Daily Skin Fix

Skin Color Does Matter

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

 

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

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

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

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

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

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

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

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

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

When exposed to sunlight, do you:

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

Again, in general:

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

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

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

 

How to Get Rid of Brown Spots on the Face

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

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

Unfortunately, yes.

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

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

From easiest to most difficult:

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

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

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

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

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

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

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

• Diagnosis: Melasma or “mask of pregnancy,” is caused by a combination of hormones, predominantly estrogen from pregnancy or birth control, and sun exposure. Once it starts, melasma tends to reoccur very easily with minimal amounts of sun exposure, even if the hormonal trigger is removed.
• I divide melasma into two types: “relatively easy” and “hard.” The difference is dependent on how deep in the skin the pigmentation is found, and whether both the hormonal stimulation and sun exposure can be reduced. Deeper pigment is harder to improve.
• Treatment: Involves both removing the triggers, and using creams and procedures to reduce existing pigment. Daily, year round, broad spectrum sun protection and avoidance of sun exposure is absolutely essential. Reducing hormonal triggers is often a challenge as pregnancy eventually ends, but often the need for birth control continues. Even if the hormonal trigger is removed, the melasma remains “turned on” and even tiny amounts of sunlight cause it to reoccur. Treatment at home with skin lighteners, prescription skin bleaches, retinoid creams, and sunscreen, combined with in-office chemical peels or SilkPeel are tried first.  “Easy” melasma usually responds fairly well to this treatment. For more resistant cases, Intense Pulsed Light, laser, and deeper chemical peels under the supervision of a dermatologist experienced in treatment of pigment, are considered. Results are varied, and these procedures may actually make pigment worse.
• Ease of treatment: Difficult-very difficult.

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

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

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

How to pick like a dermatologist

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

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

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

When should I pull the flaky crust off?

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

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

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

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

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

Answer is: When it completely lifts off by itself.

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

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

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

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

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

 What are the possible complications from picking?

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

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

Answer is: All of the above.  So stop.

How do I know I am picking too much?

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

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

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

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

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

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

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

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

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.

Patient Appreciation Week Sale

All Dr Elaine’s Skin Care 20-30% Off
+ Free Shipping

So don’t miss out on our Patient Appreciation Week Sale. All Dr. Elaine’s skin care is 20-30% off, and of course, our everyday free USPS Priority Mail shipping. The sale ends Sunday July 17th at midnight CST.

If you have never tried our fabulous skin care, now is the time. And if you are already a fan, thank you.

Dr Elaines’s Advanced Skin Treatment is a dermatologist (and guess who that might be?) developed clinical skin care line that combines anti-aging cosmeceuticals with proven natural botanicals. Cosmeceuticals are cosmetics that have effects on the skin. The main groups are the peptides, antioxidants, growth factors, and vitamins. They improve fine lines, roughness, blotchy pigment, loss of elasticity, dullness, acne, and stimulate collagen production. Our botanicals are plant derived compounds that are used for their antioxidant, anti-inflammatory, exfoliant, moisture balancing, and collagen stimulating properties.

We offer specialized skin care products for acne, anti-aging, skin pigment lightening, sensitive skin, rosacea and hair and body. Clinical skin care is both a preventative anti-aging strategy and a repair strategy for skin that needs help. It is your everyday health program for your skin, and the foundation of an anti-aging program. Your skin is smoother with a healthy glow, reduction in appearance of lines, wrinkles, acne blemishes and brown discoloration.

If you have never been to our web site SkinTreatment.com here is where you can find what you need: Patient Appreciation Sale Dr Elaine’s Skin Care on Sale 20-30% Off including all skin care on sale through Sunday July 17th, midnight CST. If you know what you need, or are shopping for skin care after our Patient Appreciation Week Sale, these sections are always available, which show our current special offers: All Acne Skin Care on Sale– all of the special offers for our acne skin care, including sets at a discount All Anti-Aging Skin Care on Sale–all of the special offers for our anti-aging, and lightening skin care including sets at a discount All Skin Care Sets on Sale–all discounts on skin care sets or kits All Skin Care on Sale–everything–all skin care that is on sale

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.

Just out–our Summer 2011 Cosmetic Dermatology Newsletter

Hot off the presses, the Summer 2011 edition of our famed SkinTreatment.com Cosmetic Dermatology Newsletter. This time we discuss CoolSculpting, Thermage, Botox price shopping, what’s new at ASTC, our social media, and the ever-popular Thoughts from Dr Elaine.

Also gives information about our upcoming Patient Appreciation Week Sale. During week of July 11-15 get 20% Off Botox, Juvederm, Thermage, CoolSculpting, and all Dr Elaine’s Skin Care. Online skin care sale runs July 11-17 on SkinTreatment.com

Click the text link below for the newsletter
Summer 2011 Newsletter.pdf

How I look natural, polished and beautiful every day with cheap, quick, and natural makeup

I really, really hate to get up in the morning so I am usually running late. I definitely prefer a natural look for my skin, and as I have said many times before, it is much better to have good skin and wear less foundation so that is what I do. I can’t wear eye shadow. Ever. I have sensitive skin, called atopic– which means that many things irritate it like brushes, strong fragrance etc and I live in extremely dry climates. No matter what I do, no matter what kind of shadow or brush I use, my eyelids get irritated, red, and rashy if I ever wear eye shadow for even one day, and they stay that way for months after even one application of eye shadow. Also, I use a retinoid (currently Refissa) and of course daily sunscreen on my eyelids and have for years. So the lids are actually pretty good and tight for 57. So I haven’t worn eye shadow or eyeliner for years. Again this fits with my philosophy that I would rather have good skin on my eyelids, than wear cosmetics on them. They actually look better without shadow or liner.

Since I am always running behind in the morning, I want my cosmetic application to be quick. I want them to stay on all day. I rarely touch them up during the day, except that I sometimes reapply lip color once during the day. Once is my limit. And I hate to shop so I want something I can either buy online, or pick up when I absolutely have to go to the drug store or grocery store. There is absolutely no way I am going to drive to the mall and shop at the cosmetic counter. It is fine if you like to do it. I don’t.

My goodness the list of things I hate is getting pretty long….hate to get up, hate to shop, hate to reapply makeup, hate to style my hair, hate to dress up. Oh, well.

So I use, in order of application:

1. Clarins Self Tanning Instant Gel to my face and neck about 3 times a week. It gives me a natural color, isn’t sticky, dries quickly, and I can also apply to my body if I want. Since I use our Correcting Serum, Antioxidant Exfoliant, and Refissa my skin is nicely exfoliated so the tanner goes on smoothly. Applying self-tanner to exfoliated skin is the key to getting a natural look. I buy it online at Sephora.com (4.4 oz $33)

2. Then I apply Dr Elaine’s Antioxidant Mineral Powder in Tan with applied with one of our sponges that we supply free with the powder. It gives a great, natural finished look that I love. I never use a brush to apply mineral powder. I go get it from the storage room, but you can buy it on our web site or in the office. (.32 oz $32.99)

I blend it down my neck and be sure that I pat it on the eyelids and the inside corners of my eyes. Then I take a 100% cotton ball and blend it into the hairline, and wipe the excess of my eyebrows.

3. I do need lip color and I have a great find that I have been using for about 5 years. It is Cover Girl Outlast All-day Lipcolor in #556 Berry Preserve. The box comes with 2 lip products–a color and a moisturizing topcoat. The color is called All-Day Colorcoat and the topcoat is called, appropriately, Moisturizing Topcoat.

It really does stay on all day! This color is great for me and looks very natural. I load the applicator, but then wipe the excess off against the rim. If you apply too much it does flake later in the day. Then I apply the topcoat. I have tried many of the other “all-day” lipsticks, many expensive lipsticks, over the years. This one is by far the best for me. About half the time I will apply it once again after lunch, if I am work.

I get it at Walgreen’s. (2.3 ml and the set is $9.99 but fairly often you can get 2 for price of one at Walgreen’s and then I stock up) But note: you are not allowed to go to the two Walgreen’s I frequent–on Georgia in Amarillo, Texas or on Tatum and Shea in Phoenix Arizona–and buy it all up! Use your own Walgreen’s, or another drug store or the grocery store. I don’t go to those places.

4. Then I curl my eyelashes before I apply mascara. If you curl them after, like you are often told to, you get more lash breakage. But I heat the eyelash curler and it curls the lashes just like a hair curling iron. I use a Shu Emura eyelash curler heated with a hair dryer on hot but tested for temperature on my wrist just like a baby’s bottle. It makes the curl last all day. You do have to be careful because the metal heats up quickly, and if you apply it too close to the skin you could burn yourself.

My lawyer wants me to remind you not to heat it up like a hot poker and stab yourself in the eye and then blame me. He says you should do this at your own risk.

But it works.

Shu Emura really is the best eyelash curler, I order mine online from Sephora.com ($16.00).

5.Maybelline Great Lash Mascara Classic Volume Brush #100 Blackest Black. I use the straight brushes, I don’t like the curved ones, and don’t need them because my eyelashes are already curled. Sometimes I will splurge on Maybelline The Colossal Volum’ Express (sic, weird name, I wouldn’t have chosen it) straight (non-curved brush). Occasionally I will use the waterproof if needed, like for graduations, funerals or swimming, but for daily I use the non-waterproof. The waterproof ones do dry the lashes a little more.

You really don’t need expensive mascara. If you want to pay $40 for a tube, go ahead, but it is not any better than Maybelline. Really.

I buy mine at Walgreen’s ($5.49)

6. Recently I got a little carried away with eyebrow tweezing. I know, I am always going on about my pet peeve, tweezing too much. Guilty as charged. So when I do, I use Smashbox Brow Tech – Taupe/Soft Brown eyebrow powder and apply it with Smashbox Angle Brow Brush #12.

I order it online from Sephora, and for confidentiality it comes in a plain brown wrapper ;)

Smashbox Brow Tech ($34.00), Smashbox Angle Brow Brush 12 ($20.00)

7. For special occasions I apply our Mineral Glow in Blushing Shimmer for a subtle glow. .32 oz ($32.99)

So that is it. I timed myself this morning and it takes me 3 minutes, start to finish. Quick, reasonably priced, reliable, products easily obtainable, and lasts all day. Mission accomplished. Natural, polished and beautiful every day.

 

 

 

 

A little paint and spackle can work wonders, but all the makeup in the world can’t make bad skin look good.

It is by far and away better to have good skin, than good makeup. With that in mind here are Dr Elaine’s top 10 rules for wearing cosmetics:

1. Heavy foundation may cover a pimple, but it makes you look older, and harder. A million times better to have good skin, and wear little or no foundation. So I put my time, energy and money on my skin.

2. There should be evidence to the naked eye that there is live human skin under your foundation. Ditto for blush.

3.  Concealer on pimples or marks plug up pores and cause breakouts later. Don’t just kick the can down the road.

4. Most women need some lip color, either their natural color if they are lucky, or with a lip color product if they are not. But lip color should always approximate a color that is seen, somewhere, in live humans. Bubblegum Pink and Bright Maroon are not in that group.

5. Corollary–blush color, if used, should also approximate a color that actually occurs in live humans. Fuchsia and Burnt Orange are not in that group.

5. If you use lip liner, it should be subtle enough that you don’t look like you are playing dress up with Mommy’s lipstick.

6. For everyday, eye shadow should not include the color family robin’s egg blue. For nights and special occasions eye shadow and eye cosmetics can be more dramatic and artificial. That is because in those situations eye shadow is subconsciously classified as “decoration” closer to jewelry, while lip color, cheek color, and foundation remain subconsciously classified as “natural beauty.”

7. Foundation on oily skin often turns more orange as the day progresses. Choose accordingly.

8. Don’t buy cosmetics based on friendship with the company rep, unless the cosmetics are really right for you.

9. Spend the most money on getting the perfect, natural looking foundation. That is the trickiest for cosmetic companies to do right. Mascara absolutely, lip color often, and eye shadow a fair amount of the time are just as good from the drug store as the expensive brands.

10. Try very hard to find the “sweet spot” with your makeup and cosmetics. The sweet spot is in between wearing no makeup at all and looking like you just got out of the hospital but are still ill, and wearing so much makeup that you could make some extra money while waiting at the bus stop to pick up the kids. The “sweet spot” is where you look natural, polished and beautiful.

Next: How I look natural, polished and beautiful every day.