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.

Allergic Contact Dermatitis to Nickel

Allergic contact dermatitis (ACD) to nickel is a common skin condition with symptoms ranging from mild to completely debilitating. Nickel is the most common cause of ACD in the western world, and its incidence is increasing in the United States, but in Europe its incidence is decreasing because of steps taken by the European Union to decrease the amount of nickel people are exposed to.

Nickel is a bane for many earring wearers because it requires guesswork and expense to find which earrings cause problems and which do not. Even gold less than 24k has enough nickel in it to bother many women. Symptoms commonly include redness, irritation, itching, and swelling at the earlobe where the earring touches the skin. Treatment generally includes some combination of avoidance and topical steroids (like hydrocortisone cream or triamcinolone). Since 24k gold is fairly expensive and a little too soft to make good earrings, some companies make 24k gold-plated earrings, which some people use without getting any reaction.

Dimethylglyoxime is a commercially available chemical that can help people who have nickel allergy decide which earrings to buy. The potential buyer puts a couple of drops of the chemical on a cotton ball and touches the metal in question. If it turns pink then the metal contains nickel, and another pair of earrings will have less of a chance of causing ACD.

Nickel allergy does not just affect the ears of earring wearers. An itchy rash in the middle of the lower abdomen might be "jean dermatitis" caused by the nickel in the button of jeans and other pants. Nickel is in door handles, coins, and countless other things we touch every day. Often the skin of our hands is so thick that it does not react, but the thin skin around eyes and mouth will. In some cases the disease is so debilitating that people get a "systemic contact dermatitis" with the whole body reacting with violent itch and redness to even small amounts of nickel in foods like chocolate, nuts, oatmeal, canned foods, tea, and anything cooked in stainless steel pots and pans.

Dermatologists can do something called "patch testing," where s/he applies some patches to the back and then "reads" the results a few days later. Sometimes chemicals beyond what one expects are the culprit of what can be a very miserable condition.

New FDA Sunscreen Rules

The FDA released some new rules about sunscreen, which will go into effect next year. Some of these new rules are probably good, including a rule that will require suncreens with a sun protection factor (SPF) less than 15 to carry a warning that they are not shown to prevent skin cancer, only burning. The FDA is implementing tests before they allow a sunscreen to be labeled as "broad spectrum," and this is probably a good thing too.

A number of concerns remain or have been exacerbated by these new rules, though. To start, the maximum SPF labelling now allowed will be "50+". Supposedly this rule has been created because there is not enough evidence to suggest that a sunscreen with an SPF of, say, 100, is superior to a sunscreen with an SPF of 50. The fact is, though, that higher SPF sunscreens have been shown to be superior to SPF 50 sunscreens in high-UV environments.

Moreover, I believe companies have been encouraged to make better sunscreens by being allowed to market higher SPFs. True, there is no evidence that an SPF 100 is better than, say, an SPF 85, but when everything is "50+" it will be impossible to differentiate the ability of good sunscreens to protect, and this has been shown to be important in trials comparing sunscreens with SPF 50 to sunscreens with SPF 85.

Furthermore, FDA testing is flawed. Current rules require a sunscreen to be applied at 2mg per square cm, and most people apply sunscreen less than half this thickly. SPF protection declines rapidly with thin application, so if you apply at 1mg/square cm you will get less than an SPF 25, which, frankly, is not good enough for at-risk consumers in high-UV environments or with fair skin.

Another disappointment in these new rules relates to UVA coverage. Unfortunately the FDA continues to fail to give consumers easy-to-read labelling relating to UVA protection. Many sunscreens will be allowed to be labelled "broad spectrum" that fail to meet basic UVA protection standards in Europe. Again, the labelling encourages mediocrity and I am afraid it will give consumers a false sense of security.

Good luck to all of us in finding our new favorite sunscreen when the labels change next summer!

Lights For Acne

I had a friend ask me about light treatments for acne, so I thought I should review that today. First of all, light therapy is not for most people with acne. For the most part it is not effective enough for many people seeking help with their acne. The cost-effectiveness of light therapies in acne have not been well studied, but in my opinion you get a lot more bang for your buck with other acne treatments. That being said, there are a select group of patients for whom light therapy for their acne is the right choice. These include people who get easily irritated by topical treatments.

Light therapies have not been compared well to conventional treatments (eg, pills and creams).

There are several types of light used in acne including visible light (especially blue lights), various lasers, a type of light called Intense Pulsed Light (called IPL by dermatologists), and a type of light treatment called Photodynamic Therapy (what we call PDT).

Very few trials of light in acne are well designed. Many of these products are what the FDA calls "cleared" for acne, and this should not be confused with FDA "approval." The standard for getting a device "cleared" is very low and does not mean that the device actually works. With that in mind I will talk about the various types of lights.

Blue light - This is a popular type of treatment for acne. Blue light comes in a variety of wavelengths and intensities. Some blue lights give intense pulses of light at narrow wavelengths (415-425 nanometers), while others use longer wavelengths (470 nanometers). The theory behind blue light comes from the study of Propionibacterium acnes, which makes a substance that you can excite at 415 nm to kill it. In several short-term studies it performs about as well as using 5% benzoyl peroxide. Some light sources are inexpensive and available for home use. Some units, which may or may not emit stronger light than the home units are available only at the dermatologist's office. It has NEVER been shown to work for anything more than moderate acne.

Intense pulsed light - Unlike laser, which is made up of one wavelength of light, intense pulsed light (IPL) typically consists of a range of wavelengths (e.g., 400-1200 nanometers or 530-710 nanometers). It can be used alone for acne or in combination with topical chemicals to make skin more reactive to the light. It is probably effective for mild to moderate acne, but you need to get the light in the office, and it costs somewhere in the neighborhood of hundreds of dollars per treatment. There are not great studies looking at IPL alone without the use of photosensitizers.

Photodynamic therapy - More commonly used for treating a type of precancer (actinic keratosis), this type of therapy can be used with IPL or with a blue or red light. This type of treatment requires the application of a chemical, most often aminolevulinic acid (ALA), prior to exposure to a light. Like with the other types of light treatment, the studies are limited by small numbers and mediocre design. It probably works better than IPL or visible light alone, but the side effects can include photosensitivity, blistering, crusting, and burning, which are rare with IPL or visible light alone.

So, my take on light therapy is that there is definitely a role for it, but dermatologists haven't worked out exactly what that role is. For people who really hate putting on creams or taking pills it may be the way to go. You probably get more efficacy from PDT--treatment with light in combination with a photosensitizer-- than from light exposure alone. The skin cancer risk of exposure to these lights has not been worked out.

Acne: an introduction

Acne affects almost every teenager to some degree. Some are lucky to escape teenagerhood with mild acne consisting only of blackheads and whiteheads, which dermatologists call comedones (comb-ee-dones). Most people though have inflammatory lesions like papules and pustules. A few people have one of the more severe types of acne with nodules and cysts that go on to severe scars.

To understand the treatment for acne it helps to know what causes it. In a nutshell, skin cells that are normally shed from inside pores become "sticky" for reasons we don't entirely understand. Behind this sticky plug of skin cells oil (also known as sebum) builds up. Hormones increase the production of this sebum. This sets up an environment where bacteria grow and create inflammatory byproducts that cause acne.

From that description you can see some of the "targets" where we can start to treat acne. To break up the plugs of skin cells we often give people Vitamin A-derived medications. Probably the best-known medication of this kind is Retin-A (also called tretinoin). Retin-A breaks up these plugs and prevents new comedones from forming. Accutane (isotretinoin) is the oral cousin of Vitamin A that treats all of the known causes of acne. It increases the turnover of skin cells to clear out the comedones, decreases sebum production, and has been shown to decrease the types of bacteria that cause acne. Accutane, like all medications, has the potential to cause side effects, and some of them are potentially serious. For many people with severe acne, however, it remains the treatment of choice today even after decades on the market.

Antibiotics, both topical and oral, play a role in treating all kinds of acne. Topically your doctor might prescribe clindamycin or erythromycin. Oral antibiotics for acne range from a class of medications called tetracyclines (including doxycycline and minocycline), to another class called sulfonamides. It would take too long to mention all the details of antibiotics used to treat acne, but suffice it to say that they do a fantastic job at treating acne--particularly inflammatory acne--for many patients.

So far I've talked about prescription medications for acne, but some of the best medications are readily available over the counter. Benzoyl peroxide is a topical medication available as a face wash and in bar form in various strengths up to 10%. It is also found in many prescription products alone and as a combination with antibiotics and Vitamin-A derivatives. The two big downsides to benzoyl peroxide are irritation and bleaching. It will bleach any clothes and towels it comes into contact with. The 10% formulations are irritating to most people if you use it for extended periods (like overnight). To combat these to problems my recommendation is to use 10% benzoyl peroxide (my favorite is Oxy brand face wash) in the shower. Put a small amount on your face for 5-10 minutes and then wash it off well before drying your face. Moisturize with a good non-comedogenic (non-pore-clogging) sunblock after the shower.

Another great over-the-counter product is salicylic acid 2%. Two percent salicylic acid is available from many brands. I like the formulation that Neutrogena makes in their Oil-Free Acne Wash. It decreases inflammation and breaks up the formation of comedones like many other acne products. Like benzoyl peroxide and Retin-A some people may find it irritating so it is important to use face moisturizers and/or alternate with a gentler wash like Cerave.

Unfortunately there is no perfect combination for everybody. If the over-the-counter products are not working well enough for you then it may be time for a visit to the dermatologist. Often you can get things under control with a few months of an oral medication and then go back to topicals only.

To recap, here are some of my favorite products for acne available over the counter: Neutrogena Oil-Free Acne Wash, Oxy Face Wash (with 10% benzoyl peroxide), and Cerave foaming face cleanser.

What's the best way to wash my face?

Most soaps contain chemicals called surfactants (charged fats) that can have a tendency to remove the protective cholesterol and fats from the skin. Soaps also tend to be alkaline (have a pH above 7), which probably contributes to their propensity to irritate even normal skin.

Dove products, although often called soap, are actually milder, neutral (pH of 7) cleansers called syndets. They tend to be less drying and irritating and are often recommended by dermatologists over soaps.

Many liquid cleansers have several types of fats added to them to replenish what the cleansing surfactant component take away. Many brands of mild liquid cleansers exist, and essentially none of them have been studied head-to-head. Theoretically, brands like Cerave, which contain types of moisturizers named ceramides in addition to cholesterol and other fatty acids in a more natural ratio. Studies have not compared ceramide-based cleansers with other types of moisturizing cleansers so it is not possible to say with certitude that they are better than other cleansers, but the theory is appealing to many dermatologists.

At the end of the day I recommend one ceramide-based cleanser in particular, namely Cerave, because it is reasonably priced, my patients have fantastic results, and because I find the theory of replacing what is naturally lost appealing.

Six Sun Tips

For most of us sun exposure comes to the forefront of our minds this time of year when we are getting outdoors for yardwork or vacations, but really we are exposed every day to the sun's radiation. Around 95% of solar radiation is UVA (the kind of radiation thought to cause more photoaging than skin cancer), but UVB causes more direct damage and is thought to be more important for causing things like skin cancer. With that background, here are some practical tips for sun care:

1. Wear a sunscreen of SPF 50 or more every day on your face and arms. I can think of virtually no exceptions to this rule. Even when you do not get a sunburn you are accumulating sun damage constantly. There are really two reasons to put on a very high SPF sunscreen. The SPF of your sunscreen declines over time. If you are not swimming, sweating or wiping your skin, then after 4 hours the number is reduced by a third. After 8 hours it is cut by two thirds, so if you start off with an SPF of 100 then on the ride home from work 8 hours later than you may still have in effect an SPF of 30 on your face.

2. Buy something that says "non-comedogenic" for the face. There are many nice brands of sunscreen out there. Most of the ones I like for the face say "non-comedogenic" somewhere on the label. This means it is less likely block pores on your face.

3. Sunscreen should not give you an excuse to stay in the sun for hours on end. Sunscreen has been shown to reduce the risk of melanoma (in 2011 for the first time), but that was in people who were getting "incidental" exposure. There is no proof that sunscreen alone can reduce the risk of skin cancers including melanoma in people who are getting more than "incidental" exposure. Sun avoidance with shade, hats, long sleeves, and going out early in the morning or in the evening instead of in the middle of the day are an essential part of sun health.

4. Clothes often have a lousy SPF. You might think that going outside with a T-shirt on protects that area from the sun's damaging rays. In fact, a regular cotton T-shirt gives you an SPF of only 10. I would never tell anybody to wear an SPF of 10 for any reason. It does not block enough radiation.

5. Put the sunscreen on and then wait before you get dressed or get in the water. Good studies have shown that people who either get dressed or get in the water right after they put on their sunscreen lose a lot of the SPF. If you can wait 20 minutes to let the sunscreen adhere well to your skin you will get the full benefit. This is yet another reason to use a very high SPF (as if you needed any more).

6. What about Vitamin D? This is a question I get a lot. The truth is that nobody knows how much Vitamin D is enough. Very smart people who study this full time argue about what the right dose of Vitamin D is. Right now the recommendation for most people is 600 Units a day. My best guess is that it will end up being higher like around 2000 Units per day because every time Vitamin D is studied it seems like more is better, and the toxicity from too much Vitamin D is actually very rare. It has never been seen in doses below 10000 Units per day.

As far as what brand of sunscreen is the best, there are many that are very similar. The important things are you want something "non-comedogenic" for the face and something with a very high SPF. I often tell patients to try several types and see which ones they enjoy the most. Neutrogena is widely available, comes in an SPF 100, and feels nice and dry after you rub it in. For the arms and chest you can try the Target brand spray (up & up) SPF 60, which did exceptionally well in the Consumer Reports sunscreen testing.

Enjoy all your summer activities and don't be shy about asking questions!

Vitamin C and Skin

Vitamin C, also known as ascorbid acid, is a vitamin found in many fruits and vegetables. It can also be used topically to treat things like hyperpigmentation (dark flat spots often caused by acne or other conditions like melasma) and photoaging. In this post I will break down what is actually known about topical Vitamin C and what questions about topical vitamin C still remain to be answered.

Topical Vitamin C is the most abundant antioxidant in human skin. It does several things in the skin, but probably the two most important relate to regenerating the anti-oxidant properties of Vitamin E and to getting rid of free radicals, which are created when the sun's radiation hits the skin. In addition to these things, Vitamin C is involved in a lot of other processes involved in making blood vessels and collagen, but I am just going to focus on the skin today.

Regular Vitamin C, is absorbed best when (no surprise here) it is in a very acidic form. A pH of 3.5 (in between vinegar and stomach acid, roughly), has been shown to absorb best into skin. As you can imagine, rubbing an acid on your face can be irritating so many people have developed "cousins" of Vitamin C that are more stable at a neutral pH (7), but still have the same ability to scavenge the free radicals produced by the sun.

So that's a little bit about the science behind Vitamin C. But does that science translate into improved skin? The answer is probably yes. In one (small) clinical trial of topical Vitamin C (the regular kind, not one of the fancy substitutes), where patients got the Vitamin C on half their face but just the vehicle (all the ingredients of the cream without the Vitamin C) on the other side, the side with the Vitamin C had significant improvement in photoaging (sun damage) after 3 months of use.

Vitamin C has been suggested to have other uses as well, including as a lightening agent for dark spots either caused by melasma (a "browning" of the skin often occuring in pregnancy or on oral contraception) or inflammation such as acne.

Vitamin C has also been shown to work as a sunscreen. It seems to work better at blocking UVA (more the cause of photoaging than skin cancer), and Vitamin E seems to work better at blocking UVB (more the cause of skin cancer than photoaging).

All these good things Vitamin C reportedly does need to be taken with a grain of salt. In reality we know far less about what topical Vitamin C does than we do about what most prescription treatments do to the skin. The clinical trials have been small and some of them have been done better than others. The laboratory data seem promising, but they often do not translate to the clinical setting. Stay tuned for more as the science of Vitamin C becomes clearer.

For now, if topical Vitamin C is something you think you might want to add to your skin regimen there are a number of products available in various formulations. Obagi and NuFountain are two companies that make affordable Vitamin C preparations. You may want to start out with a 10% L-ascorbic acid formula. It that is too irritating step down to the 5%. If the 10% formula is a piece of cake for you then you can consider increasing to the 20% lines.

I hope you enjoyed. Please feel free to email me with any questions.