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

How to Get Rid Of Your Past:
Removing Brown Spots From The Sun

In a previous post, Out Damn’d Spot, Out I Say we discussed how to tell what kind of brown spots you have, so you know what needs to be done to get rid of them. They are of very different causes and presentation, and have very different treatments. And it’s always a good idea to know what you have got, before you decide what you need to do. Let’s start with the easiest to treat, relatively speaking, brown discoloration from past sun exposure.

To recap, here is what you see:

• In the mirror: Scattered pin-head to quarter size flat brown or reddish brown spots on face, neck, chest, forearms, and hands. Some may be scaly.
• Diagnosis: Actinic damage from past sun exposure, most commonly in lighter skinned people. Freckles are small, relatively regular in size and distribution, flat and most common in redheads. There are two kinds of actinic, or “sun spots”. Actinic pigmentation are flat brown or reddish brown spots, irregular in size and distribution, but not scaly. Actinic keratoses, or AK’s, are also scaly or crusty.
• Treatment: Daily sun protection with clothing and sunscreen, prescription retinoid creams such as Retin A or Refissa, over the counter Retinol, prescription or over the counter bleaching creams, Intense Pulsed Light (IPL), Chemical Peels, Particle Free Precision Microdermabrasion/Dermal Infusion such as SilkPeel, LED treatments such as GentleWaves, and laser treatments such as Fraxel Laser. For pre-malignant sun damage treatments are liquid nitrogen destruction, prescription medications and photodynamic therapy such as IPL/PDT.
• Ease of treatment: Moderate.

So, now you know how you got where you are—spots, and blotches from sun damage.

• Freckles are small pinhead size brown to red to tan flat spots and are found on any part of the body that’s exposed to the sun, like the face, nose, shoulders and chest. They become darker in the summer and fade in the winter. Freckles can occur on all skin tones, but they’re more common in those with fair skin, red hair and light-colored eyes, and occur from childhood onward. Freckles give character and individuality, and many people with freckles like them and don’t desire removal, but remember the reason for them is overexposure to the sun and are a sign of sun damage.

• Sun spots are isolated discolorations appearing from prolonged sun exposure over extended periods of time. They are random in distribution, vary in size and color from tan to reddish brown, to dark brown, larger than freckles, usually flat. They’re most common on the hands, sides of the face, chest and neck, and any other part of the body that’s regularly exposed to the sun. Most common in lighter skin types, but can occur in anyone who is exposed to sun over a period of time. Sunspots usually tend to show up on the skin later than freckles, but as early as your 20’s and 30’s if you have light skin or have had significant sun exposure. Over time, as they become pre-malignant actinic keratosis they may become scaly, and accompany the crinkly texture changes, broken blood vessels and wrinkles of chronic sun damage.

Home Treatments:

• Daily Sun Protection: Of course, as with much of life, the best offense is a good defense. And the defense is sun protection started at an early age and continued though out life. And it is even more important if you have skin type I or II and live in a sunny climate such as southwestern US, southern US, the tropics or Australia; work or recreate outdoors; or grow up on the beach. I have gone over this before, and I know you don’t want the lecture again. If you do, read my previous post Quit Complaining and Wear Your Damn Sunscreen. The vitamin D issue? Topic for another day.

• Prescription Retinoid creams such as Retin A or Refissa: Retinoids are compounds which are able to penetrate the top layers of skin. Retinol is the naturally occurring form of Vitamin A and is converted to the biologically active form, retinoic acid, in the skin. Prescription retinoids are forms of retinoic acid, and are stronger than retinol. Retinoids have well documented anti-aging, sun damage reversal and acne treatment effects, and are considered the gold standard in both anti-aging and acne treatment. Prescription tretinoin, or the other prescription retinoids  include Retin-A, Retin-A Micro, Refissa, Renova, Differin, Tazorac) that come in creams and gels. I have been using one form or another of prescription tretinoin for 25 years. The key is to use the right form. I use currently use Refissa (it is the old Renova 0.05% now a branded generic), tretinoin 0.05% in an emollient base. It is much easier to tolerate than Retin-A, and even easier to tolerate than Renova 0.02%. Creams are much easier to tolerate than gels. The key is to have your face completely dry before you put it on at night, and use it on a regular basis, not intermittently. When your face is damp you absorb more and it is more irritating. When you use it, get dry and red, stop, get better and start again, your skin peels, reforms just in time to peel again when you restart it. And your skin never gets tolerant of it. You can do it every other night or even every third night to start and work up. Be very careful with exfoliants, which can cause microscopic abrasions which allow the tretinoin to penetrate and cause inflammation. Even using a washcloth or facial cloth, synthetic cotton balls (use 100% cotton), cleansing brushes, or a makeup brush to apply loose mineral powder can cause you to not tolerate it.

• Over the counter Retinol: In general, the strength of pure time-release retinol in medial grade, non-prescription products is 0.1-0.5%. The percentage may increase up to 1.5% if the product is actually a mixture of retinol, retinyl palmitate and retinyl acetate.

• Prescription or over the counter bleaching creams: Prescription hydroquinone, non-prescription hydroquinone and other over the counter bleaching creams are often helpful in addition to the other methods we are discussing. That is a complicated topic, and one which we will discuss in depth when we discuss the bane of pigment problems, melasma, later. So you will just have to stay tuned, and return later.

Office Treatments:

• Intense Pulsed Light (IPL): A series of 3-5 Intense Pulsed Light treatments (called IPL, Photofacial, or Photorejuvenation) reduces broken capillaries, redness, brown pigment, age spots, and freckles. It is ideal for those who have lighter skin, with discolorations and little or no textural problems, because it targets the pigment in cells and broken blood vessels to destroy them, while not disrupting the other, lighter parts of the skin.  Red areas get redder for 24 hours, and dark spots get darker for 5 days, and then peel off.It is absolutely essential that you use daily sunscreen, and avoid sun exposure for 3 weeks before treatment, to reduce the natural pigmentation in the surrounding normal skin. Patients with skin types III and up must be especially careful. If you don’t you are at risk of getting burned. Also it is essential that you are evaluated and treated by a physician who is trained and experienced in the skin. IPL is a great procedure when properly done, but one that takes skill to do right. We see patients who have had treatments by individuals with little training or experience and who then develop burns, more pigment, or who are given many low energy treatments with little results. IPL also can be used to improve the red and brown discoloration on the neck, chest, back of the arms, and hands from sun damage. The healing time is longer and the risk of burns higher if you don’t follow sun protection or if done by an inexperienced or untrained operator.

• Chemical Peels: At-home products with glycolic or fruit acids and a series of in-office light chemical peels can improve discoloration by peeling off the top layer of pigmented skin cells, and allowing better penetration of other surface treatments. They are best when used with home retinoids, prescription hydroquinone or other skin lighteners. Skin may be red, dry and flaky for up to 5 days.

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

• LED Treatments such as GentleWaves: GentleWaves LED Photomodulation uses a painless light emitting diode treatment to stimulate collagen and elastin production and improve mild brown discoloration over a series of 8 or more treatments. There is no downtime, but should be used with other treatments, and improvement is variable.

• Fractional Laser Treatments Patients who don’t respond well to the treatments above or who also desire improvements in mild to moderate wrinkles, large pores, surface irregularities, or acne scarring are candidates for fractional laser treatments such as Fraxel Laser Treatment or Active FX. Fractional lasers deliver energy deeper into the skin through thousands of deep tiny columns breaking up deeper pigment, resurfacing sun damage, irregular surface changes, wrinkles and scars. There are two main types, ablative requiring less treatments, but have a longer recovery time and discomfort during treatment and non-ablative which require more treatments, have less recovery time and discomfort during treatment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

8) Not knowing when to stop with plastic surgery

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

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

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

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

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

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

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

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

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

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

I have just two words–Darwin Award

Top 10 Aesthetic Skin Resurfacing Tips

Here are my top 10 tips on cosmetic skin resurfacing, in no particular order. My philosophy is to err on the side of safety. You may get away with breaking the rules. You may not.

These are my opinions, your doctor may feel differently.

1. Top home treatment for skin resurfacing–hands down– are prescription retinoids (Refissa, Renova) in a high enough strength (0.05% or higher)

2. Top home treatment for skin resurfacing without a prescription is glycolic acid containing skin care in a high enough strength to do some good (8,10 or 15%)

3. Remember to stop your retinoids and glycolic acid 3-5 days before a light chemical peel, microdermabrasion, or facial waxing unless you like the scabbed up look.

4. Don’t expect more from the less aggressive treatments than you are likely to get. Fresh, glowing skin with reduced acne and some blending of pigment–yes. Removal of wrinkles and acne scars, growths–no.

5. If you are thinking of doing a deep chemical peel and have any degree of natural pigmentation, or any ancestors even 3 generations back that have any degree of natural pigmentation–think twice. And then think again.

6. When a male doctor tells you that “you will be a little crusted for a couple of days” he usually means “you won’t be comfortable going out in public for a week or more”.

7. For any aggressive skin resurfacing procedure, it is almost always better to do your whole face instead of just a segment. That way if you do get any color change it will at least blend somewhat into the other areas.

8. Be very careful with ablative CO2 laser skin resurfacing, even fractional, on the neck and chest as the risk of scarring is higher on those areas. And the scarring can involve the whole area not just a small section.

9. If you have had an ablative laser (CO2) skin resurfacing procedure, fractional or non-fractional, and are having any problems, such as increasing pain, persistent redness or sensitivity, blisters, insist that you are seen and evaluated by the doctor. Early treatment of complications can reduce scarring.

10. Take the bleaching and sun protection instructions seriously. And follow them.

Skin Resurfacing
Prevent and Correct Early or Moderate Changes
With Dermatology Office Treatments

When you are starting to see changes that you don’t want to see, it’s time to start with some of the lower intensity in-office resurfacing procedures. You are in this category of early to middle changes if you are seeing loss of glow, dullness, clogged pores, fine lines and the beginning of brown spots.

Options are light to mid-depth chemical peels and medical microdermabrasion.

Chemical Peels

Although chemical peels have been around for awhile, they are still very helpful. Chemical peels use surface agents to exfoliate and regenerate tissue by destroying layers of the epidermis. They can be divided into 3 levels corresponding to the depth of penetration in the skin. How deep they penetrate is directly responsible for what kinds of problems they can treat, the recovery time and the risk of side effects. Superficial peels include the alpha hydroxy acid peels (Glycolic Acid), beta hydroxy acid peels (Salicylic Acid). Mid level chemical peels include low strength Trichloroacetic Acid (TCA). Deep chemical peels include high strength TCA and Phenol.

With the advent of lasers, we, and many dermatologists are no longer performing mid or deep level chemical peels because of the increase in complications and reduced predictability compared to laser resurfacing.

Superficial chemical peels are used to sun damage (photoaging), acne, melasma, brown spots, texture and dullness. They may improve fine lines over time. These peels usually require a series of treatments at an of 6 treatments at 2-4 week intervals. They may be combined with acne surgery, which is the gentle removal of blackheads and pimples with sterile instruments.

Usually your face is red for a few hours and has small crusts if blackheads or pimples were removed. The skin feels tight for a day or two and then lightly peels at day 5. Patients who are treated for anti-aging return to normal activities immediately.

SilkPeel Particle Free Precision Microdermabrasion With Dermal Infusion

Microdermabrasion involves a controlled stream of particles to exfoliate the skin. SilkPeel particle-free microdermabrasion treatments use a refined diamond tip to precisely exfoliate and infuse the skin with topical dermaceuticals at a controlled intensity that improve results. There are specific dermaceutical solutions for bleaching, acne and anti-aging.

SilkPeel Dermalinfusion is used in anti-aging treatment to exfoliate dull dead skin, increase smoothness and glow, treat melasma, some brown spots and give your skin an overall healthy appearance. Treatments may improve fine lines over time. SilkPeel treatment usually requires a series of treatments at an average of 8 treatments at 2-4 week intervals.

After SilkPeel treatment your skin may be flushed for an hour. Otherwise it usually has no flaking, tightness or peeling. Patients return to activities immediately with no down time. It is especially popular before a big event, like a wedding, reunion or holiday.

Both Chemical Peels and SilkPeel are great skin resurfacing options for early to moderate aging changes.

But sometimes you need more than a tune up.

Next: Skin Resurfacing–when you need an overhaul.

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.

What are those “white beads” under my skin?

We have a lot of patients ask about them.  They are called milia, they are very common, benign, keratin- filled cysts.  The treatment for them are glycolic acid peels that we do here in the office.

During a glycolic peel, the natural sugar acid, glycolic acid, is applied to the surface of the skin which removes dead skin cells and stimulates collagen production.  Glycolic acid peels give a fresher, smoother surface and are very effective in treating some types of acne and pigmentation.  At the time of treatment,our nurses also perform extractions to remove milia, black heads and acne.  Patients usually schedule glycolic peels every 2 weeks for a series of 6 treatments and then maintenance treatments.

Call our office at 806-358-1117  today to schedule and receive instructions.

Elaine Cook MD

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.