Acne and Acne Scarring

Acne is primarily due to the blockage of a pore or oil gland that subsequently becomes inflamed either because of the blockage itself or invasion of skin bacteria. While prominent in the teenage years due to hormonal changes, acne is also seen in all ages as a result of stress or application of acne-forming compounds.

The treatment of acne centers on preventing pore occlusion and reduction of inflammation. Basic acne-fighting ingredients include salicylic acid and glycolic acid to reduce pore occlusion, and benzoyl peroxide to decrease inflammation. Additional acne prevention can be obtained with retinoids and topical/oral antibiotics. Treatment should begin with a basic or advanced skin care regimen. In addition, your physician may prescribe several of the following prescription treatments:

One of the most common questions confronted in dermatology offices amongst patients with acne is how to get rid of acne scarring. This is such an important question because, as acne has its own problems, occasionally the resulting acne scarring can be as cosmetically disturbing as the original acne. Many advances have been made to alleviate the appearance of acne scarring, but no over-the-counter remedies are currently available. The following discussion and suggestions must be carefully reviewed with your experienced dermatologist.

The first step in the treatment of acne scarring is treating the underlying acne. Without an effective anti-acne regimen, treating acne scarring will be futile as more scars will occur despite treatments.
Your regimen may include simple over-the-counter acne care or prescription topicals such as Retin-A or Tazorac. Other treatment options include antibiotics, Blu-Light Photodynamic therapy, and oral isotretinoin therapy. These choices are made between you and your experienced dermatologist.

Acne scarring can be divided into two primary groups: rolling acne scars and ice-pick scars. Rolling scars are best described as hills and valley that are truly accentuated with tangential lighting. Ice-pick scarring is the sharp, deep pitting holes made as if an ice-pick was poked into the skin. The treatment of these two different types of scarring differs in both the methods used and the rate of success.

For rolling scars, there are surgical, ablative, and non-ablative methods to reduce scarring. Surgical methods include subcision treatment where a needle/blade is placed underneath the scar and moved side to side to loosen up the underlying scarred tissue. Another treatment option is using a filler such as Restylane® or medical grade silicone to fill up the scar. Non-ablative therapies include using an infrared laser to heat up and remodel the tissue underlying the scar. Ablative therapies include dermabrasion (manual sanding of the skin) or ablative lasers, such as the Er:YAG or CO2 lasers, to remove the top lasers of the skin and essentially even out the "hill-tops and valleys" of the rolling scars. Newer laser treatments include the use of fractional resurfacing laser technology (Fraxel, Starlux). The data is still quite new, but these lasers appear to combine excellent efficacy with minimal downtime

For ice-pick scarring, surgical methods include punch excision, where a cookie-cutter circular instrument is used to remove the scar under anesthesia and a stitch may or may not be placed to help with healing. Another new technique involves using 90% Trichloroacetic Acid applied with a toothpick. This serves to damage the skin within the scar and promote scar remodeling. The other treatment methods mentioned above also apply: use of the filler substances, dermabrasion, and laser resurfacing.

In general, non-ablative laser therapy may reasonably lead to 50-70% improvement of rolling acne scars. Subcision and use of fillers are ideally used for limited rolling acne scarring and punch excision treatment may be used if isolated ice-pick scarring is noted. For more extensive scarring of either type, dermabrasion or ablative laser therapy tends to be the best option.

Many of these treatments are skin-type specific and must be determined upon close consultation with your dermatologist. While these treatments are not covered under any insurance, the cosmetic results may be well-worth the price. Make sure to discuss all the possible therapy options and combinations, as well as the reasonably expected results.

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Actinic Keratoses

Actinic keratoses are widely viewed as precancerous skin lesions that are due to previous excessive sun exposure. Characterized by scaling areas on the face, ears, neck, arms, and hands, these lesions are asymptomatic and are more easily felt rather than seen. Some may contain color and mimic a melanoma while others may thicken and become painful. Often, these lesions are rubbed off only to recur again.

While these are not cancers, many may behave similar to or transform into squamous cell carcinomas. The risk of transformation increases with time, thus it is recommended that these lesions be treated and affected persons routinely screened for the development of new lesions. There are a variety of treatment options including liquid nitrogen cryotherapy, topical 5-fluorouracil (Efudex®, Carac®), topical imiquimod (Aldara®), ALA-PDT therapy, medium-depth chemical peels, CO2 laser resurfacing, or a combination of these treatments. Sunscreen and avoidance of the sun should be rigorously practiced to prevent new actinic keratosis formation.
Sample treatment regimens include:

5-Fluorouracil (Efudex®) twice daily for 3 weeks, or twice daily on Saturday and Sunday for 12 weeks; Carac® may be used once daily for 3-6 weeks. Expect a BRISK reaction where you may turn red, irritated, and scabby, at all the actinic keratoses sites.

Imiquimod (Aldara®) once daily on Tuesday and Thursday for 12 weeks; may do for 4 weeks, then take 4 weeks off. Expect a BRISK reaction where you may turn red, irritated, and scabby, at all the actinic keratoses sites.

Diclofenac (Solaraze®) twice daily for 3 months

Irritation may be expected and a break from treatment should be done for 1-2 days. Alert your physician with any excess irritation of possible infection.

Discuss your treatment options thoroughly with your physician or physician's staff.
 

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Atopic Dermatitis, Eczema

Atopic dermatitis is a very common skin condition primarily seen in young children and associated with allergies and asthma. It commonly presents near the elbows and knees and is characterized by severe, persistent itching. The skin often scales, oozes, and may thicken over time. Infections are common and disease-control may be elusive.

The treatment of atopic dermatitis includes close consultation with an experienced primary-care physician or dermatologist. The treatment plan often includes moisturizers, topical steroids or anti-inflammatory agents, oral anti-itching medications, and perhaps oral immunosuppressive agents. Proper skin care is essential and should include:

• Warm, tepid baths (not hot) with the use of a mild, non-fragranced moisturizing soap
• Mild drying of the skin after bathing (tapping dry with a towel rather than rubbing dry
• Immediate application of moisturizer or topical medication
• Repeated application of moisturizer as many times as possible during the day

Additional treatment options include using a room humidifier to prevent the skin from drying out; and/or the application of wet pajamas / clothing with an overlying dry layer of clothes after application of topical medication or moisturizer. To decrease the bacterial load on the skin, bleach baths (1 cup bleach per tub of warm water) may be helpful; be cautious to prevent contact with the eyes.

Environmental Precautions for Atopic Dermatitis Patients

Atopic patients respond directly to the control of external irritants and allergens, therefore, every effort should be made to avoid or at least, control a harmful environment.

• Control the temperature. The room temperature should be kept on the cool side. Overheating induces sweating wchich can further cause and adverse reaction. Do not overdress and infant or a child for the same reason.
• Increase the humidity, when possible
• Minimize dust. Dust can cause irriation, and some atopic dermatitis patients are quite allergic to dust.
• Avoid perfumes, deodorant spray, and insecticides
• Avoid cigarette smoke, house dust mites (regular vacuuming, plastic mattress covers should help), and animal dander
• Avoid new rough clothing. Cotton is the best fabric. Avoid wool.
• Choice of soap (Dove, Lever 2000, Purpose, Basis, Aveeno) may be helpful. Also, you may wish to consider hypoallergenic detergents such as All Free and Clear, or Cheer Free and Gentle.

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Hair Loss

Hair loss has many etiologies. Common medical causes of hair loss include:

• androgenetic alopecia (male-pattern hair loss)

• telogen effluvium

• traction alopecia

• alopecia areata.

Androgenetic alopecia (male-pattern hair loss) is the result of genetic inheritance from many sources dispelling the common myth that it simply follows the mother's father. This condition may affect both males and females, and is commonly due to genetic influences from both the mother's and father's sides of the family. It is commonly noted as thinning of the hair on the front and top of the scalp. Hair loss is gradual and is often noted by more-than-normal hair fallout in the sink, shower, or on shirts and pillows. For women, a hormone screening for abnormalities, including hypothyroidism, may be performed. Treatment of androgenetic alopecia is primarily through over-the-counter minoxidil (Rogaine®), or prescription finasteride (Propecia®). A decreased concentration of minoxidil is available for women. Women may be prescribed aldactone, an androgen-blocking agent, or birth control pills in an effect to counteract male hormones that may be contributing to the problem. Women should NOT take or handle finasteride (Propecia®) tablets.
 

Telogen effluvium is an acute condition characterized by sudden diffuse hair loss 1-2 months after an illness, surgery, or childbirth. While the hair loss may be dramatic in some, complete hair re-growth is the norm and usually takes 4-6 months to occur. Hair re-growth may be quickened through the use of over-the-counter minoxidil (Rogaine®).

Traction alopecia is a condition caused by excess pulling on the roots of hair follicles. Often seen in African Americans, traction alopecia is most often due to the use of tight braids or application of hair weaves. Thinning of hair is seen over the frontal scalp starting at the forehead and temples and advances back over the scalp. Treatment of traction alopecia is primarily accomplished by releasing braids or constrictive hair styles, and by application of topical minoxidil (Rogaine®). Depending on the degree of damage, hair growth may not be achievable in some areas.

Alopecia areata is characterized by focal circular areas of hair loss throughout the scalp. It may on occasion be diffuse throughout the scalp. In alopecia areata, the body's immune system targets the hair follicles and leads to a disruption in hair growth. Alopecia areata is sometimes associated with thyroid problems or vitiligo. Treatment of alopecia areata includes steroid injections, oral or topical steroids, topical tar applications, topical minoxidil (Rogaine®), and contact sensitization therapy. This condition may be associated with thyroid dysfunction or diabetes. Make sure to alert your physician should you have any other bodily symptoms.
 

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Hyperpigmentation, Dark Spots

Hyperpigmentation is darkness either noted at sites of previous inflammation (bug bites, acne, trauma, surgery, etc.) or as a result of a primary skin process (melasma, sun damage). The main treatment for most hyperpigmentation includes the use of bleaching creams. The most common bleaching agent is hydroquinone in a concentration between 2-6%. Other topical agents with lightening effects include kojic acid, glycolic acid, and azeleic acid. In fact, glycolic acid peels have been widely employed in physician offices for the treatment of melasma.

Most recently, combinations of glycolic acid, retinoids, steroids, and hydroquinone have been developed to treat hyperpigmentation. Most of these combinations are prescription-only, however, use of low concentration hydroquinone and glycolic acid may be done with over-the-counter products. All patients undergoing treatment must be advised to avoid sun-exposure for risk of longer treatment times and higher probability of treatment failure.

Regarding melasma, newer treatments include the use of fractional resurfacing laser technology (Fraxel®, Starlux®). The data is still quite new, but the results noted have been extremely promising. Other laser technologies have been shown to inconsistently reduce melasma with a majority of cases eventually relapsing.

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Nail Disease

There are many different types and causes of nail disease. Several of the more common nail diseases include onychomycosis (fungus infection), onychoschizia (nail splitting), onycholysis (nail separation), and paronychia (inflammation around nail).

Onychomycosis is a fungal infection under the nail. It often presents as yellow discoloration of the nail with crusty material present directly under the nail tip. This condition is most often painless and usually is of cosmetic concern. Onychomycosis is most often seen on the toenails in the context of athlete's foot (tinea pedis), but can occur in the fingernails. The treatment of a nail fungus infection may include topical prescription creams or lacquer, or oral medications. Treatment should specifically be sought by patients with diabetes or lower leg swelling. If given Lamisil®, the usual treatment course is one 250mg tablet daily for 90 days. This medication should not be taken by patients with a history of liver dysfunction. All patients taking this medication should be alert for yellowing of the skin, abdominal pain, nausea, or vomiting. Should any of these symptoms occur, alert your physician immediately.

If you are given Lamisil, you must get a lab test prior to initiation of therapy. Cure rates for Lamisil vary between 60-85%. Although you are only treated for 3 months, it will take one year for your new, normal nail to grow out. If you choose to do Penlac Lacquer, you must apply it to the affected nails nightly for one year.

If you are given Fluconazole, you must get a lab test prior to initiation of therapy.
Onychoschizia is superficial splitting of the nail tip. The cause is not directly known, but many nails tend to be affected and trauma / picking worsen this condition. It is neither dangerous nor progressive. Treatment of this condition is variably successful with the use of 2-2.5 mg of oral biotin vitamin daily.

Onycholysis is nail separation, usually towards the nail tip. It often presents at a white area under one or several nail tips that is not red or inflamed. These areas are often caused by trauma either by grabbing objects with the nail tip, forceful manicures, or forced removal of acrylic nails. Other diseases with onycholysis include nail fungus infections, psoriasis, and medication allergies.
Paronychia is inflammation of the nail folds around the nail itself. This condition presents with red, often painful, skin around the nail. Pressure on the area may sometimes produce pus at the site. Acute paronychia (most commonly due to bacterial infection) is painful, sudden, and often pus forming. Chronic paronychia (sometimes due to yeast infection) is sometimes painful, but usually presents as red, thickened, and cracking skin around the nails. Either type of paronychia may be caused by irritation or allergic reactions. Treatment of paronychia depends on the type, but may consist of oral antibiotics, topical antibiotics, topical anti-fungals, topical steroids, or topical thymol solutions. In either case, prolonged contact with water should be avoided.

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Psoriasis

Psoriasis is chronic inflammatory condition that affects 2% of the world population. It does have a hereditary or familial tendency, and may appear on any part of the body. It is characterized by scaling, red plaques that most often involve the elbows, knees, and scalp. Arthritis and nail changes may also occur.

Psoriasis is not contagious and the risk of transmission to the children of affected individuals is not completely known. It is a chronic condition that is marked with numerous period of improvement and exacerbation. The response of psoriasis to treatment differs among individuals and is somewhat unpredictable. Treatment of psoriasis can be difficult and often requires the care of an experienced dermatologist.

Examples of treatment agents include:

Topical corticosteroids

• apply a thin layer of the medicated ointment, cream, or foam to the affected area twice daily

• strong steroid compounds should not be applied to the face, groin, elbow creases, armpits; steroid application in these areas may thin out the already thin skin leaving blood vessels showing and purple stretch marks

Topical tar / anthralin

1. apply a thin layer to each psoriatic area once or twice daily
   Calcipotriene / Dovonex

2. apply a thin layer to each psoriatic area twice daily
   * may be applied along with the topical steroid ointment

Tazarotene / Tazorac®

• apply a thin layer to the psoriatic area once or twice daily as tolerated

PUVA / NB-UVB therapy

• light therapy 2-3 times per week as determined by your physician

Acitretin / Methotrexate oral therapy

• Acitretin is taken once a day and must have monthly blood draws to monitor for possible liver or triglyceride side effects; your triglycerides may increase dramatically and lead to life-threatening pancreatitis or other long term sequelae. You may be placed on an anti-triglyceride medicine by your physician. This medication is NOT for any females who may potentially become pregnant at any time in the future. Any signs of yellow skin discoloration, abdominal pain, nausea, or vomiting should prompt stopping the drug immediately and contacting your physician

• Methotrexate (MTX) is taken once weekly and must have weekly, biweekly, or monthly blood draws to monitor for liver, kidney, or blood changes; any signs of fatigue, increased infections, of yellow skin discoloration, abdominal pain, nausea, or vomiting should prompt stopping the drug immediately and contacting your physician. After a cumulative dose of 1.5g, a liver biopsy is recommended to follow the long term effects of MTX on liver.

Cyclosporine

• Cyclosporine is an immunosuppressive medication given to transplant patient to prevent host rejection of the transplant

• This medication is dosed on body weight and is often taken once or twice daily

• blood counts, liver tests, lipids, and kidney function must be followed with routine blood tests

• high blood pressure, increased hair growth, and enlarged oil glands may be seen while taking this medication

Cellcept

• Cellcept is an immunosuppressive medication given to transplant patient to prevent host rejection of the transplant

• This medication is taken twice daily

• blood counts, liver tests, and lipids, must be followed with routine blood tests

• GI upset is the major side effect; as this is a newer medication used for a variety of conditions, there has been an association with possible lymphoma development, although no proven relationship has been demonstrated

Biologics (Enbrel®, Amevive®, Raptiva®, Humira®, Remicade®)

• These are expensive new injectable alternatives that have given new hope to many psoriasis patients

• You will need a chest X-ray and a PPD test prior to starting any of these medications

• These are newer medications. Their risks of lymphoma and long term problems is UNKNOWN.

• Enbrel is given SQ in the abdomen at a dose of 50mg twice a week; for 12 weeks if there is a family history or risk of multiple sclerosis, this medication must NOT be given

• Amevive is given IM in the thigh at a dose of 15mg for 12 weeks; it is only given in the office and blood tests are done weekly

• Raptiva is given SQ for 12 weeks; your platelets may decrease and thus you will need monthly labwork

• Humira is given SQ at a dose of 40 mg every other week for 12-24 weeks; it is currently NOT approved for psoriasis without arthritis.

• Remicade is a 4 hour IV infusion given at weeks 0,2,6 and every 8 weeks after. It is the most effective. Not for those with heart failure.

This is NOT an all-inclusive list of medications with all side effects. Make sure to consult your physician very carefully and thoroughly before undertaking any of these treatments.
 

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Rosacea

Rosacea is believed due to vascular instability leading to a chronically red-appearing face, especially around the nose and cheeks. Often, there are periods of flushing an excess redness when the affected area is exposed to certain triggers. Such triggers are:

• sunlight

• ingestion of alcohol

• spicy foods

• hot drinks

• emotional instability / anxiety

• heat

Those affected with rosacea often complain that they are "always red" or chronically "appear drunk".

This appearance can be quite socially disturbing to the affected individual. If the rosacea goes untreated, there can be rosacea-induced acne, or bumpy glandular changes of the nose, cheeks, or chin. Styes often present in those affected with rosacea.

The treatment of rosacea includes topical/oral antibiotics and other various topical preparations that may include sulfur, sodium sulfacetamide, azeleic acid, or greenish cosmetics. While there is no cure for rosacea, the facial appearance may be improved with use of any of these topical agents, and may be enhanced with laser therapy. The current gold standard for removal of the redness and blood vessels is LASER therapy.

You may be given:

Tetracycline / Minocycline / Doxycycline / Oracea

• Tetracycline should be taken one half-hour prior to a meal or two hours after a meal; this medication should be taken with plenty of water; it may be taken once to twice a day as directed by your physician

• Minocycline may be taken with or without food; if taken without food, take with plenty of water; it may be taken once to twice a day as directed by your physician

• Doxycycline may be taken with or without food; if taken without food, take with plenty of water; it may be taken once to twice a day as directed by your physician

• Oracea may be taken with or without food; if taken without food, take with plenty of water; it may be taken once a day as directed by your physician

• Finacea: use twice a day

• Metrogel / Noritate: use twice a day

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Scabies

Scabies is an extremely itchy skin condition caused by infection with the mite Sarcoptes scabeii. Most infections are characterized by severely itchy red bumps and tiny blisters that may predominately reside first in the webspaces on the hands and feet, and then spread to the arms and body. Scabies is extremely contagious and may be contracted by anyone despite extremely rigorous hygiene. It may be contracted from contact with an infected person or contaminated objects.

The mite can not be viewed by the naked eye. The diagnosis is usually made by the physician on the clinical appearance and history of the eruption, or by microscopic examination.

The treatment of suspected or confirmed scabies may include oral agents, but routinely consists of the following:

• Use of prescription topical permethrin 5% cream applied from the neck down at night and washed off in the morning. This treatment is then re-applied in the same exact manner in one week. It is important to apply the cream in an even layer to every part of the body including the genital areas, between the fingers, and between the toes.

• All clothes and bedding should be washer in hot water and dried on high heat. This is routinely done the morning after topical cream application (described above)

• Oral agents such as ivermectin may be given to you at the discretion of your physician.

Pregnant females or children under the age of 2 should not be given topical permethrin. A sulfur/petrolatum mixture may be used in the same method as described above.

It may also be necessary to treat everyone in the household on the same night in order to minimize reinfection.
 

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Spider veins, Varicose Veins, Sclerotherapy

Spider veins are most often seen on the legs and thighs of both men and women. Often the result of pregnancy, leg swelling, or hereditary tendency, these veins are tiny bluish-red "stringy, tree-like" groupings that are primarily unsightly rather than symptomatic.

The treatment of these areas is not difficult, but may involve repeat visits to the dermatologist as they tend to recur in different areas throughout one's lifetime. There is no over-the-counter treatment for the prevention and treatment of spider veins. Sclerotherapy is an intra-office procedure where the dermatologist injects a compound that destroys or collapses the tiny vessels. Such FDA-approved compounds include hypertonic saline and sodium tetradecyl sulfate. One non-FDA-approved compound recently used with great efficacy is aethoxysclerol. With a majority of these treatments, post-treatment hyperpigmentation, ulcerations, or allergic reactions may be encountered. Post-treatment use of compression stockings is strongly recommended for 7 days after therapy. Use of dedicated laser systems or intense pulsed light systems has also been used with some efficacy in treating spider veins.

Varicose veins are widely seen in many people, but are primarily noted in those persons of greater weight or after pregnancy. These are the larger compressible green-blue veins noted primarily from the knee down. The primary reason for their development is the malfunction of the venous valves that assist blood return to the heart. While sclerosants mentioned above may be used by some physicians in the treatment of these veins, there is no satisfactory treatment available asides from surgical removal. Compression hose is a staple of varicose vein therapy as well as weight or lower extremity swelling correction. If these varicose veins are associated with pain, it would be very wise to consult a vascular surgeon regarding the best available treatment.
 

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Stretch Marks
 

Stretch marks are often seen after growth spurts, rapid weight gain or weight loss, oral or topical steroid therapy, and pregnancy. Much like scars, the treatment of stretch marks is often difficult and variable successful. Progress and successful therapy may be obtained with numerous treatments, including topical formulations made specifically for stretch marks, retinoids, and various laser therapies. There are no known methods of stretch mark prevention.
 

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Wrinkles, Photodamage, Aging, Prevention of Aging

The prevention of aging has become a primary focus of the cosmeceutical industry. The main causes of aging skin are due to two primary sources: the natural decreasing elasticity of the skin with increasing age, and sun exposure.

In regards to the natural decreasing elasticity of the skin with increasing age, collagen formation and elastic tissue formation is decreased as a person age. This may be primary due to the decreased ability of collagen / elastin producing cells to reproduce as they themselves age. The result is less viable collagen and elastin production leading to saggy, thin skin tissue clinically seen as wrinkles.

Sun exposure dramatically decreases the time needed to age skin and lead to wrinkles. The harmful ultraviolet radiation in sun exposure destroys normal elastic tissue and renders it useless. The result is sagging skin clinically seen as wrinkles. Also, the skin tends to thicken and become somewhat "leathery" with greater degrees of exposure as a method of protection. Sun exposure also leads to dyschromia consisting of ruddy red and brown discoloration of the face and neck. In addition, lentigos (sun spots) are also formed and may be perceived as freckles on any part of the skin (most often the face, chest, shoulders, back, arms, and back of hands). Despite these side effects, the most serious effect of chronic sun exposure is the formation of skin cancer.
 

The baseline treatment for prevention of aging / wrinkles / photodamage is the use of sun-protective clothing, sunscreen, and retinoid products. A suitable sunscreen should be applied in generous amounts several times a day to the face and exposed body. An SPF of 15 or higher should be used on the face and 30 or more to the body. Persons should avoid the sun during the times of 10am - 3pm (peak intensity). In addition, the use of a retinoid has been scientifically shown to prevent or reverse aging. The best retinoids are obtained with a prescription from a dermatologist knowledgeable about treatment regimens and side effects, although suitable retinoids may be found in many over-the-counter products (e.g. ROC). Other topical products that may be used include those containing Vitamin C or Vitamin E antioxidants. Newer compounds include coffee berry extract (Revale®) and idebenone (Prevage®).

Laser treatments may also lessen the effects of aging and reduce fine lines / wrinkles. Such laser treatments include flash-lamp pulsed-dye or intense pulsed light systems for the dyschromia on the face / neck, infrared laser systems to tighten the skin and reduce the appearance of wrinkles, and resurfacing lasers (CO2, Er:YAG lasers) to destroy the wrinkles and allow new collagen and skin regrowth. The non-ablative lasers (do not peel off the skin) have variable results while the ablative lasers (peel off the top layer of skin) are the gold standard for all types of wrinkles, but have significant downtime. Newer laser treatments include the use of fractional resurfacing laser technology (Fraxel®, Starlux®) which combine excellent efficacy with minimal downtime.

Chemical peels and dermabrasion have also been used to treat wrinkles and photoaging with great success. In regards to treating wrinkles specifically, BOTOX® and Restylane®, Juvederm® (and similar collagen treatments) are very widely used in both treatment and prevention of wrinkles in a variety of locations. Over-the-counter BOTOX® alternative creams exist that are thought to enhance collagen production and promote thicker, fuller, and healthier skin.
 

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