Botox, etc.

Before Botox

I injected some Botox today, and I have to say that I love the stuff. In many women (and more and more frequently men as well) it really softens the forehead lines and takes years off their appearance.

Botox works best on the forehead lines and does pretty well on the crow's feet around the eyes and on some of the fine lines around the mouth. Another place where I have had a lot of success is on the neck. Some people with a "stringy" appearance to their neck muscle (called the platysma) benefit from Botox to the neck. Dermatologists love injecting the neck because they get to bill for a lot of Botox.

After Botox

Although I love Botox in the right setting, it definitely has its limitations. It does not work very well on every wrinkle. Some of the lines around the nose (the nasolabial folds) and on the chin (the marionette lines) really need fillers not Botox.

As far as who can do your Botox, really almost any physician can smooth out a forehead effectively. Dermatologists and Plastic surgeons tend to be better at controlling complications and doing some of the subtler things with Botox, but I am biased, obviously, so take that with a grain of salt.

Does Pollution Age You?

I was reading an article in the Salt Lake Tribune on air pollution, and it reminded me of a groundbreaking article from Germany in the Journal of Investigative Dermatology from few months ago. Researchers found that there was an association of air pollution with signs of aging like brown spots and wrinkles. When researchers controlled for other things like smoking, sun exposure, weight, and hormone replacement, the association of pollution levels was particularly strong with development of brown lesions called lentigos. So maybe we should be avoiding pollution for our skin as well as our lungs. Here is a link to a nice summary of the pollution and aging article if you are interested.

Melanoma Developments

Melanoma is the most well known of the "bad" skin cancers. For decades the only proven treatment for melanoma was to cut it out when it was hopefully thin enough to metastasize, but now there is new evidence emerging that may eventually lead to improved ways of preventing the development before it ever develops. Additionally, two new treatments are promising for people whose melanomas were not found before spreading.

It is hard to believe, but good evidence that sunscreen prevents melanoma only emerged in the last year. Australian scientists gave some people sunscreen and told others to follow their normal sun practices. The people who wore sunscreen on a daily or near-daily basis developed 50% few melanomas than the people who used no other sunscreen.

Other interesting areas of prevention for melanoma include aspirin, ibuprofen and oral Vitamin D. Like with sunscreen use, people who took low-dose aspirin had half the melanoma risk of people who took a placebo. It is probably too early to say that people who take aspirin definitely have a lower risk, because this study was just the type that can establish an association, not a cause. We will probably have more clear recommendations in the next few years when the appropriate studies can be done.

The best treatment for melanoma is to catch it early and cut it out. If that does not work then some people get chemotherapy, but for decades the chemotherapy has been lousy, for lack of a better word. Two new medications, though, are bringing hope to people with advanced melanoma. One of the medicines, named ipilimumab, helps immune system cells "recognize" the melanoma. The other medication, vemurafenib, affects the melanoma cells directly by blocking an enzyme named BRAF (pronounced bee-raf), which makes the cells divide. Not all melanoma has that enzyme, but in the cancers that do, this medication has exciting potential. This is an exciting time to be treating patients with a disease that has been all but hopeless for my whole life.

Fillers: an introduction

Unfortunately, part of aging can include the loss of tissues of the skin and underneath the skin. When prevention with sunscreen was not enough one option for treating this type of aging includes fillers. The market for fillers has exploded in the last decade with new classes of fillers, each of which have strengths and weaknesses. Here are some thoughts on fillers:

1. Get fillers from a reputable dermatologist or plastic surgeon. Even a good filler in the wrong hands can cause problems including infection, lumps (called granulomas by dermatologists), and, of course, bad appearance. It is an unfortunate and not uncommon problem to see patients who had filler injections performed by poorly trained doctors with bad reactions like infection and granulomas. Some of the infections are easily treated by short courses of antibiotics but other infections with bacteria related to tuberculosis require years of treatment and/or surgical excision.

2. Different fillers are useful for different things (and have different risks). The materials commonly used to fill range from hyaluronic acid (a substance the body makes itself) to hydroxyapatite (one of the components of bone) to poly-L-lactic acid (basically liquid stitches like we would use as physicians). There are many other types of fillers, and there are things like silicone I do not think should ever be injected into skin for health reasons.

3. In skilled hands there are many possibilities with each of the fillers, and there is no single "best filler" for everything. In discussion with your dermatologist you can make a plan that fits your needs. In a nutshell, some of the hyaluronic acid fillers last not quite as long as the poly-L-lactic acid filler or the hydroxyapatite filler, but the body may be less likely to have a reaction to it. Also, there is an antidote—albeit an imperfect one—to hyaluronic acid fillers in case you do not like the results.



To summarize, if you think you are interested in a filler, talk to a dermatologist or plastic surgeon. Some doctors are more comfortable using some fillers over others. Steer clear of any doctor that offers you a "permanent" filler, or whose training is in question. In the right hands and for the right patient, however, fillers can enhance beauty and take away years of age.

What is Photoaging?

Believe it or not, the vast majority of the skin's changes related to aging are caused by the sun. The sun causes fine wrinkling like the "crow's feet" seen in this gentleman on the right. Wrinkling caused by the sun can range from lines seen only when the face is in motion to wrinkles seen at rest. Sun damage can culminate in normal smooth skin being completely replaced by wrinkles.

So how does the sun cause wrinkles? Ultraviolet-A but not ultraviolet-B light penetrates deep into the second layer of skin called the dermis, where it destroys the collagen and elastic fibers.

In addition to wrinkling, the sun is responsible for many of the pigment changes that come with aging. Most of these are called lentigos by dermatologists but are more commonly called liver spots. They range from light brown and small to large and quite dark. Rarely a lentigo can become cancerous requiring removal so if you havea brown lesion with multiple colors or enlarging or you have other concerns, see a dermatologist.

Another significant contributor to aging is the loss of fat under the skin. Some of this is due to the sun, but it can also be a part of "normal" aging. Interestingly, people with some conditions like diabetes tend to retain more of their fat under their skin later in life and it can help them appear younger than many of their non-diabetic counterparts.

So these are the basic types of aging, and they can each be treated. I will discuss treatments in detail in future posts, but in a nutshell there are many ways to treat all of them, but an ounce of prevention is worth a pound of cure so put on that sunscreen.

Have a great 4th of July!

Itch Without a Rash

Itch is an incredibly complicated, uncomfortable symptom felt by all of us at one time or another. Often it is associated with a rash like eczema or a fungal infection, but sometimes people get incredibly itchy with no rash at all.

Itch without rash is a challenging diagnosis for many dermatologists. The vast majority of the time itchy patients with no rash have nothing serious wrong with them other than some minor dry skin (what we call xerosis), which is a very common problem in patients in their fifties and older. If the skin looks dry at all I will often recommend a lukewarm, short shower twice a day followed by liberal application of a gentle emollient like a Cerave lotion.

If the itching does not go away then it may be a good idea to do some further investigation, including lab work and maybe even a chest x-ray, as once in a long while the itch is a harbinger of an internal problem.

One of the most difficult things about itch is the "Itch-Scratch Cycle." Basically, when you scratch the itch you cause chemicals to be released in your skin that make your nerves more sensitive to itchy stimuli. Therefore, patients with itch do better to "substitute" beneficial things like applying a soothing lotion to the area instead of scratching.

Accutane

Accutane, also known as isotretinoin, is a much loved and much hated medication for treating acne. This is an interesting medication from a dermatologist's perspective because almost every patient with acne has thought about this medication and has some idea of where s/he stands on it.

Some patients with minimal acne come in asking for it right away and other patients dealing with painful nodules and cysts on the face, back, and chest refuse to even consider isotretinoin.

Dermatologists disagree about when isotretinoin should be given to patients, and because of the registry system known as iPLEDGE, some dermatologists do not use it at all. That being said, most agree that for scarring, cystic acne it is the drug of choice. I also like using it for patients who have tried multiple other medications without success.

Lately, isotretinoin has come under fire for its side effects, and for some reason the media and the public latch onto the side effects of certain medications more than others. Isotretinoin is in the former category of course.

The side effects of many medications, including over-the-counter medications like ibuprofen can be scary. Most people are shocked to learn that very rarely people take the prescribed doses of seemingly benign medications—like ibuprofen, for example—and die. (See a list of ibuprofen adverse reactions here for illustration.)

With that preface, what are the side effects of isotretinoin?I tell patients they definitely will get dry eyes, dry mouth, and dry noses. I ask about headaches, bowel problems, suicidal thoughts and depression, as there is some evidence that isotretinoin can make these worse. Finally, patients cannot get pregnant while on the medication or within a month after stopping the medication. I do not allow any women to take isotretinoin without also taking oral contraceptives, even if the patient practices abstinence, for many reasons including the fact that the contraception will likely help her acne. I also follow the outline of the iPLEDGE program and get a written consent from patients after they review the pamphlet (available here).

That is the formal procedure, but I also have some strong feelings about isotretinoin's side effects that I believe are supported by the dermatology literature. Personally, thought I find the evidence that isotretinoin causes depression and suicide shaky at best. There is more evidence that severe acne causes suicide. Likewise, the inflammatory bowel disease that has been linked (albeit loosely) to isotretinoin may be part of a syndrome in patients with severe acne since you can also find a loose association of oral acne antibiotic use and inflammatory bowel disease.

The truth will hopefully pan out in the upcoming years as more studies are released. The truth about isotretinoin is that there are real and potentially serious side effects, just like with any medication. However, my patients who had severe, scarring, and recalcitrant acne, who are now cured would not take back their choice to take isotretinoin for the world.