Daily Skin Fix

Your Skin Holds a Grudge:

Removing Brown Spots after Acne, Laser or Peels

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

 

To recap, here is what you see:

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

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

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

• Ease of treatment: Moderate—difficult

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

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

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

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

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

Home Treatment:

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

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

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

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

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

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

Office Treatment:

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

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

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

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

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

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

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

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

 

Don’t miss out on our Spring Fling Sale.  All Dr Elaine’s Skin Care is 20-30% Off and, of course, our Every Day Free USPS Priority Mail Shipping.

The sale ends Sunday, April 24th at midnight CST.

If you have never tried our fabulous skin care, do it now.  And if you are already a fan, stock up.

Dr Elaines’s Advanced Skin Treatment is a dermatologist developed clinical skin care line that combines effective cosmeceuticals with proven natural botanicals.  Cosmeceuticals are compounds that have effects on the skin. The main groups are the peptides, antioxidants, growth factors, alpha and beta hydroxy acids 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.

Our Ageless Effects Clinical Anti-Aging Skin Care is both a preventative anti-aging strategy and a repair strategy for skin that needs help. It is your everyday anti-aging 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, and brown discoloration.

Acne is a common problem, that affects people of all ages. Dr Elaine’s Advanced Skin Treatment Perfect Effects Acne Skin Care prevents and treats acne blemishes, pimples, blackheads, and reduces irritation, and red and brown discoloration that occurs after the pimple has healed. It also reduces the dryness that occurs with some acne medications and can be used effectively with prescription acne medications.

For Rosacea and sensitive skin try our hypoallergenic, fragrance free Gentle Effects skin care, to reduce redness, dryness and irritation.

Dr Elaine’s Silken Effects for hair and body care line, with both treatment and maintenance products help reduce dry, scaling or irritated skin and give you beautiful hair.

And finally, try Dr Elaine’s Cosmetics for antioxidant mineral powders and mineral glows, for a healthy looking, natural complexion.

If you have never been to our web site SkinTreatment.com here is where you can find what you need:

Spring Fling All Dr Elaine’s Skin Care on Sale 20-30% Off through Sunday April 24, midnight CST

If you know what you need, or are shopping for skin care after our Spring Fling Sale, these sections are always available, which show our skin care and current special offers:

All Acne Skin Care on Sale

All Anti-Aging Skin Care on Sale

All Skin Care Sets on Sale

All Skin Care on Sale

All Anti-Aging Skin Care

All Acne Skin Care

All Rosacea and Sensitive Skin Care

All Hair and Body Care

All Cosmetics

And if you want to see All Dr Elaine’s Advanced Skin Treatment Skin Care

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.

 

 

 

We all hate acne. It’s frustrating and many of our patients deal with it every day.

If you have mainly “small junky stuff” which consist of blackheads, whiteheads, pustules and under the skin, never come to a head, painful, cystic acne, then glycolic acid chemical peel treatments are for you.  You may look a little “ratty” for a day with small crusts where the pimples were, but then you will clear up rapidly.

If you have red acne, sensitive skin, or pustules, or want a acne treatment with absolutely no down-time,  then blue-light ClearLight treatments are what you need. ClearLight is absolutely pain free. You come into the office, lay down under the blue light, fall asleep, get up and go home.

These are two very different treatments that we do here in the office.  Once you see Dr Cook for an acne consult, she can determine which treatment is right for you. We are here to help.

As a part of this blog I will be posting some permanent pages about common cosmetic dermatology problems, aesthetic procedures, skin care and other topics. They will be based on what we commonly see, and common patient questions in our cosmetic dermatology clinic.  You can find them on the right navigation under 411.

Check out the first one–Acne Treatment Tips

Let me know if there is particular topic you would like to hear about.

Welcome to the SkinTreatment.com blog, opinions and observations of board certified cosmetic dermatologist and creator of  Dr Elaine’s Advanced Skin Treatment skin care line, Elaine Cook M.D.  I’ve been specializing in Dermatology for 27 years, the last 15 of which have been devoted to the practice of cosmetic dermatology, the development of my own skin care  line, and running SkinTreatment.com. This blog represents the summation of the knowledge and experience I have gathered over the years seeing countless patients and developing multiple prototypes for our skin care products. Some of the medical stories happen over and over again, some are more unusual. Some are purely cosmetic. Some are symptoms of underlying medical disease. All are important. All affect peoples lives.

I plan on discussing a variety of topics. Among them: the so-called “cosmetic” skin problems–acne, melasma, rosacea, aging skin, wrinkles, spider veins, cellulite, stretch marks, hair loss, age spots, sun spots, discoloration and more. I will also discuss the cosmetic procedures used to remedy these problems: Botox, Juvederm, Restylane, Sculptra, Laser, Fraxel  Laser, Intense Pulse Light Photorejuvenation (IPL), Thermage, Therma-Frax (also called Fraxage), Sclerotherapy, Chemical
Peels and the various other light-based treatments such as LED and blue light. Finally, I will be using my understanding of the skin in health and disease and my experience developing my own skin care line as a basis to discuss anything and everything about skin care products.

Basically, I will be discussing whatever I want on any given day.