see a lesion on exam with my 3x power magnifying glasses, it is not there. Instead, be like my patients who have had cataract surgery, except in reverse. They say “I never had all of these spots on my face until I had cataract surgery.  It gave me spots. “I tell them, gently of course, “No you did, and I have seen them on your face for the last 10 years.  It is just after your cataract surgery, you can see them too.” If you are prevented from seeing it in your 10x magnifying mirror, it will magically disappear.

So step away from the magnifying mirror ma’am, before someone gets hurt.

Next: if you must pick, do it like a dermatologist. Even though my lawyer is sitting at my shoulder trying to shake some sense into me.

How to have good nails if you actually have to use your hands

As I started to write this, I started thinking–always a good thing. I have genetically good skin, but bad nails, hair and horrible teeth. Every single tooth in my mouth is a veneer. You really need teeth for 2 reasons; to fill out your lips and the area around the mouth, to reduce loss of  bone structure around your mouth with aging, and longer teeth are associated with youth (teeth wear down and shorten with aging). But I digress–we will talk about teeth, and why you want to keep them, in another post.

Anyway, back to nails.

I use my hands all day long, every day. I really, really try to avoid housework, and as some of you know, I don’t cook. However, you will be glad to hear that when I am seeing patients I wash my hands before and after each patient and sometimes multiple times with a patient so up to 60 times a day. Contact with the numbing cream we use before Botox and filler injections, and with the various peel solutions discolor them. The powder in the gloves I wear when I am doing procedures dry the hands, cuticles, and nails and also discolor them. I am often on the computer, which wears them down as the nail hits the keyboard. Nails are meant to be tools to help your fingers accomplish various tasks, and I use them that way.

Nails thin over time with aging, and women’s nails thin worse than men’s. Both women and men tend to develop longitudinal splits which tear easily. And all the manicure/pedicure stuff women do to their nails damage them more. So I my nails are brittle, and break easily. They tend to discolor to yellow, and nail polish discolors them more. I do have one good nail trait–the free edge at the end of the nail is uniformly white so if i can ever get them grown out long enough, I can wear a light colored or sheer polish and it looks like a French manicure. That is a genetic trait, you can’t do anything to get your nails to do that if they don’t– :( sorry, bummer. I like them short, and need them short to practice medicine. Good thing, since I can’t grow them out anyway.  I like them square, another good thing, since filing them round or oval makes them more prone to breakage.

My hands get dry, and my cuticles split and tear. Because, like many women, I am a “picker” (my husband says I went into dermatology so I could do it legally) when I have a torn cuticle it bugs me so I pick or bite at it until I have made it even worse. Because of that I carry a pair of cuticle nippers in my purse and have one at my desk and bedside. As soon as I have a torn cuticle, I clip it  immediately. Because I fly frequently, during the time when the TSA was forbidding cuticle clippers as potentially lethal weapons, it was a problem. Thank you, Osama Bin Laden. Now however, I am back to carrying them with me everywhere, as part of my APM kit (Always Prepared Mom kit–cuticle nippers, tiny foldable scissors, nail file, safety pins, lip balm, small tape measure, tiny sewing kit, bandaids, topical steroid, antibiotic ointment, and kitchen sink) that is always in my purse.

I don’t allow my nursing staff to wear acrylic nails because they would be poking the patients, and because acrylic nails more much more likely to carry Staph bacteria. Luckily, my nurses and most nurses in general don’t want to have acrylic nails, but some in other settings do. It has been an issue in some surgical settings where investigations after a rash of post-operative Staph infections have occurred have shown the bacteria to be carried in acrylic nails of the operating room staff. In any event, I am the boss, so my nurses have short, natural, nails with light color polish.

For a long time I resisted going for a manicure and pedicure because of the health risks. But my youngest daughter and I started going as “mother-daughter time” and my nails do look better when a professional does them than when I do them one handed. But there is definitely a risk of infection, with wart virus, nail and foot fungus and mycobacteria. Some nail salons are better than others, but truthfully, none of them can really follow proper infection control procedures and stay in business at the low prices they are charging. The nail instruments can be contaminated, and although they clean some of them and “sterilize” them, the process they use doesn’t get rid of all contamination. And some things like the foam blocks and emery boards are never cleaned. The biggest risk is the pedicure tub. The proper procedure to disinfect is to drain the tub between each use, flush a treatment solution through it, drain that, take the filter out, clean the filter, rinse the system again, and let it dry for hours, before using it again. Have you ever seen that happen? Over the last several years I am seeing more and more nail salon clients coming in for pedicures that are not traditional pedicure type clients. They come in because their toenails are thick, they can’t care for them, and seeing a podiatrist for nail care is more expensive. Unfortunately the incidence of nail fungus increases with age, and many of these clients have nail fungus which is why their toenails are thick and they can’t care for them. And they are using the same tub right before you!!

And don’t even get me started about nail salons and double dipping into the waxing pot. I see it all the time.

I know, I know–the list of nail care products that a cosmetic dermatologist uses. I got a little long winded, and a touch off topic, something that does happen “on occasion.” But it is Friday, after all.

I promise, next post.

I always try to avoid a skin decision that will turn out badly.

And so should you–More skin decisions that are best avoided

6) Not doing the recommended patch test on the hair color box

I know, it seems stupid and you don’t want to waste time with it. You have used that brand/color before. And it is just hair color not poison. I used to think that way too.

But here is why you should do it. Paraphenylenediamine (PPD) is a chemical substance that is widely used as a permanent hair dye. PPD hair dyes usually come as 2 bottles, one containing the PPD dye and the other containing the oxidizer, and are most commonly seen in that beautiful blue-black color. Acute allergic contact dermatitis to PPD can cause severe swelling, redness, blistering, weeping, oozing, itching and pain of the entire scalp. Eyelids can swell shut. Patients who experience this unfortunate reaction are quite uncomfortable and also quite unsightly. And if they have also used it on the eyebrows, like a recent patient, the reaction extends over the face.

There are methods to try to neutralize the reaction by completing the oxidation of the PPD, and they may be of some help. But it is not uncommon for the reaction to persist for some time, until the hair grows out. Some patients even shave their heads to remove the treated hair.

And just because you have used it before, you are not safe from this reaction. Allergic contact reactions occur on the second or subsequent time that you are exposed to the chemical. It takes one exposure to sensitize you to the chemical, and then at some later exposure, you react. So it could be the second time you use it, or the hundredth. And it could even be the first time, if you have come into contact with PPD from one of its other non-hair related uses.

So if severe redness, swelling, blistering, weeping, oozing, itching of the scalp and eyelids is not the look you are going for, do the patch test.

7) Picking–and picking, and picking, and picking…..

Some people can see a pimple on their cheek, pop it once, and leave it alone. Some will dig a hole down through the muscle–really. There is a spectrum of picking from–don’t even see it and leave it alone–pick at it once–keep picking when you know it won’t help–pick at it every day because it is dry and flaky and makeup won’t go on right–pick at it several times a day and feel guilty about it–pick at it and keep the same spot going for months to years–dig a hole to China.

In my experience, women are 99.95% of the pickers. I am one, that’s why I went into dermatology, so I could do it legally.

No comments from men, please. In my experience, 99.95% of the patients who say “I just took out my pocket knife and tried to cut it off, and then it started bleeding and got infected” are men.

Here is a secret–If you keep picking at it, it will never heal and may very well scar.

8) Not knowing when to stop with plastic surgery

Natural, subtle, expertly performed plastic surgery is great. Unnatural, obviously operated upon, poorly performed plastic surgery is not. And one of the problems with going too far with plastic surgery, is that just like some other decisions in life, it can be really hard to undo the effects.

There are many reasons that people just keep going with plastic surgery, having procedure after procedure and not stopping when most others are happy with much less. It may be an attempt to fix something else like a failing marriage, Body Dysmorphic Disorder (BDD), an attempt to fix previous unsatisfactory surgical results, unrealistic expectations, peer group norms, or just that they have forgotten what they really look like. And there are plastic surgeons who don’t discourage this, although the good ones will tell you–stop.

The problem is that patients who have had too much plastic surgery look less attractive, not more. Everything looks unnatural and alien-like. Stop before you reach this stage and start looking like poor Michael Jackson.

9) Letting a poorly trained individual do something like pour acid on your face

We are seeing more and more of this kind of problem, patients coming in with complications after a medical treatment by non-medical, poorly trained, or poorly supervised individuals. Things that change your skin, change your skin. And they can change it for the better, or for worse. These cosmetic treatments are specialized medical procedures. Medical procedures need to be done by well trained medical professionals. These treatments seem easy, and when done right, usually go well. But they can, and do, go wrong. A big part of cosmetic dermatology practice is knowing and preventing the risks, by knowing what not to do, and especially knowing who is at increased risk of complications. And you better know what to do about any complications, and do it in a timely fashion.

I have been told–it was cheaper, she is my friend, I won the raffle (hint–everyone wins), they were practicing (practicing??? on your face???) and on and on.

Be a responsible consumer and patient, do your research before you commit to having a procedure. Your face and body deserve at least as much research as a flat screen TV. Maybe even more.

10) Ordering fillers, Botox or chemical peels off the internet and doing them at home

When I first heard about this, I thought it must be a joke. But yes, people actually order compounds of unknown composition, unknown sterility, unknown reactions off the internet and take a needle and syringe, and try to figure out where, how, how much to inject and stick it in their face. Many times these are either counterfeit or a non-tested “special brand”.

And these people vehemently argue that it is their right to order the most potent toxin known to mankind, one that is being counterfeited and sold by terrorist groups, off of the internet and inject themselves, because the “greedy doctors charge too much”. Because the internet is a completely trustworthy, ethical and safe system, worldwide. We are the world.

I have just two words–Darwin Award

 

I always try to avoid a skin decision that will turn out badly

Over the years I have seen and heard quite a few things that have caused me to raise my eyebrows and utter one of my stock answers–”I see.” I really like this all purpose term because it allows me to acknowledge in a noncommittal manner that I have heard and understood what I was told, without making a verbal judgment as to the wisdom of the act in question. The following are a scattering of things that I have seen and heard over the years, that warrant an “I see.” If you don’t want to hear those words come out of my mouth, avoid skin decisions that will turn out badly, and don’t do these.

1) Waxing after using a retinoid

We have information for our patients on our skin care usage instructions: “Discontinue the retinoids: Refissa, Renova, Retin-A, Differin^, or Tazorac to affected area 1 week before waxing or bleaching, or before other procedures as directed.”

Why do we say this? Because if you don’t discontinue them and then you wax, when they pull the wax off, your skin will come off with it. Most memorable was the bride to be who went to the nail salon and had her eyebrows waxed three days before the wedding and was left with nice little red oozing strips above and below her eyebrow on one side. At least they stopped after the first eyebrow. This will also happen if you are on isotretinoin (Accutane and generics) for severe acne. Anyone who waxes any part of your body should ask if you are using a retinoid, or taking isotretinoin. You certainly don’t want your skin ripped off “down there” because they neglected to ask, and you neglected to tell them, you are on isotretinoin.

Related to this issue, I was called about a patient who had surgery while on isotretinoin and when the tape that held the endotracheal tube in place during anesthesia was removed, the skin came with it. It’s not often dermatologists get emergency calls from the recovery room, but this was one of those times

2) Soaking in weird stuff

I once had a patient come in with redness, rash and blistering on her whole body. Usually in dermatology one look is worth a thousand words, but occasionally we have to take a history. Turns out she decided to soak in the bathtub in straight Chlorox so “my skin would peel”.

It did.

3) Using prescription topical steroids on the face

This one is often iatrogenic (caused by the doctor), although it is not uncommon for people to use a prescription cream that was prescribed for one condition on something else, or on another part of the body. If you use topical steroids on the face, and they are anything stronger than very mild, you are likely to get into trouble. The problem is that it works at first, reducing rash and redness. Your skin becomes addicted to them if you use them longer than a few days, and when you stop, the rash comes back worse than it was in the first place. Over time, topical steroids thin the skin on the face, cause lots of broken and dilated blood vessels, chronic redness and pimples.

This can be a real mess. Don’t assume you can just put any prescription cream on your face. All the topical steroids have very long names, sound alike, and there are about a hundred of them. If this happens, you will need a good dermatologist to help you wean off of it over time.

4) Not telling the truth about sun exposure before IPL treatment

Intense Pulsed Light is a great treatment for the treatment of sun damage, brown discoloration and spots, broken and dilated blood vessels, and redness. We do it all day long. But effective, safe treatment relies on exploiting the difference in color between the thing you want to treat– the target, and the thing you don’t–the normal skin.  Sun exposure, even if you don’t think you are tan, stimulates your natural melanin and reduces this difference in light (and therefore heat) absorption. And if your physician or nurse doesn’t know about this, you will get burned.

So if you don’t want crusted rectangles all over the treatment area, tell the truth. Just because you have taken a day off for treatment, or you don’t believe us when we tell you that it will matter, is not a good reason to risk it.

5) Unfortunate permanent eyebrow tattoo

We used to do permanent makeup application in the office, which is a tattoo applied as eyebrows, eyeliner or lip liner. In general it turned out well, and certainly helps many women who have problems applying makeup because they have difficulty seeing close up or have arthritic hands. By far the trickiest one to do right is permanent eyebrow makeup. Women are very specific about what they consider to be the right shape and appearance for their eyebrows. Unfortunately,  they are often wrong.  Eyebrows, if done correctly, have a specific starting, stopping, arch, angle and placement that is pretty well defined. When it is right, it is great, when it is not, it really detracts from the face. As many of you already know, funky eyebrows are one of my pet peeves, so there will be a column on it in the near future.

But suffice it to say, if your technician “does it your way” and it is not the right way, you may be sorry. Sometimes permanent makeup really is permanent, sometimes not, but you have to assume it will be. And don’t even get me started here on jarring color choices, or the color shift that the tattoo may undergo over time. Or the fact that your hair color may change and no longer compliment your eyebrow color.

If you are going to put a permanent tattoo in the middle of your face, do it right.

Next: More skin mistakes to avoid

 

Top 10 Aesthetic Body Sculpting Procedure Tips:
What works, what doesn’t for fat reduction and fat removal

1. Research the various procedures, their risks, benefits, results. A site I particularly like, and contribute to, is RealSelf.com. It has descriptions of the procedures, reviews by patients, satisfaction ratings, and answers to questions by physicians who are Board Certified in the core aesthetic specialties of Plastic Surgery and Dermatology.

 

2. Decide what kind of results you want, what kind of risks you are willing to take, which side effects you are willing to have and how much you are willing to pay for it.

 

3. Be very careful with physicians who are not Board Certified in the core aesthetic specialties, who have had sanctions by the Medical Board for standard of care issues, who charge significantly below the prevailing rate, or who perform non-FDA approved treatments like Mesotherapy.

 

4. If you decide to have Liposuction, go to a physician trained and Board Certified by the American Board of Medical Specialties (not any other board) in one of the core aesthetic specialties, who has a lot of experience in Liposuction, and performs it frequently.

 

5. For Liposuction don’t have procedures except in accredited facilities. Run from a physician who exceeds the official guidelines for the volume of fat removed in a single procedure. These situations are the riskiest and where the deaths from Liposuction that make the news often occur.

 

6. Do I need to say this?– Don’t have non-FDA approved treatments. Don’t have medical or surgical procedures performed by non-physicians, unless those providers are licensed medical providers like RN’s and are directly supervised by a physician who is Board Certified in one of the core aesthetic specialties. No, not a beautician practicing out of a hotel room, not a nurse who is practicing solo without supervision, not a non-medical layperson given 1 hour of training in a chain medi-spa.

 

7. Don’t expect more from a procedure than the procedure can deliver. Don’t expect Liposuction results from non-invasive procedures. Don’t expect any fat reduction or fat removal procedure to remove visceral fat (fat inside the abdominal cavity). If you can’t squeeze it, we can’t remove it. Only diet and exercise can reduce visceral fat. Expect what the procedure can realistically deliver and be happy with that.

 

8. Don’t lie to your physician about smoking, medications or your health history, just because you really, really want the procedure. This ends badly.

 

9. Don’t expect any of these procedures to significantly tighten skin and muscle like a tummy tuck, or improve cellulite. Tummy tuck results require cutting skin and sewing skin and muscle. Nothing gives permanent improvement in cellulite. Sometimes Liposuction makes cellulite worse.

 

10. Final tip: Here are the patient satisfaction ratings for the various procedures, found on RealSelf.com. Real patients who have had the procedure thought that the procedures were “worth it” in these percentages:

   FDA approved procedures

• Zeltiq Coolsculpting (84% worth it)
• Liposuction(65% worth it)
• Zerona (32% worth it)

    Non-FDA approved procedures (Quiz: What did I just say about non-FDA approved procedures?)

• Ultrashape (32% worth it)
• Mesotherapy (Lipodissolve) (32% worth it)

So that is it for aesthetic body sculpting procedures to reduce or remove fat.

Next: I haven’t decided. Stay tuned.