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.

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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.

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.

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.

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If you already use Dr. Elaine’s skin care, take advantage of this great sale to stock up. If you are considering trying it, this is a great opportunity.

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

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

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

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

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

At  night, no matter how tired I am:

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

For Body:

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

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

Next: how I do cosmetics

How girl dermatologists do skin care

Female dermatologists are often thought of as the experts on effective, scientific skin care. And that’s because we are. So how does this girl dermatologist, and I use the word “girl” loosely, do skin care? I want to be the best I can realistically be, and that includes my skin. The key to doing the best you can with what you’ve got, it to know what you’ve got. To some degree, you inherit the skin you’ve got. But skin you’ve got is also the result of what you have done, and what you are doing.

Before I became a dermatologist, I always just took my skin for granted and didn’t think much about it. I have moderately sensitive skin, and am “atopic.” Atopic tendencies are genetic, and people who are atopic have skin that is more sensitive than others, gets rashes easier, itches at things others don’t, have little bumps on the upper arms, and often have a family history of asthma or hay fever. If you cut the tags out of all of your clothing, been told you were “allergic” to grass, or wool, or whatever, you are atopic.

Very luckily for me, as a child, adolescent and young woman, I didn’t ruin my skin in the sun. Although I would have loved growing up on the beach, I didn’t.  In Oklahoma City, beaches are hard to find. I wasn’t on the swim or tennis team. We didn’t belong to the country club. Many of my friends would lay out in the backyard and tan. However, sticking to the webbed straps of a wobbly chaise lounge, sweating in the hot humid air, swatting the flies that would continually swarm around was not my idea of fun. So I didn’t do it. Later I was too busy with pre-med and medical school to have any fun outside. So I escaped the early sun exposure that shows up as damage twenty or thirty years later.

I never really had acne as a teen or young woman. Only in middle age, which is not fair and I plan to sue someone, as soon as I figure out who to sue. I pigment moderately easily, and had a decade or so dealing with melasma. Caused by a combination of hormones, either birth control pills or devices, pregnancy or just the hormones made by the body, melasma is a brown pigmentation on the face, especially cheeks and above the upper lip. It is often in a pattern, 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.

I always ask patients “where is your family from, the old country?” It not because I am just nosy, it is because it makes a difference. The tendency to make abnormal pigment, to get wrinkling with sun damage, to get broken blood vessels and redness, to have sensitive skin all have a genetic basis and that genetic basis is tied to ethnic background. People who have ancestors that had more natural pigment, Hispanic, Asian, American Indian, Black, Middle Eastern etc, respond to anything that happens to the skin, such as pimples, rashes, procedures, treatments, with increased pigmentation. It is hard to fix, so you want to avoid it. If you have light skin, like most Northern Europeans, especially Irish and Scots, and you get a lot of sun exposure over the years, your skin will get thickened bumpy elastosis, wrinkling, loss of elasticity and skin cancer, and you won’t like that either. The list goes on. My family background is German, Dutch, and a little American Indian, so I don’t get sun damage easily, but can make abnormal pigment.

There are 3 components to coming up with your own skin care plan–quiz–soul searching–reality. Kind of like coming up with a life plan.

1. Quiz–What kind of skin do I have?
2. Soul searching–What kind of results do I want?
3. Reality–How much time and money am I willing to spend?

Dr E takes the Dr E  Skin Care Quiz:

• Is your skin very dry, dry, combination, normal, oily, very oily?–Dry
• Do you get breakouts?–Yes, 3-4 per month, painful medium sized pustules and small cysts, and I don’t like it one bit.
• Is your skin sensitive?–get rashy or itchy easily? Yes, didn’t I just say I was atopic?
• If you are out in mid-day sun without sunscreen do you get some immediate darkening of your skin? Yes, a moderate amount
• How much sun do you get daily? Noooooooooooooooooooooooo
• Do you wear sunscreen every day? Duh, yea
• Are you a “soap and water and nothing else”, “I will do 3-4 steps in the morning and same in the evening”, or “as much as it takes” kind of woman? I am a “as much as it takes kind of woman.”
• Are you using any prescription surface treatments like Retin-A, Refissa or for Rosacea? Yes, I have used retinoids in one form or another continuously for the past 30 years.
• Which of the following are a problem–
  • Brown spots–No, see 5 and 6
  • Broken blood vessels–Yes
  • Fine wrinkles–No, see 5 and 6
  • Deeper wrinkles—No, see 5 and 6
  • White “beads” under the skin–Yes, a few
  • Flaking or peeling–Occasionally, from retinoids

Dr E does some soul searching

• What kind of results do I want? Here is what I want–I want have the very best skin I can have.

• I want smooth, uniformly pigmented skin with small pores, minimal wrinkles, no broken blood vessels, no gross brown crusty things, no pimples, and no reddish brown spots after pimples have gone. I want my skin to be approximately in the same place on my face that it was twenty years ago. When I stretch it, I want it to bounce back in less than 10 seconds. And it should not be oily, not be dry, but just right, like Goldilocks porridge.

What am I willing to do to get it?

• No, I am not willing to do a great deal for hair care and nail care. But I am for skin care. Why you ask? All three are visible to the world. All three can make you look worse, or hopefully, better. But, a very important difference. Taking care of your hair and nails make them look better today, but in general don’t influence the appearance tomorrow. I can fry my hair with bleach, color it blue, get split ends and it will still grow it out fine. I can get fungus under my nails, warts around the cuticles, and significant deformity of the nails after acrylics, etc  Although treatment of warts and fungus is difficult and often recurrent, to at least some degree they can be prevented or treated. Preventing nail damage is basically avoiding sharing nail care instruments, whirlpool tubs etc that are contaminated by other customers in nail salons, and not wearing fake nails continuously.
• But skin care is a different story. I can prevent undesirable skin changes, I can improve the ones that are there, and I can change the nature of my skin. In contrast to hair and nails, which are completely replaced when they grow out, skin cells are turned over on the very surface, with lesser turnover under the top layers. That’s why destroyed collagen and elastic fibers, elastosis, scars, pre-cancer, and skin cancer, pigment, broken blood vessels, and brown growths are permanent and don’t “grow out”. Taking care of your skin today makes it look better today and tomorrow. If I don’t take care of it today, it will look worse tomorrow, and some of those changes aren’t fixable.

We all make mistakes in life. It’s just that the consequences of some are worse than others, and some are easier to fix. So the answer to the question “How much time and money am I willing to spend?” Whatever it takes.

Next: what it takes for this dermatologist, every day, to take care of her skin