Acne is inflammation of a special hair follicle. This specialized follicle occurs anywhere from the mid chest up. Around puberty this follicle makes not only more oil, but a different kind of oil. This change leads to formation of blackheads in the follicle, accumulation of certain kinds of bacteria, and redness and inflammation. Blackheads are not dirt, and acne is not usually primarily from food or poor washing techniques. Most teens grow out of their acne by the early twenties; however we all know how miserable even a few pimples can be.
Acne is made worse by: sweating, stress, chlorine (indoor swimming pools), restaurant oils, mineral oil products (some moisturizers, hair products, etc). Sometimes, especially for girls, acne is a sign of abnormal hormones or thyroid disease. Usually, however, acne is a “normal” part of being a teenager.
If you are prone to oily skin, simple care of acne includes using benzoyl peroxide or salicylic acid cleansers. However if your skin tends to be dry or sensitive, these drying agents might make you worse. In that case gentle cleansers and moisturizers can help.
Acne is always worth treating if it bothers you. If over the counter remedies do not work, please come see me. Prescription treatment options include: topically, there are benzoyl peroxides, topical antibiotics, azeleic acid, sulfur, retinoids (such as retin A and differin). Pill forms include antibiotics, Accutane, and spironolactone. There are procedures which are not covered by insurance. I can offer peels; some centers offer blue light therapy and more aggressive peels as well.
Retin A (Prior Authorization): I have given you Retin A cream to treat your actinic keratoses, your acne or perhaps your wrinkles. Because of your age, your insurance won’t pay for the medicine – no matter what. Therefore my office will not go through the prior authorization process. You are responsible for paying for the creme out of pocket.
Accutane is a “vitamin A derivative” pill that shrinks oil glands. It is a very effective treatment of most types of acne, but not all. It is usually a five month course, the dose determined by weight. There are rare risks associated with the medicine, and therefore I monitor patients on a monthly basis with close follow up during the course. I watch bloodwork for changes in white blood cell count, liver function, cholesterol and triglyceride. Girls must be on birth control and pregnancy tests are performed monthly as well. Other side effects I watch for are headaches, dizziness, achy muscles and joints, lower back pain, change in vision; the possibility the medicine causes depression and even suicide is controversial. Data most recently do not support this concern. Nonetheless I watch closely for changes in mood while a patient is on the medicine. Most patients have at least some improvement on the medicine—sometimes acne clears completely and permanently. However, because of other rare side effects like hypersensitivity reaction, it is very important to follow up every month for assessment.
There are three kinds of sun related skin cancer: basal cell cancer, squamous cell cancer, and melanoma. All are related to the sun but in different ways. Basal and squamous cell cancers are related to direct sun and directly related to sun. This means they occur where you get sun—primarily the face. And if you get them, it is almost definitely from sun. Meanwhile, melanoma is related to a list of risk factors: family history of melanoma, five or more severe blistering sunburns, growing up in a tropical environment if you are white skinned, and use of a tanning booth. Finally, and most importantly, if you are not black or Hispanic you are at risk for sun related melanoma. Melanoma can occur anywhere—even your armpit or the bottom of your foot. It can occur in your eye, mouth, or genital area. Of course in these places it is not related to sun.
Prevention of skin cancer is important, but it is becoming clear to dermatologists that it is not as simple as complete sun avoidance (sun has beneficial as well as harmful effects). Therefore I advocate the “common sense” approach to protecting your skin. First, do not try to get a tan. Lying on the beach at noon exposes you to a whole lot of sun all at once, and causes damage not only to your skin cells but your immune system. Peak hours of the day are 10 to 4, and during that time in the sunny seasons a hat, t shirt and shade are great ideas. I mention sun block last not because it is not important, but because it is not as effective as the other methods, and it remains somewhat controversial. Sun block makes sense if you know you are going to be out for a long time and not able to protect your skin. I recommend zinc and titantium based sun blocks such as dermatone spf 36 fragrance free, cotz brand, and vanicream spf 30 or 60.
Because you cannot turn back time and erase your past sun exposure, and because melanoma is not just related to sun, it is important to know what signs to look for with skin cancer. I hope the following can help you make sense of what is somewhat confusing information about skin cancer.
Signs to look forward with skin cancer:
- Basal cell cancer—“bleeding”
- Squamous cell cancer—“sandpaper”
- Melanoma—“milk chocolate”
Basal cell cancer can bleed spontaneously, and this is often how we find it. It is most often on the face. It starts out pink or pale—a little bump that slowly grows. It may take a year or two to become noticeable, and it often eventually bleeds. These are not life threatening. They almost never metastasize (spread throughout the body). However, they can cause “local destruction” and be quite devastating, especially if on the eyelid, nose, mouth or ear. Treatment is excision, Mohs’ micrographic surgery, Aldara cream or rarely, radiation.
Squamous cell cancer usually presents as a “sandpaper” spot on the face or back of your hand. It is not just rough or warty (like the “barnacles” on your body), but picky like a grain or sand or even little piece of glass embedded into the skin. When caught at this stage they usually resolve with liquid nitrogen or Aldara or 5-FU cream, and they are known as an “actinic keratosis” or pre cancer. However squamous cell cancer can be aggressive—rapid growth, pain, older age of the patient are signs for concern. Treatment sometimes requires excision and even more aggressive treatment. This is fortunately less common.
Melanoma is the most concerning of the three skin cancers. It is the cancer of moles, and it can occur at any age. With melanoma, change in general is the most important thing to be aware of, but there are specific changes we focus on. I use the term “milk chocolate” to get you thinking of brown color. Milk chocolate as a color of a mole is usually GOOD—its dark chocolate and licorice (dark brown and black) you must look for.
More specifically, with melanoma you are looking for change in an existing mole, or a new mole that is dark or changing.
Color, size and shape are all changes we look for, but especially dark color.
Furthermore, melanoma usually starts out FLAT. This may come as a surprise. It is not the raised moles you need to focus on, but the flat ones. In fact, people often mistake their flat moles for freckles.
Here is a way to understand the distinction of raised and flat moles. Your body is constantly surveying itself to make sure there is nothing in it that is harmful. From the time you are born, your body is trying to get rid of your moles. Your moles are collections of the cell called the melanocyte, and moles are induced primarily from sun exposure. You could say your body considers them abnormal and potentially dangerous, and so your body wants to get rid of them. It tries to do so by slowly raising them up over time. Thus, a mole is most benign if it is slowly raising up. It is not “fighting back”. A flat mole, on the other hand, is fighting back. It’s a little more aggressive. A flat mole has more “potential” to go bad.
Most flat moles are of course normal, but you want to watch them more closely for change than you would a raised mole. Raised moles can become irritated and even bleed, but this tends to occur from irritation rather than because it is becoming dangerous. So, watch for color, size or shape change especially of flat moles.
The exception to the “raised/flat” rule is an important but rare exception called nodular melanoma. Nodular melanoma is a rare, extremely aggressive melanoma. It is red or black, and erupts over a couple of months. This kind of melanoma is an emergency.
The bottom line is, if you are worried about a spot; please show me or your regular dermatologist. Sometimes the spot you are worried about is a “seborrheic keratosis” (barnacle). These spots are so raised up they are almost falling off. A clue with these spots is you can practically get the edge of your fingernail under the edge.
(The term eczema means “to boil over” in Greek. Poison ivy reactions, for instance, are a form of extreme eczema.)
“Eczema” is a general term that most often refers to “atopic dermatitis”. If you are prone to eczema, whether as an adult or a child, general sensitive skin measures are usually your safest bet (see below). It is worth considering that what you think of as simple eczema, could be triggered by something specific you are being exposed to (common causes of contact allergy eczema include nickel, or work exposures), or it could be psoriasis.)
Childhood eczema (atopic dermatitis) is genetic and often inherited. Children with eczema often react to cats, dust, dust mite, fragrances, nickel, and sometimes foods such as eggs, milk, peanuts, and some fruit. Stress, dry weather, sweating and irritation can set off atopic dermatitis.
Kids with eczema sometimes have asthma, hay fever and allergies, and other family members often have these, as well. Eczema usually hangs on throughout life, showing up in different ways. You might find yourself reacting in different ways at different times of your life.
DRY SKIN/SENSITIVE SKIN
Treating dry skin can be a constant process, especially in the winter. Sometimes dry skin reflects a health problem, especially thyroid disease. More often it is inherited, seasonal, and/or related to advanced age.
Moisturizing is at the cornerstone of treating dry skin. Because dry skin is also often sensitive skin, the kind of moisturizer sometimes makes a big difference. To be on the safe side, a moisturizer without many additives or fragrances is the best bet. Some good choices include Cetaphil, Curel, Eucerin, Neutrogena, shea butter.
Unfortunately “unscented” usually means there are masking fragrances included. Even “fragrance free” products sometimes have “essential oils” (like rosemary oil, or lavender oil, for instance) that the company is using as emollients.
Cost does not always reflect value. Some really inexpensive and effective choices include Crisco and Vaseline (!). Acidification helps dry skin heal, and so acid mantle cream, Lachydrin and Carmol are good medicated creams.
A technique that really helps dry skin, especially if you are really itchy, is the following: soak in a comfortably warm/hot tub for 15-20 minutes. Do not use soap, which is very drying. When you dry off, just pat dry so you don’t irritate your skin. Then immediately moisturize. This technique allows your dead skin to swell, and gently break the bonds with your living skin.
Psoriasis is often, but not always, inherited. You are more likely to inherit it through your mother. It is a chronic skin and/or joint condition that most often shows up either when you are a teenager or in late middle age. While it can involve any part of the body, it most often involves the elbows, knees, scalp, sometimes hands and feet. It sometimes shows up in brows, and on the side of the nose.
Triggers of psoriasis include stress, infection (especially strep throat), and some medications including beta blockers for high blood pressure and heart problems. Injury to the skin can make it worse, such as a cut or a sunburn (even though small amounts of sun can help it). It also can “overlap” on the skin with dandruff, or yeast infections in the armpits, under the breasts or in the groin.
There is no cure for psoriasis. There are many treatments, which means no single one is perfect. The treatments range from mild to strong topical steroids; tar; vitamin d and vitamin a creams; uvb light, and uva light; pills like cyclosporine, methotrexate and acitretin; and most recently the “biologics” Enbrel, Amevive, Humira, Raptiva and Remicaide.
Warts are caused by strains of the HPV (human papilloma virus). This virus only infects keratinocytes, and it does not invade the body. Because warts are up in the top layers of the skin, your immune system can have a hard time “finding” the wart. Treatment of wart might seem simple—just cut the wart out and its gone. The problem is that the wart virus is also in the skin cells around the wart you can see. When you remove the main wart, the virus takes off from the other cells. Therefore, our treatments are really ways of “waking your body up” to notice the wart. We hope that your immune system can step in and do the rest.
Putting duct tape over standard wart treatment, and peeling the tape off after a few days, is a good way for you to try to treat the wart yourself. If you cant get rid of it that way, you can come in to have your wart treated by me. However, warts are hard to get rid of no matter what we use to treat them.
When I biopsy a mole and send it to be looked at by a pathologist, I am looking to see whether or not it is a melanoma (cancer of moles). Even if it is not a melanoma, a mole can be still concerning enough to need further treatment.
The pathologist will look at the cells of the spot and determine if any of the cells have “atypia” (abnormality). The degree of this atypia will determine how concerning the spot is. There are four categories of atypia. The mole could be entirely normal, or it could have mild, moderate or severe atypia. Normal or mild means we don’t need to do anything further to the spot. Severe means the spot is close enough to melanoma we need to remove it so it doesn’t turn into a melanoma. Moderate atypia means we want to remove the spot completely to make sure it’s gone, but we are not terribly worried about it.
If you have had a mole with moderate or severe atypia, it makes sense to be checked every year or so.
Scabies is a mite that lives in the top layers of skin. It is contagious, but not all people with the mite on their skin will have symptoms. You get scabies from people, their clothes or their bedding. Therefore you can catch them from friends and family, hospitals, nursing homes, schools, hotels and motels, used clothing stores.
The mite is most likely to cause a rash in your armpits, around your belly button, in your groin, lower back, wrists and between the fingers. However, it can occur anywhere. It is very uncommon on the face or scalp.
Treatment includes using permethrin topically or ivermectin pills once or twice one week apart. Your household should all do the treatment whether they have symptoms or not.
The cream is put on at bedtime and washed off in the morning. Apply it everywhere from the jaw down, and behind the ears. Every nook and cranny, including belly button and under the nails.
Take all the bedding from the last three days, including shoes and jackets, and either but them in plastic bags, out in below zero temps, or wash in hot soapy water. You don’t need to fumigate the house or wash your bed, just sheets and pillow cases. However, if a family member spends a lot of time on a piece of furniture (such as a recliner), the best thing is to avoid that piece of furniture for a period of time.
LIQUID NITROGEN TREATMENT (LN2)
LN2 is used to treat AKs (actinic keratoses or pre-squamous cell cancers), SK’s (seborrheic keratoses or “barnacles”), warts, skin tags, and other spots.
LN2 freezes the top layers of skin. At 190 degrees below zero, LN2 causes frostbite which leads to a blister.
The blister that forms is not always visible when the spot is thick, such as with a wart or SK. If you do see a blister, you may pop it, but do not need to. The top layer of the blister will dry and crust off over time. This process can take a full month (sometimes even longer), so please be patient.
If the spot is itchy, dry or bothersome you can put Vaseline or lotion on it. You may cover it with make up.
Thicker spots sometimes need multiple treatments to go away completely. Furthermore, warts are notoriously difficult to treat. Whether they fall off with liquid nitrogen or not, they often recur because they have evaded your immune system. This is an unfortunate and frustrating fact about warts—no matter how I treat them at the office, the ultimate resolution of them requires that your immune system fights them off.
Signs and symptoms
Melanoma is the cancer of moles. It is the most concerning of the common skin cancers. We know there is a relationship between melanoma and sun, but it isn’t as straightforward a relationship as there is with other forms of skin cancer (basal and squamous cell cancers). The immune system plays an important role in melanoma, and it is certainly known that the immune system is affected by stress. I would like to epxlore the possbility of a connection between stress and melanoma.