Over-the-Counter Treatments for Acne

By Melissa Sanoff-Wiener, RPA-C

Even before humans could write, they were trying to get rid of their acne, and ancient Egyptians’ first notes on papyrus referenced pharaohs with problem skin. In the U.S., acne is the most common skin condition there is. Fortunately, we’ve come a long way since ancient times: We understand the processes in play, and we have effective treatments.

According to the American Academy of Dermatology, as many as 40 to 50 million people in the United States have some level of acne at any one time, the result of factors including hormones, genetics, and stress. People often deem pimples a rite of passage for teens. But people of all ages can get acne.

The term itself refers to the skin bacteria p. acnes, which can contribute to the formation of pimples, nodules, and cysts. Our skin is designed to regenerate and expel old cells as new cells form. But if our skin produces too much oil, called ‘sebum,’ it can cause pores to get clogged, trapping dead cells beneath the surface and triggering pimples. If surface bacteria also gets trapped, it can cause more severe acne in the form of nodules and cysts.

Acne can carry significant social and psychological tolls, particularly for adolescents. It’s important that patients and their families realize that acne can be successfully controlled, and that for less severe acne, there are a number of different products patients can buy without a prescription.

5 Tips Regarding OTC Acne Treatment:

1. Apply products that limit troublesome bacteria: A number of products limit the overgrowth of p. acnes. For regular widespread application, benzoyl peroxide can be used, while sulfur-based products can be used for more targeted treatment, both to control bacteria and unclog pores.

2. Use products that address clogged pores: These include topical medications with alpha hydroxy acids (AHAs), salicylic acid, or retinol, as well as mechanical exfoliants, such as cleansing cloths.

3. Consider a combination approach: Some products work well together. For example, patients can use exfoliating towelettes with benzoyl peroxide to address the dual causes of acne.

4. Don’t over do it: Patients want acne to clear up fast. Unfortunately, that’s not how OTC products work. It may take up to eight weeks for pimples to begin to clear. In the meantime, patients need patience. Overuse of products can increase skin inflammation and irritation. Scrubbing and overwashing can trigger the production of more skin oil, making the situation worse. In terms of the products themselves, higher strengths don’t necessarily work better: benzoyl peroxide products with concentrations of more than 2.5 percent, for example, may be too strong. And harsh scrubs can be overly irritating. Using gentle cleansers and following product directions offer the best possibility for clearing skin.

5. For more severe acne, consider seeing a dermatologist: We classify acne on a scale of 1 to 4 in severity. For patients whose acne does not respond to OTC products or is more severe – for example, if their skin develops nodules or cysts – a dermatologist can customize a treatment plan. We have a range of very effective techniques, from prescription medications to outpatient procedures, to help patients recover from and prevent more serious breakouts, as well as ward off after-effects like scarring.

The fact that acne is so common doesn’t mean patients should just live with it. There is no reason for patients to suffer from the discomfort or social anxiety that acne can cause. Their drugstore and skin care experts can offer reliable treatments.

Managing the Skin-Whitening Condition Vitiligo

By Dr. Hirshel Kahn

Winnie Harlow’s striking appearance regularly turns heads. The fan-fave from America’s Next Top Model – face of the Spanish fashion brand Desigual – has more than one million Instagram followers. This embrace was impossible for Harlow to imagine when she was younger – and left high school to escape peer torment over her unusual appearance: vividly contrasting dark and light patches of skin covering her body, the result of the skin condition vitiligo. Vitiligo usually does not cause physical harm. That said, the emotional toll can be quite severe.

Researchers are still working to unravel the genetic mystery of vitiligo, which causes patients to lose melanocyte skin cells. Melanocytes produce the pigment that gives skin its color. Without them, our skin is white.

According to the Vitiligo Research Foundation, as many as two percent of the world’s population suffers from the condition, with most experiencing what is known as “nonsegmental” or “generalized” vitiligo, where patches of skin on both sides of the body lose pigment, often in a symmetrical pattern. Vitiligo is not contagious. With nonsegmental vitiligo, an autoimmune response appears to be at work, with the body destroying its own melanocytes. Family history seems to be a risk factor, but many patients do not have relatives with the condition.

For patients, part of the challenge of coping with vitiligo is its unpredictability: The condition typically appears without warning, with about half of patients developing symptoms by the time they’re 21, according to the American Academy of Dermatology. After its onset, start-and-stop skin whitening episodes can take place without warning.

Ongoing research may provide the key to preventing the skin’s loss of pigment cells.

5 Recommendations for Managing Vitiligo

1. See a doctor as soon as you suspect vitiligo: In almost all cases vitiligo is not going to clear up. In fact, just the opposite. Once a patient sees skin color fading, they should consult a doctor. If it is vitiligo, they should be evaluated to make sure that other autoimmune diseases are not present and to ensure that their eyes are not affected. Also – importantly – early intervention can be crucial to empowering the patient to manage the condition and make informed choices.

2. Create an individualized treatment plan: Most current treatments focus on adding color to whitened skin. Approaches range from non-invasive cosmetics and dyes to steroidal creams, immunosuppressives (in topical or pill form), UVA light therapy, and laser therapy. There is also emerging use of surgery to introduce new melanocyte cells into affected areas of the skin. In some cases, a combination of therapies is used. Patients who want to minimize the appearance of vitiligo should partner with their doctor to create a treatment plan that will best meet their needs. Treatment involves several factors: Location and extent of the pigment loss, the patient’s tolerance for side effects, and time constraints.

3. Choose your doctor carefully: There is exciting research being done, for example, potential surgical approaches to repigmentation, as well as an increased genetic understanding that may pave the way for preventing loss of melanocytes. Patients will want to have a doctor who stays current regarding breakthroughs that may benefit them.

4. Maintain realistic expectations: Most treatments take time, e.g. steroidal creams usually take at least three months before effects are seen and light therapies require long-term sessions. Also, even successful treatments may fade. Patients should have a very clear understanding of what the treatment involves and what the outcome may be.

5. Pay attention to emotional needs: Many vitiligo patients suffer low self-esteem, social anxiety, and depression. Our emotional wellbeing is intrinsic to our overall health. Patients need doctors that are emotionally supportive and can provide referrals to adjunctive therapies. Online support groups such as Vitiligo Support International and Vitiligo Friends can provide a community, as well as a source for ongoing developments.

Early intervention and forming a partnership with one’s doctor are essential steps to managing the challenge of vitiligo.

Hirshel Kahn, M.D., is board certified and specializes in dermatology at Advanced Dermatology P.C.

Do Not Resuscitate Tattoo Dilemma:

A critically ill and unconscious 70 year old male patient arrived in a Florida emergency room in December of 2017 with a tattoo across his chest that read, “Do Not Resuscitate” with his apparent signature.

The patient did not carry an identification so the hospital officials were unable to contact any family members to see if he previously had made a formal do not resuscitate request.

The hospital was unsure what to do in such a situation. They could not contact anybody to see if he had an existing do not resuscitate request, but on the other hand, it would seem that the patient was trying to make it clear that he in fact did not want to be resuscitated.

In the end, the ethics committee decided to honor the dying man’s tattoo request. Their reasoning was that the tattoo was an expression of authentic preference. Later, social workers found the patient’s “out-of-hospital” do not resuscitate order from Florida’s Department of Health.

This case emphasizes the difficulty in and complexity of a patient’s last dying wishes. Perhaps the patient had regrets over his tattoo choice, which is not uncommon. Therefore, he may have changed his mind later on and no one would know.

There was a case in 2012 regarding a 59 year old patient with multiple conditions who was admitted to the hospital for a lower knee amputation. Across his chest there was a tattoo that read “DNR.” In his personal information, he made it clear that in fact he would like to be resuscitated, if need be. When inquired about his “DNR” tattoo, he said that when he was younger, he was playing poker with some friends. They made a bet that whoever lost would have the letters “DNR” tattooed across his chest, regardless if this was what the individual wanted. Therefore, because he lost, he was the recipient of the “DNR” tattoo. He did not think that his tattoo would be taken seriously and did not proceed to have the tattoo removed, even though he was advised to by hospital personnel.

Kerry Bowman from the University of Toronto said that if the decision had been up to her to decide whether to respect the dying man’s tattoo wish of “Do Not Resuscitate” or not, she would respect the wish. Her reasoning is that a person would have to go to great means to make their wish clear and obvious to anybody.

Do not resuscitate forms are not always readily available and “a standard tattoo may be a readily accessible method for communicating a strongly help care preference,” stated associate professor Melissa Garrido at Icahn School of Medicine at Mt. Sinai in New York City.

At Advanced Dermatology P.C., we offer a wide variety of laser treatments for tattoos. Sometimes people want their tattoos lightened for the purposes of having a new tattoo designed onto that same area. Other people want their tattoos completely removed for multiple reasons. There are individuals whose tattoos do not respond to laser treatment. At Advanced Dermatology P.C., we have lasers such as Pico, Cynosure, Versipulse, and Medlight which help remove tattoos, even those which did not respond well to their first laser treatment.

Scar Wars: Winning the Battle Against Keloids

By Dr. Joshua Fox

Time may heal the wound, but – for some of us – the scar that is left behind will not fade. When it comes to keloid scars, the opposite happens. These scars expand beyond the initial wound site. Their appearance can be a big problem, and they also can cause, pain, discomfort and limit movement.

In normal cases, our body creates a scar to heal from a wound. But in the case of keloid scars, our body fails to turn off its cellular skin-repair processes. As a result, there is an overgrowth: shiny pink skin-colored or purple flesh that bubbles up, above and beyond the wound’s boundary. We’re still learning about the biological misfire that causes this uncontrolled growth.

In general, about ten percent of us are keloid prone, but those with darker skin are more susceptible, with as many as fifteen percent developing keloids. Genetics plays a role: Fifty percent of sufferers share the condition with other family members. Age is also a factor, with most patients developing the scars during their teens and 20s, often when they are actively growing. Pregnant women and athletes also seem to be more susceptible to this malady.

Keloids can be triggered by minimal skin damage: an injection, a piercing, a tattoo. The scar overgrowth may take place long after the initial wound has healed and may continue to grow over a period of time. They generally do not resolve on their own.

Keloids themselves are benign. But their appearance can be distressing and deforming. Also, they may be itchy, painful, and sensitive. And depending on their size and location, they may inhibit movement.

Because these scars are prone to reoccur if cut out, keloids present a complex dermatologic challenge. We need to help patients navigate the maze of treatment options so they feel empowered to make effective choices.

6 Recommendations Regarding Keloid Scars

1. Remain aware of how keloids form: Most keloid scars are triggered by some kind of skin damage. This is really important in terms of understanding treatment plans – and also regarding other life choices, like decisions about whether to get a piercing or a tattoo, for a person prone to this problem.

2. Take time to consider options: There are a range of treatments including lasers, steroidal and chemical injections, freezing procedures, and radiation techniques. It’s vital for patients to work with their doctors to understand which will be most effective for their own situation. Whether the scar is early- or late-stage, its size and location are all factors in customizing the most effective treatment plan. The treatment therapy also depends if they just want to eliminate the pain and itching, or if they want to completely remove the appearance of the keloid.

3. Understand the role of combination treatments: A combination of treatments can minimize the existing scar and also limit subsequent regrowth. Steroidal injections, for example, are often combined with cryotherapy, which applies freezing temperatures to minimize the scar. We may also add a cocktail to the injections including various types of steroids, anesthetics, and immunosuppressants to improve the results. And if surgery is warranted, additional treatment to prevent regrowth is required. The great effectiveness of pairing surgical removal with superficial radiation therapy.

4. Stay alert for treatment advances, such as Cryoshape™: The ‘Cryoshape™’ procedure involves freezing a keloid scar from the inside. This causes the scar tissue to die and eventually fall off. Also – importantly – the internal freezing appears to destroy abnormal keloid cells and inhibit regrowth. We’re seeing really good results. There are also new topical treatments many of which include silicone in either a liquid or patch form. Pressure and massage may also have a role in treatment.

5. Choose your doctor carefully: If not treated properly patients can end up with additional scarring or with a series of frustrating outcomes. Also, since research is ongoing and new treatments are emerging, it’s important that your doctor is on top of the most current techniques.

6. Take preventative steps to avoid additional scars: Keloid-prone patients should avoid unnecessary skin damage, like piercings and tattoos. If surgery is needed, patients should work with their doctor on a post-op plan to minimize scarring. In the case of skin injuries, the American Academy of Dermatology web site includes a list of self-care steps that can limit keloids.

The good news is our growing understanding of keloids is giving us improved techniques to help patients.

Joshua L. Fox, M.D., F.A.A.D., Medical Director at Advanced Dermatology PC. He is board certified and specializes in skin cancer, cosmetic surgery, and laser procedures.

Getting the Red Out: Addressing the Appearance of Broken Blood Vessels

By Dr. Lance Barazani

Over time, what may have started out as an “itsy bitsy” spider vein can become a real concern. We call them ‘spider veins’ because of their web-like appearance. But really they’re ‘broken’ blood vessels: veins that are not properly returning blood to our heart. They can be unsightly and – in some cases – indicate a medical problem.

Age is one risk factor for spider veins, which are sometimes referred to as “telangiectasias.” As we get older, so do our veins, which are the tubes that bring blood back to our heart for a refill of oxygen to be delivered to the rest of our body. Our veins have valves to make sure that blood continues to flow to the heart. If those valves don’t work well, blood backs up, causing spider veins and, in more severe cases, varicose veins.

Genetics, injury and disease, sun exposure, hormones, diet, and prolonged sitting or standing can also contribute to spider veins. As a result, the American Society for Dermatologic Surgery reports that most of us will see some level of vein breakdown during our lifetimes. Women are more susceptible due to hormones: Regardless of age, forty percent experience vein issues, with four out of five women having problems by age 80.

Spider veins usually appear on patients’ legs and faces, which can cause significant cosmetic concerns. In addition, though infrequent, spider veins can be a sign of circulatory problems that require medical treatment.

5 Tips to Address Spider Veins

1. Start with a thorough medical examination: Especially for treating leg veins, it’s important that patients are carefully evaluated to make sure that the appearance of spider veins is not related to an underlying circulatory problem. Also, the doctor needs a comprehensive understanding of the nature and extent of the vein damage so that a tailored, effective approach can be used.

2. Legs or face? Location matters: The type of procedure that is used depends in part on where the veins are. In general, laser and light-based treatments are used for the face, where spider veins may appear as the result of conditions such as rosacea. For the legs, chemical injections – called sclerotherapy – are often used. Another more recent approach for spider veins on the legs is endovenous laser therapy (EVLT).

3. Choose your doctor carefully: Spider-vein procedures are generally minimally-invasive outpatient treatments, and the patient can usually expect to be back to their normal routine by the next day. That said, these procedures are surgeries, and the doctor’s knowledge and expertise are important for the best outcome.

4. Manage your expectations: Whether chemical or laser, spider-vein treatments work by disrupting the problem veins so that they eventually dissolve and disappear, with blood flow rerouted to fully functioning veins. But this takes time, usually at least three to six weeks. Also, it’s important that patients realize that more than one treatment may be needed to address the appearance of spider veins.

5. Take preventative steps after the procedure: Part of managing expectations, is understanding that treating spider veins will not prevent new ones. Patients should be aware of the steps they can take to support healthy veins: staying active, watching their weight, limiting sun exposure, avoiding hot baths, refraining from prolonged sitting or standing, wearing comfortable, non-restrictive clothes and, when possible, using compression hose.

Above all, it’s helpful for patients to know that while spider veins are inevitable for many of us, if they become disruptive, there are effective treatment options.

Lance Barazani, M.D., F.A.A.D., is board-certified in dermatology and specializes in all areas of medical dermatology for adults and children, the prevention and treatment of skin cancer, cosmetic dermatology and laser surgery. Dr. Barazani was recognized on New York Magazine’s list of top doctors for 2016 and has also received recognition as a Castle Connolly Top Doctor and a NY Top Doctor.