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.

Fraxel and IPL BOGO Free Sale

Back by popular demand, we are once again offering our Fraxel and IPL BOGO Sale. During the months of October and November, with the purchase of either or both Fraxel or IPL treatments, with each treatment you get a second site treatment of the same procedure of equal or lesser value FREE! If you purchase a Fraxel for your face, you will get a free treatment for your eyelids or neck. If you purchase an IPL treatment for your face, you get a free treatment for your neck. Both the primary and the free second site treatment must be completed at the same time. You have until April 1, 2012 to complete your procedure in order to qualify for the free treatment, and you can purchase more than one Fraxel or IPL BOGO, as long as they are completed by April 1, 2012.

Fraxel Laser treats fine lines, wrinkles, sun and aging related texture changes, pigmentation, spots and acne scars and reduces pore size. Eyelid Fraxel Laser treatment improves lines and crepiness on eyelids.

IPL Intense Pulsed Light Treatment improves sun damage, unsightly brown pigmentation and facial veins and also reduces the blushing and flushing of Rosacea.

Both are IPL and Fraxel are extremely popular. Fall is a great time to do your procedure, as you will need to be sun protected during your treatment series. Call us at 806-358-1117 or 800-417-SKIN for more information or to schedule your treatment.

Take advantage of this great offer! It’s a great deal. Don’t miss out or I’ll say “I told you so”.

The fine print about skin resurfacing–risks, side effects, and other unpleasant things

So here is the fine print on risks and side effects of the skin resurfacing procedures we talked about. The risks and side effects are similar with all resurfacing procedures: infection, scarring, pigment problems and redness. This differs from the expected post treatment course such as crusting, flaking etc that we discussed previously, because the risks and side effects are things that, thankfully, don’t usually happen, and ones we don’t want to happen.  The incidence and severity of these reactions vary among with the procedure, with the patient, and with the physician.

Infection: Infection risk can be viral, bacterial or yeast. Viral risk is from the cold sore virus with a post procedure outbreak occurring in someone with a history of frequent cold sores. The virus can then spread into the treated area causing scarring. It can occur with any of the procedures but is more common after the more aggressive procedures. Anyone with a history of cold sore infections should receive preventative treatment with Valtrex. Bacterial infection can occur after picking with any of the procedures. Without picking it is very rare in the less aggressive procedures, more common but still unusual in the more aggressive procedures. Fungal infection, usually with Candida yeast only occurs after the more aggressive procedures.

Scarring: Can occur with any of the procedures, but in the absence of picking, or infection, should not occur in the less aggressive procedures. Much more common after deep chemical peels and traditional dermabrasion.

Pigment problems: Patients with any degree of natural pigment are at increased risk for permanent pigment change, usually darker but sometimes lighter skin, after all resurfacing procedures. The risk rises rather steeply as you move from the less aggressive to more aggressive procedures. At risk skin types include: Hispanic, Asian, American Indian, Middle Eastern, East Indian, Black, including those with these skin types in their genetic makeup several generations back. Caucasians who tan easily and those who get sun exposure are also at risk.  Careful patient selection, not treating irritated skin and reducing post treatment sun exposure are important.

So here are my assessments of the degree of risk for each procedure:

Light Chemical Peels

• Infection: Occasional viral infection if not pretreated.
• Scarring: Very rare unless picking.
• Pigment problems: Uncommon if proper patient selection and patient follows sun exposure precautions. More common if they don’t.

SilkPeel (medical microdermabrasion)

• Infection: Very rare viral infection, unless pretreated.
• Scarring: Very rare
• Pigment problems: Rare

Deep Chemical Peels

• Infection: Moderately common, less if pretreated
• Scarring: Moderately common
• Pigment problems: Uncommon if very fair skin, moderately common if darker skin

Traditional Dermabrasion

• Infection: Moderately common
• Scarring: Common
• Pigment problems: Uncommon if very fair skin, moderately common if darker skin

Non-Ablative Fractional (Fraxel re:store)  Laser Resurfacing

• Infection: Uncommon viral infection, unless pretreated. Very rare bacterial or fungal
• Scarring: Uncommon
• Pigment problems: Uncommon if fair skin, moderately common if darker skin

Ablative Fractional CO2 (Fraxel re:pair and others) Laser Resurfacing

• Infection: Uncommon viral infection, unless pretreated. Rare bacterial or fungal
• Scarring: Relatively uncommon on the face, occasional on neck, chest, arms
• Pigment problems: Uncommon if fair skin, moderately common if darker skin

Who are the highest risk patients?: Patients with a fair amount of natural pigment (darker skin types, or those with darker skin types in their genetic background), smokers, pickers, thin skin, those with tendency to form scars, those with undisclosed recurrent cold sores, and those who don’t take the sun precautions seriously.
Disclose all medical information, follow instructions–what a concept

Who are the highest risk physicians?: Physicians without an in depth, formal training in the skin in health and disease, those who aren’t willing to not treat inappropriate patients because of a profit motive, those who aren’t willing to take the time to be sure the patient understands and follows instructions.
Training, experience and ethical standards–what a concept

What are the highest risk procedures?: From highest to lowest–Traditional dermabrasion and deep chemical peels, then fractional ablative laser resurfacing, fractional non-ablative laser resurfacing, light chemical peels, SilkPeel.
Deep chemical peels, and traditional dermabrasion are the most risky procedures. If you are going to proceed with these, be sure the physician is trained, experienced and does a lot of them.

Remember, these are my opinions and what I tell my patients. Your doctor may feel differently. Don’t make your decision regarding procedures on what I tell you, unless you are my patient. Make your decision based on what your doctor tells you.

Next: Aesthetic skin resurfacing tips

Aesthetic Skin Resurfacing Treatments

• Costs
• Number of Treatments
• Recovery Time

As with any aesthetic skin procedure, you need to weigh the benefits of skin resurfacing procedures against the cost, number of treatments needed and recovery time. Of course, these vary by patient, by the severity of the problem that we are treating, and by physician.

The following are averages, your problem may require more or less treatments, your recovery time may be longer or shorter, and the cost may be greater or less than average. Many cosmetic practices offer discounts for packages of a series of treatments, or for multiple procedures performed together or on the same day. So the following are averages, your doctor may charge more or less:

Light Chemical Peels (Glycolic Acid 50-70%)

• Cost: $75/peel or package of 6 for $375
• Number treatments needed: 6
• Recovery time: 1 day of crusted pimples, mild flaking 3-4 days

Medical Microdermabrasion (SilkPeel)

• Cost: $165/treatment or package of 6 for $825
• Number treatments needed: 6
• Recovery time: none

GentleWaves LED

• Cost: $ 140-185/treatment
• Number treatments needed: 6
• Recovery time: none

Intense Pulsed Light (IPL)

• Cost: $500-700 face/treatment
• Number treatments needed: 2-3
• Recovery time: Redness for 1 day, brown spots turn darker and peel off day 5

IPL/PDT

• Cost: $1000/treatment
• Number treatments needed: 1-2
• Recovery time: Redness and light sensitivity for 3 days, crusting of pre-cancerous areas for 1-3 weeks depending on severity

Laser resurfacing results, recovery time, need for anesthesia and costs vary based on the procedure. For example Fraxel now has 3 different versions of the original Fraxel, all named Fraxel (which leads to confusion when patients don’t know which version is which–bad idea I think but no one asked me): Fraxel re:fine (used by aestheticians), Fraxel re:store (the original Fraxel) and Fraxel re:pair (fractional ablative CO2). As you go up the scale, the cost and recovery time increases and the number of treatments decrease. Fraxel re:pair may require IV anesthesia in a surgery center.

Fraxel re:fine laser resurfacing

• Cost: $750-$1000/treatment
• Number treatments needed: 4-6
• Recovery time: 1 day redness, mild flaking 3-4 days later

Fraxel re:store laser resurfacing

• Cost: $1000-$1500/treatment
• Number treatments needed: 3-5
• Recovery time: 1 day redness and swelling, 5 days bronzing skin, fine flaking day 6-7

Fraxel re:pair laser resurfacing

• Cost: $3000-$5000/treatment + possible anesthesia and facility costs
• Number treatments needed: 1-2
• Recovery time: Pinpoint bleeding  and oozing for up to 48 hours. Swelling and crusting for 1 week, redness for 1 month

Laser resurfacing results, recovery time, need for anesthesia and costs vary based on the procedure. For example Fraxel now has 3 different versions of the original Fraxel, all named Fraxel (leads to confusion when patients don’t know which version is which–bad idea I think but no one asked me): Fraxel re:fine (used by aestheticians), Fraxel re:store (the original Fraxel) and Fraxel re:pair (fractional ablative CO2). As you go up the scale, the cost and recovery time increases and the number of treatments decrease. Fractional ablative CO2 resurfacing technology may require IV sedation and ambulatory surgical facility which may increase costs.

So there you have it, as always in life, there are tradeoff’s and you just have to decide what you want, what you need, and what you are willing to do to get it.

Next: Now the fine print about skin resurfacing–risks, side effects, and other unpleasant things

Skin Resurfacing–the Overhaul
Prevent and Correct Moderate or Advanced Changes
With Dermatology Office Treatments

When you are seeing more advanced changes and look in the mirror and think “I really don’t care for these changes,” it’s time to move on to some of the moderate to advanced dermatology in-office resurfacing procedures. You are in this category of moderate to advanced changes if you are seeing one or more of the following changes: etched lines(lines that don’t totally go away when you stretch the skin), enlarged pores, loss of elasticity, the irregular bumpy slightly yellowish sallow surface that dermatologists call elastosis, and more pronounced brown spots, and worsening of old acne scars.

Options are:
Deep Chemical Peels
Traditional Dermabrasion
and Laser Resurfacing

Deep Chemical Peels

Deep chemical peels have been around for a long time. They include high strength Trichloroacetic Acid (TCA, and Phenol peels. Both will penetrate deep enough into the skin to treat at the level at which deep etched wrinkles and acne scars reside, and that is how they treat deep etched lines and acne scars. The problem that is also the drawback, that they penetrate deep enough into the skin to cause scarring. Because they are applied by hand, by a physician, they are dependent on the thickness of the skin, the preparation of the skin before the procedure and the amount of acid applied. And even in the hands of a skilled physician who has performed many deep chemical peels, there is an inherent unpredictability with the depth that the acid will penetrate. Because of this, the risk of side effects such as permanent pigmentation changes, and scarring are greater than with laser resurfacing. Also sometimes they actually cause enlarged pores. Phenol peels always cause permanent loss of pigment so that the skin turns snow white. This is acceptable if your skin type is extremely fair, but not if you have any significant natural pigment. Both require general anesthesia.

I did a fair amount of deep chemical peels under anesthesia early in my career, but have abandoned them in favor of laser resurfacing. I will say that Phenol peels remove etched lines above the upper lip more completely than any other treatment, by replacing the skin and wrinkles with what is essentially a sheet of white scar. But this requires a patient with very fair skin, and the patient will be required to wear makeup every day forever to cover the fairly marked difference in color between treated and untreated skin.

Traditional Dermabrasion

Traditional dermabrasion (not to be confused with microdermabrasion), involves using an electric medical sanding tool to sand off the skin. It is used most often for deep acne scars. The problem again is that the depth of the treatment is dependent on the skin thickness, and the skill of the physician doing the procedure. Deep acne scars are from acne cysts that occur deep enough in the skin to cause a scar. Traditional dermabrasion is performed at the level of skin where scars form. That is why traditional dermabrasion replaces acne scars with a sheet of new scar. The skin never really looks or feels normal.

Laser Resurfacing

Laser resurfacing is divided into ablative and non ablative depending on whether the surface layer of the skin is removed with treatment (ablative) or not (non-ablative). It is also divided into fractional and non-fractional.

The first skin resurfacing lasers in the 90′s were ablative and non-fractional CO2 lasers. Non-fractional ablative lasers only required one treatment but usually required general anesthesia. Patients looked like they belonged in a burn unit for 2-3 weeks, were red and sensitive for months. Although not known in the first few years of use, some patients developed permanent loss of pigment in the treated skin several years after treatment. Additionally the risk of scarring, though less than deep chemical peels and traditional dermabrasion was unacceptably high. I also did many ablative non-fractional CO2 laser treatments in the 90′s but like most physicians switched to fractional laser resurfacing when it became available.

Fractional laser resurfacing was developed to address some of these problems. Fractional means that only a fraction of the skin is treated at a time by creating thousands of tiny treated channels in the skin surrounded by untreated skin. This allows safer treatment with much less risk of scarring and permanent pigment change, but requires more than one treatment to achieve best results. Fractional lasers are either ablative (destroys the top layer of skin) or non-ablative (does not). Fraxel was the first laser to utilize the fractional technology. Fractional laser resurfacing creates microscopic “wounds” within targeted areas beneath the outer layer of skin. The natural healing process produces collagen and healthy skin cells.

The original fractional laser resurfacing treatment Fraxel, is now Fraxel:restore, and is non-ablative. Fraxel:repair is a more recent development and is ablative. Ablative lasers require less treatments, but each treatment has a longer recovery time. Ablative lasers also may require general anesthesia. Non-ablative lasers may be safely used on the neck, chest, forearms and hands. Ablative lasers carry a risk of scarring in these areas.

We use Fraxel:restore as our patients prefer more treatments with less downtime and less discomfort with each treatment. They also don’t want general anesthesia which ablative procedures may require. In the last few years, many new resurfacing lasers have emerged. All have their pros and cons, but there are now multiple choices, and each physician usually has a personal preference.

Laser resurfacing treats mild to moderate wrinkles, surface irregularities, blotchy pigment, acne scarring, large pores, and stretch marks. Skin is smoother, less wrinkled and more refined with smaller pore size.

Photos of before and after Fraxel eyelid treatment
Photos of before and after Fraxel facial treatment

Next: How to know which skin resurfacing treatment is right for you.

Fall Back into Youth
Fraxel Laser and IPL Photorejuvenation BOGO Sale

Since we are talking about repairing sun damage and skin resurfacing I wanted to remind our patients that our fabulous BOGO Fraxel Laser and IPL Photorejuvenation sale ends November 30. You can purchase either or both Fraxel or IPL treatments, and with each treatment you get a second site of equal or lesser value free. If you purchase a Fraxel Laser procedure for your face, you will get a free treatment for your eyelids or neck. If you purchase an IPL Photorejuvenation treatment for your face, you get a free treatment for your neck. You have until April 1, 2011 to complete your procedure in order to qualify for the free treatment, and you can purchase more than one Fraxel Laser or IPL BOGO, as long as they are completed by April 1, 2011.

Fraxel Laser treats fine lines, wrinkles, scars and reduces pore size. IPL Photorejuvenation treats brown spots and broken blood vessels. Both are extremely popular treatments. Call us at 806-358-1117 in Amarillo or 800-417-SKIN in the rest of the Texas panhandle for more information or to schedule your treatment.

Here is more information on Fraxel Laser benefits, and IPL Photorejuvenation results . Or here ff you want to see photos of before and after Fraxel results, or photos of  before and after IPL results. Check the website where you can always find our latest cosmetic and aesthetic treatment sales.

It’s a great deal. Don’t miss out or I’ll say “I told you so”.

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.