For acne that just won’t go away…

Question:  My acne is so bad I’m desperate to try Accutane – but I’ve heard scary things about its side effects. What’s the truth about this medication and how can I get rid of this acne once and for all?

Sick and tired of acne? Try Isotretinoin
Sick and tired of acne? Try Isotretinoin

Answer: First of all, the brand “Accutane” is no longer available so we should speak about it using its generic name which is isotretinoin. Isotretinoin is an acne medication that does resolve acne in most patients once and for all.

Isotretinoin is more mainstream than you think. While we do use it for severe acne and acne that just doesn’t resolve after we’ve tried many other well-known combinations of medication, both topical, oral and in combination; we also use it in  patients who need to have perfect skin such as models, actresses, those in the public eye and in patients who are (frankly) really sick of having to deal with and look at their acne on a daily basis.

Although isotrentioin is approved only for severe cystic acne, it is really useful in less severe forms of acne to prevent the need for continuous treatment and repeated office visits those patients require. In my opinion, oral isotrentioin is warranted for severe acne, poorly responsive acne (acne that improves by less than 50% after 6 months of therapy with combined oral and topical antibiotics), acne that relapses off oral treatment  or acne that induces scarring and  psychological distress.

Isotretinoin is the only thing that I can tell you will cure a patient of acne. Generally speaking, a patient who we have treated with isotretinoin will almost certainly never break out to the same degree again. Most patients are pretty clear for usually up to 5 years after finishing the course. For those with acne and rosacea, oral isotretinoin has been shown to induce a full remission in many cases.

How I prescribe isotretinoin

I usually start patients at a half-dose  (20-40 mg daily) to decrease flare-ups of the cystic acne and then increase it on a monthly based on the patient’s response. A higher dose based on a patient’s weight, increases the likelihood of a prolonged remission. While a usual course may be around 5 months, sometimes I extend the length, again,  based on the patient’s response.

The major advantage to choosing isotretinoin treatment is realiability in almost all patients.

A course of isotretinoin leads to a remission that may last many months or years. Approximately 40-60% of patients remain acne-free after a single course of isotretinoin. About one-third of patients who relapse will need only topical therapy; the others sometimes need oral therapy. I often retreat patients with isotretinoin again because it is reliably effective and we can predict their side effects.

What you can expect while taking isoretinoin

Isotretinoin is a potent teratogen (affects a developing fetus) and causes severe birth defects if taken while a woman is pregnant. For this reason the medication is tightly regulated; both the prescriber and the patient need to be registered with the iPledge program in order for us to write the prescriptions and for the patient to receive them. What is important to remember is that use of isotretinoin does not  affect future pregnancies; however, pregnancy is absolutely contraindicated while the patient is taking isotretinoin.

Although you may experience any of the physical side effects such as dryness, inflammation of the lips (chelitis), nosebleeds (epistaxis), sensitivity to the sun (photosensitivity), itchy skin,  and many others, most are extremely manageable.

There have been many claims of adverse events from patients while taking this medication, so we monitor patients thoroughly during their course of treatment. These include elevations in blood cholesterol, gastrointestinal disorders, liver enzyme elevations, psychiatric disorders, visual and hearing impairment and others.
However, in all my years of prescribing the medication, I have rarely stopped the drug because of the side effects.

I do tell patients taking isotretinoin to:

  • Avoid the sun due to hypersensitivity
  • Avoid waxing and electrolysis due to skin sensitivity
  • Use two effective forms of contraception

The truth is, when the patient is thoroughly monitored and all precautions are managed, isotretinoin is an extremely effective option for patients with the worst cases of acne and for those patients who acne is negatively affecting their lives.

I’ve even taken it myself – twice!

-Jodi

 

Too much sweat?

Question:  Is there such a thing as sweating too much? What can I do about it if I’m constantly soaking through my clothes? It’s so embarrassing, especially at work!

shutterstock_155697284Answer:   Yes, the condition definitely heats up during the summer months but can plague sufferers all year long with overly sweaty armpits, palms and even on soles of the feet. It  is called hyperhidrosis which just means “excessive sweating.”

Hyperhidrosis is simply abnormally heavy perspiration. Sweating is a normal bodily function, but some people may have overactive sweat glands that produce more sweat beyond what is required for regulation of body temperature. It can be most noticeable at the armpits because sweat can soak through clothing and become obviously embarrassing. Or you may also be aware your palms are often sweaty so you avoid shaking hands with others.  Hyperhidrosis can occur  in many parts of the body whether exposed to triggers such as heat, physical activity or exertion, embarrassment, stress or not.

How do we treat excessive sweating?

First, we’ll evaluate your excessive sweating for any potential causes of secondary hyperhidrosis (for example, an underlying disease that causes excessive sweating such as hyperthyroidism).

To gauge your sweating problem, we will try you on stronger prescription-grade antiperspirants which can also help block sweat glands to reduce sweating. Typical over-the-counter antiperspirants are 1-2% aluminum chloride but prescription products can contain up to a 20% solution of aluminum chloride hexahydrate or similar aluminum salts. While these can be irritating in those with sensitive skin and sweat glands, they do reduce perspiration, however they require continuous usage.

After a few weeks of trial, if the prescription products do not reduce your sweating problem well enough, we can now use Botox® (onabotulinumtoxinA), which is FDA approved for the treatment of excessive sweating of armpits. We also use Myobloc® (rimabotulinumtoxinB) or Dysport® (abobotulinumtoxinA) off-label as an alternative, especially for those who have excessive sweating on palms and soles of feet.

These injections work to temporarily de-nerve the sweat gland and results in a local reduction in sweating where injections have been administered for up 5 months. Injections must be repeated at regular intervals to keep excessive sweating at bay and you may still need to use an antiperspirant.

-Jodi

Prescription retinoids versus drug-store retinols

Question:  I’ve seen plenty of products in the drug store skincare aisle that contain retinol and say they reduce the appearance of fine lines while balancing an uneven complexion. Is this the same as the Retin-A products I can get by prescription?

Read drug store retinol cream labels looking for vitamin A!

Read drug store retinol cream labels looking for vitamin A!

Answer: While they are both derivatives of Vitamin A, called “retinoids,” and used to promote faster skin cell turnover, they are not the same.

All retinoids have been well-studied, tested and been proven effective and powerful for treating skin issues ranging from acne to many signs of aging, including sun damage.

But there is a marked difference between retinoid products you get only by prescription and the retinol products you see on drug-store shelves.

Retinoid products are prescription-only skincare products containing the most commonly-known natural vitamin A derivative, tretinoin which comes in name brands such as Atralin, Retin-A (and Micro) among others.  These proven prescription products increase the rate of cell turnover to uncover healthier skin-whether it’s reducing fine lines or evening out the texture or color of your skin.  Common side effects include dryness, redness, cracking,  irritation and skin peeling. There are two other prescription strength (lesser known) prescription retinoids-tazarotene (Tazorac) and adapalene (Differin).

If you find, during the dead of winter, that dryness, peeling, redness and cracking are more pronounced, simply reduce the usage of your prescription retinoid to just once per day, or every other day or even every two or three days until side effects are diminished. By the way, winter weather and drier indoor heat may be exacerbating your already winter-dry skin, if you need to use them less don’t worry, the powerful retinoids still do their job!

Retinol products don’t require a prescription so you can buy them over-the-counter at the drug store or grocery store, without a prescription. Retinols are simply a synthetic, weaker version of a retionid and as such, they act more slowly than a retinoid. However, these products can be useful if you find prescription retinoid products too strong for your skin. They are also a good beginning step to starting your skin on a topical retinoid.

When choosing a drug store retinol product, check the ingredients list to make sure vitamin A is listed toward the top of the ingredients list. Also, in terms of packaging, look for an air-tight bottle that keeps the light out (exposure to light makes the products less stable and effective and more susceptible to bacteria growth.)

Other skin tips:

  • Reduce your skin’s exposure to hot-hot water.
  • Add a humidifier to rooms where you spend a lot of time.
  • Use an emollient (thick) cream to counter peeling and cracking skin.
  • Always wear sunscreen.

-Jodi

Active? Watch out for a mucocele

Question:  Help – what is this bluish, clear very noticeable round lump on my lower lip?

Answer:  I had a young patient come into the office this week with just that:  A clear, bluish-tinted  bump on her lower lip. It was more than just a “fat lip.” I immediately suspected a mucocele because of the bluish tint, roundness and the lower lip placement, so I asked the mom if her daughter had hit or bumped her lip in some way. Yes, she had been riding her bike and fell, hitting that portion of her lip against her teeth. But a mucocele is not just a child’s occurrence…it can happen to anyone who bumps their lower lip on anything which can be common in active adults when skiing, kayaking, climbing, mountain biking or other activities.

Any face-first fall can cause a mucocele

Any face-first fall can cause a mucocele

Luckily, a mucocele is easy to treat.  Usually, just one soft, round, painless lesion (lump) appears noticeably on the lower lip, which may be anywhere from 2-10 mm in diameter. It may look clear or bluish and the bluish tint represents a bruising to the mucous duct from the trauma.  The exact cause of the lump is a rupture of a minor salivary (mucous) duct, which causes a leaking of mucous into cystic spaces combined with inflammation from the trauma.

As new connective tissue is formed, scarring may form. That’s why I always drain the mucocele (cyst) of its excess fluid to allow the healing process to begin before any more damage to surrounding tissue occurs. A quick, tiny incision to the cyst releases the thick fluid. If scar tissue forms we may treat it using cryotherapy (freezing) or a laser resurfacing treatment.

I also recommend rinsing the mouth thoroughly with a mixture of one tablespoon of salt to one cup of warm water four to six times per day to help it heal.

A cyst like this can occur elsewhere in your mouth. Musicians who play wind instruments may develop a mucocele opposite the upper second molar on the inside of the cheek (called the buccal mucosa) from the repeated pressure on the mucous duct there.

A mucocele can also form anywhere in the mouth when there is a true blockage of a salivary duct (which may turn painful), so always see a dermatologist or dentist immediately if you see or feel a bump in your mouth.

-Jodi

What to do about an inflamed, raised, hard scar

Question: I had an injury to my shoulder earlier this year and while the wound has mostly healed and is no longer scabby, the resulting scar is still painful, raised, hard and lumpy. It’s bigger and uglier than the original wound. What can I do?

Answer: There are two types of scars that resemble what you describe and there’s a lot we can do in the dermatologists office to help them look and feel better.

Keloid scar

Keloid scar

Keloids and Hypertrophic Scars

This type of scarring is usually after local skin trauma (e.g., laceration, tattoo, burn, vaccination or surgery) or as a result of an inflammatory skin disorder (e.g., acne, bites or abscesses).

Scars are composed of new connective tissue that replaces lost tissue in the dermis or deeper parts of the skin, as a result of injury. Their size and shape are determined by the form of the previous wound. The process of scarring is characteristic of certain inflammatory processes. A resulting scar can be thin (atrophic) or thickened, fibrous and overgrown. Some individuals and some areas of the body (e.g., anterior chest) are especially prone to scarring. Scars may be smooth or rough, pliable or firm, they can be pink or violaceous or become white. They can also be hyperpigmented (darkened). Scars are persistent and normally become less noticeable in the course of time.

At times though, and in certain anatomical locations (e.g., shoulders, sternum, mandible and arms) they can grow thick, tough and corded forming a hypertrophic scar or keloid. Under normal circumstances,  wound healing takes place through the rapid and repeated reproduction of fibroblasts (the most common cells of connective tissue) at the wound site. But when fibroblast activity continues unchecked and excessive collagen (protein found in connective tissue) is deposited at the site of injury, the scar gets too big and a hypertrophic scar or keloid is formed.

Hypertrophic Scar remains confined to the borders of the original wound and most of the time, retains its shape. It is characterized by hardness, redness and irritation compared to the surrounding skin and can take the form of a firm papule or nodule.

Conversely, a Keloid is an overgrowth of dense fibrous tissue that you’ll notice extending beyond the borders of the original wound. Like a hypertrophic scar, a keloid can be hardened, raised and often darkly discolored. Keloids do not regress, appear to get better or shrink over time on their own. Instead they grow in a pseudo tumor fashion and distort the size and shape of the original lesion.

If you know you have a hereditary predisposition toward keloid scarring, mention that to your dermatologist because then we will not try to surgically remove them (called excision) because keloids tend to recur.

The differences… A hypertrophic scar can occur at an any age and usually stays within the borders of the original wound, whereas a keloid commonly occurs in the third decade and enlarges beyond the area of the initial wounding with web-like extensions. Keloidal growth can also be triggered by pregnancy and compared with hypertrophic scars, a keloid can often be painful and super-sensitive.

How we treat stubborn keloids and hypertrophic scarring

We often use a 3-step process in the office to attack raised, hardened scars as soon as we notice a scar is exhibiting signs of hardening, as early as one month-post op, in the case of a scar due to surgery.  The earlier you treat a keloid or hypertrophic scar, the better your results will be.

We inject  5-fluorouracil “5-FU” (used primarily as an anti-cancer drug but also used for the prevention of scars in glaucoma surgery for at least 15 years) combined with a specific low-dose corticosteroid (to reduce further inflammation and any pain) along with Pulsed Dye Laser treatments.

5-FU works to reduce skin’s metabolism rate and inhibits the over-production of the fibroblasts building up on and around the wound. We combine that with Kenalog (triamcinolone), the low-dose corticosteroid, and perform injections one to three times per week, at regular intervals such as Monday, Wednesday and Friday, depending on how red, hardened and inflamed the scar is.  Once the scar softens, injections can be reduced to two times per week, once a week and then every other week, monthly and finally, every six months. The Pulsed Dye Laser is used to decrease any redness, to normalize the wound surface and improve skin texture at the scar and to further blend scar into surrounding skin and we perform those treatments in intervals of four to eight months apart.

While any keloid or hypertrophic scar can be treated with this technique,  you’ll get the best results the younger the scar is. The more inflamed and symptomatic the scar, the better the response to treatment. Older scars that have been hardened for many years and are not inflamed, red, itchy or painful, will not respond as quickly or as thoroughly. Hypertrophic scars respond better than keloids, which frequently recur, although small isolated keloids (less than 2 cm in diameter) usually completely resolve with this technique without recurrence.

No matter what, keep all scars out of the sun for best healing, at least until the “pink” of new skin is gone because exposure to the sun only makes scars darker.

-Jodi

 

 

 

 

 

 

 

If you get a sore or scar on your scalp does it always cause permanent hair loss?

Question:  I’ve noticed more hair fall out than usual recently, so, upon looking at my scalp and feeling around more closely, I’ve found several different areas with  around my scalp where there is no hair. Some areas of hair loss feel smooth with no hair in them and some are sensitive and painful, as if a sore is there or has healed. HELP!

Answer:  Clinically, we call that cicatricial alopecia which is the medical term for hair loss due to scarring.

Once a sore has formed the hair follicle may be damaged and hair falls out. Once a scar is formed, hair will usually not grow again and hair loss will be permanent, called scarring alopecia.

Sores, inflammation and scars on the scalp for any reason can cause hair follicles to die, and resulting hair loss can be permanent!

Since scars, sores or inflammation  occur due to many different causes, you should head directly to your dermatologist so you can have your scalp examined and a diagnosis made. The sooner you figure out the the source, the sooner you can begin treatment to cure any lesions (sores) so they don’t scar and cause permanent hair loss. Once  hair loss occurs, hair does not usually grow back because the scar tissue has killed the hair follicle.

How we diagnose cicatrical alopecia, or scarring alopecia

It’s a process that starts with many questions. We will ask you about any recent illnesses, injuries, allergies, your lifestyle, medications and your haircare regimen. We will closely examine your scalp using a magnifying glass and a special light to determine if the lesions have bacterial or fungal causes. We will feel your entire scalp and any lesions feeling for inflammation, sores or scales to determine the exact nature of the lesions and how they appear at different stages and locations. We will also document any hair loss that has occurred and take pictures for future reference. Often, we will take a biopsy of the sore or scarred area to determine the exact cause (if bacterial or fungal) and also to examine the health of the hair follicles to ascertain the severity of the condition. (We use a 4mm punch biopsy to provide an adequate specimen from an active lesion. Sometimes we will also take another sample from an unscarred area.)

inflamed, causing hair loss

inflamed, causing hair loss

Any type of scalp reaction or injury resulting in a lesion that causes a scar can cause death to the hair follicles and permanent hair loss and we call that scarring alopecia. Lesions that cause scars and hair loss can be caused by any of the following conditions and diseases:

UNKNOWN ORIGIN & AUTOIMMUNE

  • Discoid lupus erythematosus (DLE):  A chronic skin condition characterized by inflamed sores that begin as  a red, inflamed patch with a scaly and/or crusty look and feel. The patches leave noticeably discolored, raised scars. Hair follicles are damaged first by the sores and then the resulting scar tissue causes permanent hair loss.
  • Lichen planopilaris: Also called follicular lichen planus, this a rare inflammatory condition results in patchy progressive permanent hair loss. Initially you may notice some small or spiny red bumps around involved follicles which may or may not be itchy. This eventually forms larger reddish lesions (resembling a lichen pattern) and scar tissue which damages hair follicles and causes hair to fall out and not grow back. Additionally, Frontal Fibrosing Alopecia appears to be a variant of lichen planopilaris. This occurs in mostly older women and appears in a band-like pattern in the frontal and temporal areas of the scalp. Often, a patient’s eyebrows are also affected.
  • Sarcoidosis: This disease, also with unknown origin,  causes collections of mixed inflammatory cells (granulomas) which form lesions resulting in scarring at many different parts of the body, including the scalp.

FUNGAL

  • Seborrheic dermatitis:  We believe this condition is an inflammatory reaction related to an over-abundance of a normal  yeast species  found on the scalp called M. globosa. It produces toxic substances that irritate the scalp causing a scaly rash.
  • Ringworm (tinea capitis): On the scalp, this common fungal infection characterized by itchy red rings can result in scaling and hair loss  in children, and can progress to folliculitis, too (see below).

BACTERIAL

  • Folliculitis decalvans: Simple folliculitis is any bacterial infection of the hair follicles. But when hair loss is caused by  redness, swelling and pustules surrounding hair follicles that appears to be spreading, it is called folliculitis decalvans. Another type of scarring alopecia, hairs shed as follicles are completely destroyed by the inflammation. A resulting scar is left behind where hair will no longer grow.  Simple folliculitis (one sore) can stem  from a bug bite or a scratch and flare-up or spread if infected with the bacteria Staphylococcus Aureus but recently we have found Methicillin Resistant Staphylococcus Aureus (MRSA) in some lesions and boils, so we always want to take a culture in any open lesions on the scalp, especially those that are spreading. In additiona variant of folliculitis decalvans occurs in African Americans who present with ingrown hairs of the beard (pseudofolliculitis), acne keloidalis (a destructive folliculitis of the back of the scalp) and scarring alopecia.

TRAUMA

  • Central Centrifugal Cicatricial Alopecia (CCCA): Usually seen in African American women, this type of scarring alopecia usually develops on the crown and spreads peripherally to form a large oval of hair loss on the scalp. Originally, this type of hair loss was thought to be caused by hair straightening with a hot comb or due to the hot petrolatum used with the iron; however, was also found to take place in patients without the use of hot combs or straightening methods.

How we aggressively treat lesions that cause scars…

permanent scars & hair loss

permanent scars & hair loss

Once we know what may be causing the lesions, we can treat them to minimize spreading, scarring and any resulting hair loss, using any of the following treatments or combinations of treatments:  

  • Oral and intra-lesional steroids
  • Topical corticosteroids
  • Oral retinoids (isotretinoin)
  • Antimalarials (hydroxychloroquine)
  • Antibiotics (tetracycline, doxycycline, minocycline)
  • Antifungals (itraconazole)
  • pioglitazone
  • Immunosuppressants (cyclosporine, mycophenolate mofetil)
  • DHT blockers (dutasteride internally and minxoidil topically to -induce hair growth if follicles are alive.)

I have found that most patients experience hair loss very gradually (and cannot see the back and top of their head) and the prolonged course of the disease may cause a lack of necessary action. You need to know that the progressive destruction of hairs will result in ever-expanding areas of permanent hair loss.  So, no matter what, go see a dermatologist as soon as you feel any sores, pimples, pustules, pain, itchiness, scaliness or inflammation on your scalp, whether or not they have already caused hair loss, because they need to be treated ASAP and aggressively as possible.

-Jodi

 

Can babies go in the sun?

Question:  I’ve heard conflicting opinions about what age babies can go in the sun. Is there a sun exposure rule for healthy skin for babies?

Always have baby wear a had to shade her face in addition to sunscreen in babies over 6 months

Always have babies over 6 months in age wear a hat plus sunscreen and other protective clothing

Answer:  I  second the advice of the The American Academy of Pediatrics, the U.S. Food and Drug Administration and the American Cancer Society: Keep babies under 6 months old out of the sun entirely and do not apply sunscreen on babies younger than 6 months.  Babies who are 6 months or older should be protected with clothing, hats, a broad-spectrum sunscreen and shade. Look for broad-spectrum formulations specifically for babies and toddlers who have more sensitive skin than adults. The time that they spend in the sun should be very limited.

Did you know? More than half of a person’s lifetime sun exposure occurs before age 20. Remember, skin keeps impeccable records, so every minute spent in the sun adds up as skin damage and possibly skin cancer. More than one million Americans develop skin cancer every year mostly from long-term exposure to ultraviolet radiation from the sun.

UV exposure makes you look old before your time and causes:

• Wrinkling

• Blotching

• Drying

• Leathering of the skin

Beginning with babies 6 months and older, limit time in the sun and protect skin with sunscreen and protective hats and clothing whenever exposed.

-Jodi

What good is coconut oil for hair and skin?

Question: I’ve been reading more and more about using coconut oil for hair and skin. Do you think this is a good idea? Can you tell me how to buy coconut oil and how to use it properly?

As a solid its an ointment or balm, warmed to a liquid a liquid its a moisturizing, conditioning oil

As a solid, its an ointment or balm, warmed to a liquid, its a moisturizing, conditioning oil

Answer: I love coconut oil as an added treat for hair and skin (as long as you are not allergic to nuts or coconut). But, I only recommend buying organic unrefined expeller-pressed virgin coconut oil (also called VCO).

I think VCO is a great addition to any hair and skin routine because:

  • It has no preservatives, additives, or color.
  • It’s available at any local health food store or online.
  • It’s affordable at $9 for a small 14 oz. jar.
  • It’s a multi-use beauty product:  Coconut oil is  a solid (like butter) at room temperature and ideal as an ointment or lip balm, but if you place the jar in  warm water, it melts into a liquid oil perfect for massaging, baths, a moisturizer or a hair mask.
  • That smell is like being on a desert island (refined VCO  does not retain its natural coconut aroma).

The real beauty of VCO for skin and hair is its natural, molecular composition

Not only does VCO have a high saturated fat content-composed of 90% saturated triglycerides, but its low molecular weight and straight linear chain (called a medium-chain fatty acid, in contrast to other saturated fats comprised of long chain fatty acids which make them larger molecules), it is able to permeate the hair shaft  and skin surface rather than just sitting on top. That’s what makes it so effective. If you use it at room temperature (when it is solid) it is the perfect ointment to relieve dehydrated, chapped, scaly and itchy skin and it can even improve symptoms of psoriasis and excema.

The medical literature supports my own observations of VCO as a healthful skin conditioner and moisturizer. Studies have shown that  VCO use may improve skin barrier function (protecting skin from bacteria and fungal intrusion) and  decrease trans-epidermal water loss (skin’s ability to retain moisture). Animal studies have shown that coconut oil use can improve wound healing and increase collagen production, too.

For hair, in addition to its high absorbability, VCO contains a high percentage of the saturated fat, lauric acid, which also is highly attracted to the protein in hair. Because VCO actually absorbs through the hair shaft, it has positive effects on the strength of hair while it prevents hair damage and protein loss from styling, brushing and even chemical treatments.

 A little coconut oil on your skin and hair goes a long way:

  • As a daily body moisturizer, after shower or bath
  • As a bath oil
  • As a skin exfoliator for skin and to help control dandruff in hair
  • As a cuticle conditioner
  • As a lip balm
  • As an intensive hair mask, from scalp to ends
  • As a scalp or body massage oil

Coconut oil can be greasy if applied too heavily, but don’t worry, it absorbs in a few minutes leaving behind that beachy smell and softer, healthier, smoother skin.

It can be applied on wet or dry skin. But only apply to dry hair because water limits the VCO from coating the hair properly and permeating the hair shaft. To remove VCO from hair, do not wet first. Simply lather up shampoo in your hands and apply directly and completely over hair and scalp, from roots to ends, then rinse thoroughly.

VCO can be applied in the same way to children and adults. Just be sure that you don’t use coconut oil at all if you are allergic to nuts or to coconut.

Have you tried virgin coconut oil yet? What’s your favorite way to use it?

-Jodi

 

Should I be using a retinoid?

Question:  As I’ve moved through my thirties and into my forties, I’ve noticed a marked change in my facial skin. I have some dark spots and discolorations and my face seems thinner overall and a little more sallow. I’ve heard about using a Retin-A cream but I thought that is for acne or wrinkles. Is it for me?

Answer:  Actually Retin A is not just for acne or wrinkles. It is a simple, inexpensive topical cure-all for all pre-mature aging and photo-aging (skin damage caused by sun exposure).

shutterstock_149722304

How your skin looks and feels as you age is influenced by many factors such as genetics, environmental exposure (sun, medication, mechanical stress), hormonal changes and metabolic processes. All of these factors, some of which have to do with your lifestyle and some  you have no control over, cause a change in skin structure, function, and appearance as you age. Although, we dermatologists have studied and seen first-hand that solar UV radiation (sun exposure) is the single major factor responsible for  the unwelcome, premature  effects of skin aging on face, neck or back of  hands such as:

  • Coarser, rougher skin feel and appearance
  • Sallowness
  • Wrinkles
  • Irregular coloration and discolored spots or patches
  • Discolored brown spots called lentigines
  • Telangiectasias (little red visible blood vessels)
  • Benign neoplasms (abnormal, yet non-cancerous, masses of discolored or raised tissue)
  • Pre-cancerous lesions called actinic keratoses and lentigo maligna
  • Cancerous lesions such as basal and squamous cell carcinomas and malignant melanomas.

So, what’s a “retinoid?”

First, a little science lesson.  You may hear or read about a lot of terms that all have “retin” in them. That’s because the retinoid family comprises vitamin A (retinol) and its natural derivatives such as retinaldehyde, retinoic acid and retinyl esters, plus many other synthetic derivatives. Vitamin A cannot be synthesized by our bodies, so it needs to be supplied and is naturally present in foods as the compound beta-carotene. Retinoids are required for a vast number of biological processes inside the body such as embryo development, reproduction, vision, growth, inflammation and cell differentiation, proliferation and apoptosis (naturally occurring cell death for normal cell growth stages).

Retin-A (tretinoin) is the most popular retinoid for facial skin and is also the retinoid most studied for the treatment of chronological or photo-aging. I have tracked numerous studies which have repeatedly shown clinical improvement in photo-damage with tretinoin treatment, as well as with some other topically applied retinols such as isotretinoin and retinaldehyde (which are not my favorites because they are not as potent or stable.) Longer-term studies (6-12 months) on tretinoin were carried out once short-term studies showed that patients’ skin condition continued to improve in appearance over time. Additionally, most of these studies compared the use of the various strengths of tretinoin to arrive at the optimal concentration for the treatment of skin aging.

How do retinoids work?

Retinoids are known to speed up the cellular processes such as cellular growth and differentiation. Retinoids work on the skin surface by prompting surface skin cells to grow and die quicker and slough off faster, making way for new cell growth underneath. In this way, they cause discolorations and spots to lighten and they hamper the breakdown of collagen and thicken the deeper layer of skin where wrinkles start.

Interestingly, current studies have found that the mechanism by which collagen and elastin are lost after skin is exposed to UV radiation may be blocked when topical tretinoin is applied before sun exposure. More studies are ongoing.

What about side effects?

The most common and frequent adverse effect of topical retinoids is called the “retinoid reaction” which you may or may not experience as burning, peeling, reddened or inflamed skin at the sites of application or in skin folds such as around the nose or lips where additional product might be deposited by accident. It’s this reddening and peeling that occurs within the first two weeks of use which cause many patients to give up therapy before realizing any of the benefits which can take two to three months or longer to see and feel. What most people don’t know (or wait for) is that the skin builds up tolerance to the retinoid treatment and side effects eventually subside. Also, you can reduce application amount and days or try a lower potency formula to start if you experience these side effects. The most important factor in success with tretinoin is to follow the entire course of treatment not to give up!

The other side effect associated with tretinoin therapy is photo-sensitization (you will be more sensitive to the sun’s rays and burn easier), which normally occurs at the beginning of treatment. I always advise patients on tretinoin therapy to avoid excessive sun exposure and use a broad-spectrum sunscreen of at least SPF 30 (and a hat).  Your skin’s response to UV radiation should also return to normal after a few months of treatment.

We love combination creams

I have found that the way to counter the side effects is to use a retinoid combination cream containing a corticosteroid to reduce inflammatory response and if discoloration or brown spots is one of your problems, you might want to add 4% hydroquinone (a known skin bleaching agent). We think that this combination may be even more effective than the individual components alone.

Has tretinoin worked for you? How long did it take?

 

UV rays and location, location, location…

Question:  Is it true that the sun’s UV rays are stronger in the South?

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That big line on the globe is the equator – Do you live near it on either side?

Answer: Yes, this is true. The closer your location is  to the equator (the line that is equally distant from the South Pole and the North Pole which also separates the Northern Hemisphere from the Southern Hemisphere on a map or globe), the more potent the sun’s rays. This is because they hit the earth more directly for a greater part of the year which accounts for the higher skin cancer rates in  “sun belt” locations. People who live or vacation in the Southern United States  or in Central and parts of South America and Africa should be especially aware and diligant of the need for sunscreen, hats and protective clothing and eye glasses whenever outside.

You may see lots of tanner people in these locations and that’s because they are exposed so much more to the UV rays from the sun. Remember, there is no such thing as a healthy tan (no matter what society would lead us to believe) because tanning is the skin’s response to the sun’s damaging rays.

If you’re unsure how close you are to the equator, check this global equator map.

-Jodi