Clinical Photography

Clinical photography is the art of taking photographs used in medical records to compare physical attributes such as the skin before and after treatments or time. They are invaluable for patients and doctors because they can clearly show differences in the skin. Digital photography has become so commonplace that this can now be done at home. There are numerous technical aspects, but the most important thing is consistency. Every part of the photograph should be consistent every time. This includes the position, location, angle, lighting, background, removal of makeup and jewelry, covering of clothing and hair, and use of flash. Consistent settings help to clearly define what a treatment has done.

ABCDE's of Melanoma

The ABCDE's of melanoma are signs to look for in moles which cause concern for malignant melanoma. If you see any of these signs, you should have the mole looked at by a dermatologist and possibly have a biopsy to make sure it's not malignant.

A: Asymmetry

The mole should look symmetric. If one side looks different than another, it may be a good idea to have it looked at by a doctor.

B: Border Irregularity

The border should be smooth. Jagged or irregular edges are signs for concern.

C: Color Variegation

The color of the mole should be uniform throughout. If there are multiple colors, or new colors such as black, blue, or red, you should have the mole checked.

D: Diameter

The diameter of a benign mole is generally no more than 4-5 millimeters, which is about the size of a pencil eraser. Moles that are larger than this size should be checked, especially if they are actively growing.

E: Evolution

If there is anything about the mole that is changing or evolving, it is a good idea to have the mole checked.

Botox Myths and Facts Part 3

Myth: Botox will leave me with a frozen face.

Fact:

Although results are visible, treatment with Botox does not make you look like you had work done. The muscles causing the frown lines are relaxed, so you can still have expressions, just without the wrinkles.



Myth: If I stop using Botox, my face will look different than before.

Fact:

The effects of Botox last 3-4 months. When the drug wears off, your face will look like what it did before the treatment. 



Botox Myths and Facts Part 2

Myth: Botox is only for the rich and famous.

Fact:

According to the Aesthetic Surgery Education Research Foundation Botox Cosmetic Use Survey of 1048 patients (2005) the most common users of Botox  are working mothers aged 40-55; and those with an annual household income of less than $ 100,000 are more likely to use Botox than those with an annual household income of more than $ 150,000.

Myth: Botox isn't for men.

Fact:

Men make up nearly 10% of all Botox treatment and that number continues to grow.

Botox Myths and Facts Part 1

Myth: Botox is not safe.

Fact:

Botox has been used therapeutically for 17 years. The same formulation received FDA approval in 2002 for treatment of moderate to severe frown lines between the brows. It has also recently been approved for treatment of migraine headaches. It is used off label for wrinkles on the forehead, around the eyes, on the nose, and around the mouth as well as treatment for excessive sweating in the palms and underarms.

Myth:  There are creams that work better than Botox.

Fact:

Topical creams work on the surface of the face. Botox works on the the muscles under the skin which cause the deeper wrinkles to form. Once the muscles relax, the skin overlying it can smooth out. When used in combination with creams such as Obagi Elastiderm, better results are seen because treatment is directed at both the superficial and deep wrinkles.

Acne

Acne is a common problem affecting many people. It is common during puberty and in adolescence, but can occur throughout a person's life. It is caused by plugs in glands and affects the face, trunk, and buttocks. You can see blackheads (open comedones), whiteheads (closed comedones), pustules, nodules, and cysts. Hormones or other causes lead to increased keratin production, which blocks sebum secretion, leading to these lesions. This creates an environment suitable for the growth of the bacteria P. acnes, which leads to inflammation. Other causes of acne include emotional stress, excessive pressure on the skin, certain medications, and various topical products. Contrary to popular opinion, foods such as chocolate have not been proven to be associated with acne. But you can avoid such foods if you feel it helps.

There are a number of treatments for acne depending on the severity. These include topical products such as benzoyl peroxide and topical antibiotics such as clindamycin or erythromycin. Some products contain combinations of these. Products containing acids such as glycolic acid and salicylic acid help with exfoliation. Retinoids such as Retin-A (tretinoin), Differin (adapalene), and Tazorac (tazarotene) can provide significant improvement, but may also cause irritation. For this reason these are often started on a three to four time per week regimen and gradually increased to daily use. They should not be used during pregnancy or when females are breast feeding. Oral antibiotics such as doxycycline, minocycline, and tetracycline can be added for moderate acne. Use of sunscreen is imperative because these medications cause sensitivity to the sun. Oral contraceptive medications may improve acne for females who have more problems during their menstrual period. Accutane (isotretinion) is an oral medication used for severe acne when other medical treatments do not work. This has become less popular for a number of reasons including side effects such as dryness and the possibility of birth defects as well as requirements for regular blood tests. Procedural treatments for acne include manual extraction, chemical peels, and laser therapy.

This is a patient who saw improvement after four weeks of the Obagi Clenziderm system, which includes 2 % salicylic acid and 5 % benzoyl peroxide.



Melasma

Melasma, also called chloasma, is a disorder where dark or hyperpigmented patches appear on the skin. It usually affects the face. Common areas of involvement include the cheeks, forehead, upper lip, and jaw line. Women are affected about ten times as often as men. It is more common in patients with darker skin tones such as those with ancestry from the Middle East, Southeast Asia, Africa, and South America. Melasma is sometimes called the mask of pregnancy because it can be induced by hormonal changes that occur during pregnancy, and also around menopause. Other causes include sun exposure, genetic predisposition, contraceptive medications, other medications such as dilantin, or unknown or idiopathic causes.

Melasma sometimes goes away spontaneously, that is without any treatment. But when it doesn't, it may be difficult to treat. Bleaching agents such as hydroquinone are the mainstay of treatment. Hydroquinone is available over-the-counter at 2% strength. Usually stronger doses are needed; these require a prescription. Other, less effective, bleaching agents include azelaic acid, kojic acid, and licorice extract. The use of daily sunscreen is also mandatory. Sunscreens with SPF of at least 30 with UVA and UVB protection are recommended by the American Academy of Dermatology. Other medical treatments include retinoids such as retin-A. Procedural treatments which are often used in conjunction with medications include chemical peels and laser therapy.

Below are pictures of patients with melasma who saw improvement after 12 weeks of using the Obagi Nuderm Condition and Enhance system, which contains a cleanser, toner, exfoliant, sunscreen, and 4 % hydroquinone.

Sclerotherapy

Sclerotherapy is a procedure to treat spider veins. Spider veins are small, superficial veins that appear of the surface of the skin, usually on the legs. They can be blue or purple and appear in a lattice pattern. Spider veins are completely harmless. They occur frequently in women in the aged 30-50.

Almost anyone with unwanted spider veins can be treated, except women who are pregnant or nursing. Other relative contraindications include those with skin infections, uncontrolled diabetes, fever, history of deep vein thrombosis, anticoagulant therapy those patients taking corticosteroids.

Sclerotherapy is performed by injecting a sterile solution into the small veins using a very fine needle. The chemical irritates the small vein and over two to four weeks, the vessel turns into scar tissue that fades, eventually becoming virtually unnoticeable or invisible. Some blood vessel may have to be injected more than once, some weeks apart, depending on its size and response to treatment. In any one treatment session a number of vessels can be injected.

Sclerotherapy is generally used for the very small superficial veins next to the skin. It is not effective for large veins and requires large amounts of the sclerosants with the potential to be absorbed. When large veins are treated with sclerotherapy, a stronger solution and a higher volume is required. Following the treatment for larger veins, compression hose stockings are usually recommended to be worn for at least 2 weeks. It is best to get spider veins treated in the winter months as one can easily wear stockings.

Walking is highly recommended soon after the procedure. But any high activity sports should be avoided for the first two to three days.

Sclerotherapy should never be done on the face and hands. The hand veins may not look pretty at times, but they should never be treated. If the facial veins are very conspicuous, laser is a better option than sclerotherapy.

Besides some stinging pain, sclerotherapy can rarely cause a few side effects. Allergic reactions are rare. A few individual may develop irritation or intense itching at the site of injection. If the chemical is injected outside the vein, profound discoloration and pain can occur.

There are certain things that can be done to minimize spider vein formation. Regular walking with low-heeled shoes and exercise as well as wearing support hose may prevent formation of some spider veins.

Juvéderm

Juvéderm is a hyaluronic acid compound used as a dermal filler. Juvéderm has been approved by the FDA for use in cosmetic treatments of fine facial wrinkles and folds, such as nasolabial folds (the creases running from the bottom of your nose to the corners of your mouth, aka smile lines or parentheses). Treatment with Juvéderm can smooth out folds and wrinkles, add volume to the lips, and contour facial features that have lost their fullness due to aging, sun exposure, illness, etc. Facial rejuventation can be carried out with minimal complications.

Juvéderm is injected into the skin with a very fine needle. The injection process generally takes only about 15 minutes. The product produces a natural volume under the wrinkle, which is lifted up and smoothed out. The results can often be seen immediately. Most patients need one treatment to achieve optimal wrinkle smoothing and results last for approximately one year.

Treating wrinkles with Juvéderm is fast and safe and leaves no scars or other traces on the face. Most side effects are mild or moderate in nature, and their duration is short lasting (seven days or less). The most common side effects include temporary injections site reactions such as redness, pain/tenderness, firmness, swelling, lumps/bumps, bruising, itching, and discoloration.

Vitamin C and your skin

Vitamin C is a great product for almost all skin types. It is an anti-oxidant and has a lot of effects. Anti-oxidants reduce free radicals, which can lead to aging such as wrinkles and sun damage. Vitamin C stimulates collagen synthesis, improving laxity, reduces inflammation, suppresses pigmentation, retains moisture, enhances sun protection, and replenishes vitamin E. The active form is L-ascorbic acid. It is found in a number of foods including artichokes, asparagus, avocado, broccoli, carrots, cauliflower, corn, cucumbers, green peppers, lima beans, mushrooms, onions, peas, potatoes, spinach, squash, and sweet potatoes. A lot of these ingredients are used in facial treatments. Other anti-oxidants include coffee berry, kojic acid, and green tea; but these do not have all of the effects as vitamin C.

What is your skin type?

The Fitzpatrick skin type scale was developed in 1975 by Dr. T.B. Fitzpatrick in the Department of Dermatology at Harvard University. There are six types, numbered in Roman numerals from I to VI. Type I is the fairest and type VI is the darkest. Red and blonde hair with freckles and blue eyes are common in lighter skin types while black hair and dark brown eyes are common in darker skin types. It is based not only on the color of the skin, but more importantly, the reaction of the skin to sun exposure. This scale is important when considering procedures because darker skin types have a propensity for a phenomenon called post-inflammatory dyspigmentation, which is a change in color after inflammation caused (in this case) by a procedure. For example, procedures such as chemical peels, laser resurfacing, or dermabrasion have the potential to cause color changes in dark skin types. One way to reduce the possibility for this is to use bleaching agents such as hydroquinone for 4-6 weeks prior to the procedure and continue for several weeks after the procedure.

Type I: very fair, always burns, never tans

Type II: fair, burns easily, sometimes tans

Type III: light olive, rarely burns, usually tans

Type IV: olive, rarely burns, always tans

Type V: brown, rarely burns, tans profusely

Type VI: dark brown, never burns, tans profusely

How does Botox work?

Botox is a protein derived from the bacteria Clostridium botulinum. The protein interacts with nerve endings in contact with muscles, like the muscles in the face. This interaction prevents the release of a molecule called acetylcholine, which is required for the muscle to contract. In this way, the muscle becomes relaxed, and the wrinkles on the overlying skin disappear. It is important to note that during a Botox treatment, the bacteria are not injected into the skin, it is only the protein, so there is no infection and there should be no signs of botulism.

Where can Botox be injected?

Botox can be injected in a number of locations. For cosmetic procedures, it can be injected in a number of locations on the face. It is FDA approved for injection into the glabella, the area between the eyebrows, to improve frown lines. It is also used in the forehead to improve the horizontal wrinkles formed when one raises one's eyebrows. It can also be injected into the crow's feet areas, those areas just beside the eyes which form wrinkles when a person smiles. Botox can be injected into specific locations in the forehead and around the eyes to produce a non-surgical facelift. It can improve the so-called smoker's lines, the vertical lines above the upper lip when injected in small amounts in these areas. It can lift the edge of the mouth if injected into the DAO muscle in the lower face. Less commonly, it can also improve neck lines and chin lines.

Botox does not work on all wrinkles. For example, the nasolabial folds, also called smile lines, do not improve with Botox injections. Fillers such as Juvederm work well in these areas.

Botox is used by doctors other than dermatologists and plastic surgeons for other indications. For example, it has recently been approved by the FDA for use in the therapy of migraine headaches. This has been highly publicized. It can also be used to improve hyperhidrosis, or excess sweating, in the palms, underarms, and soles of the feet. The amounts used for these purposes are significantly higher than those used on the face.

What is Latisse®?

Latisse^® is prescription-strength product which enhances the upper eyelashes by increasing their growth including length, thickness, and darkness. Latisse^® is the first and only FDA-approved drug for eyelash hypotrichosis, which is a name for inadequate eyelashes. It is not available at retail stores or over the counter.

The product is applied to the eyelashes daily. Applicators come with the product, and application is easy. The onset is gradual. Initial results are seen within four weeks, and full benefits occur after four months of continuous treatment. Mascara can be used at the same time.

Patients with glaucoma are cautioned when using this product. Common side effects include itchy eyes and eye redness. There may be temporary darkening of the upper eye lid and there is a possibility of permanent iris darkening.

The way Latisse^® was discovered is interesting. Allergan, the company that makes Latisse^®, marketed a medication called Lumigan, which contains the same active ingredient (bimatoprost) as Latisse^®. They found that patients using this medication for glaucoma had the side effect of growing longer lashes. They then did a study on safety and efficacy and Latisse^® was approved by the FDA in December 2008. In the two years since then, over 1.5 million bottles of Latisse^® have been sold. It has gained a lot of exposure by spokesmodels including Brooke Shields and Claire Danes.

What do Chemical Peels do?

You’ve heard of Botox and laser hair removal, but what is a chemical peel and what does it do? A chemical peel is a simple procedure used to improve the color, texture, and smoothness of the skin. Chemical peels and other skin treatments have been performed for many years to treat a variety of skin disorders. Many skin conditions can be improved when receiving a series of peels. It helps with blemishes, fine wrinkles, and uneven color. Fine lines will be softened, dull skin will appear more radiant, rough or uneven skin will become smoother. Sun damaged skin or blotchy skin will even out. Acne scarring may be softened. A peel does not eliminate sagging or excess skin. Each treatment is customized for patient skin type, specific problem areas and the delicate areas of the face.

Chemical peels are usually performed on the face, but can be done on anywhere on the skin. A controlled amount of acid is gently and carefully applied to the skin, causing the surface layer to slowly peel off over a period of a few days to a week. The new cells and collagen are stimulated during the healing process to produce a smoother, tighter, younger looking skin surface. The acid is left on the skin for a short period of time. Then, depending on the peel, it is neutralized with water or base. The procedure generally takes less than 15 minutes.

There are different types of acids used in chemical peels. Glycolic acid is the weakest, providing a mild peel. Salicylic acid is somewhat stronger, but still providing a superficial peel. The gold standard is the TCA (trichloroacetic acid) peel, which provides a superficial to medium depth peel. Phenol is a deep peel and is not commonly performed because it requires a heart monitor. Additionally, many fruits contain acids which are commonly used for chemical peels; these are usually weaker than glycolic acid peels. Within these categories, the strength of the peel can be changed by adjusting the percentage of the acid, the amount used, and the time of exposure. For example, a 35 % TCA peel is stronger than a 10 % TCA peel. Also, two passes on the skin will produce a greater effect than only a single pass, and the longer the acid is left in contact with the skin before neutralization, the stronger the effect.

Most of the discomfort after a chemical peel will be during the first four to eight hours after treatment; over-the-counter pain medication helps. The first two days after the peel, patients will have pinkness of the skin, giving it a “rosy” glow. Avoid exaggerated facial expressions during this time because this may lead to scarring. The skin will feel tight for two to three days, then it will begin to peel or flake which continues for seven to 10 days.

Aftercare instructions are very important to prevent scarring and discoloration. Apply Aquaphor® up to six times per day for the first few days in a thin layer to improve healing. Do not remove flaked skin by pulling, picking, or rubbing. This can cause discoloration or scarring. It is important that during this time you minimize sun exposure and wear protective sunscreen every day. Use a sunscreen every day, even if you avoid the sun. Recommended sunscreens have SPF of at least 30 and provide UVA and UVB protection. Protective hats and sunglasses are also recommended. Do not use a jacuzzi, steam room, or sauna for two days. Do not perticipate in physician activities which results in sweating for two days. Wash your face with a gentle cleanser daily. Do not use wash cloths, mechanical scrubs, glycolic acid, salycylic acid, retinoids, skin lighteners, wax, or strong astringents for seven days. Do not get electrolysis, collagen injections, Botox, depilatories, and facial waxing for seven days. Do not tan for the next month.

What can lasers do?

It's amazing to see all the new applications that are available using a laser. It seems like every day there is something new that can be done.

By now everyone is familiar with laser hair removal. This is the most common laser procedure and ranks second to Botox in outpatient cosmetic procedures over the past few years. A laser or light source is applied to the skin causing the growing hairs to be destroyed. Multiple treatments are required and different lasers and setting are used based on skin type.

Another popular application is the use of lasers for pigmented and vascular lesions, that is dark spots and veins. Again, various lasers or light sources are used depending on the type and location of the lesion as well as the patient's skin type. Multiple treatments are required, but the results are often amazing. This is the principle behind the common procedure called "photo-facial."

Skin tightening is used for loose skin. If there is too much laxity, surgical intervention may be better. Talk to a doctor to see which is best for you. In this treatment, it is not really the light, but the heat caused by the laser or light source that has the effect. The skin is heated via a laser, light source, or radiofrequency causing the collagen in the skin to contract and leading to the formation of new collagen. This causes the skin to tighten. It is used commonly to treat places like sagging jowl lines.

Resurfacing is one of the most expensive procedures, but has the best results. This is used for improving surface texture, fine to deep wrinkles, pores, and scars. There is ablative and nono-ablative resurfacing. Ablative resurfacing produces better results, but has a longer down time. There are also fractional devices which partially ablate the skin. In this procedure, tiny portions of the skin are destroyed. When new skin forms over the wound, the skin is smoother in texture and color. It is also tighter and has a youthful glow to it.

Sun Protection

Protecting the skin from the sun is very important. Sun exposure can lead to cancer and pre-mature signs of aging including wrinkles, laxity, roughness, and color irregularities. There are multiple ways to protect yourself from the sun.

Limit direct exposure to the sun during the peak hours of sunlight: 10 AM - 4 PM. When outside, wear long sleeved shirts and long pants to protect your arms and legs. Wear a hat with a broad brim when outside. Wear protective sunglasses when outside. Stay in shady areas when outside. It is important to remember that you can have sun exposure in places like a car through the windows, so protect yourself there too.

Avoid artifical tanning devices such as salons. This is perhaps the worst thing you can do to your skin. Spray tans are fine. Get regular skin checks for melanoma, especially if you have a family history of skin cancer.

Wear sunscreen every day, even if it is overcast. Even on cloudy days, some sun penetrates the clouds and reaches the skin. Use sunscreen with an SPF value of at least 30. Use a broad-spectrum sunscreen with protection against UVA and UVB. If outside for prolonged periods, re-apply sunscreen every two hours. Surfaces such as water and snow can reflect a significant amount of sunlight, so be sure to use sunscreen when around such surfaces.

The majority of sun exposure a person receives is in the first two decades of life. Thus it is very important to protect children in these ways. Teach by example, apply sunscreen, wear protective clothing and eyewear, stay in the shade when outdoors, and avoid sun exposure during peak hours.

Afraid of Botox?

Afraid of Botox?

This is a common comment. Many people are afraid to get Botox because it is a toxin. Below are three facts that dispel the myths associated with Botox.

1. Botox does not contain the bacterium Clostridium botulinum, the bacterium that causes botulinum. It only contains the protein which is involved in the effect. Unless the bacteria are in the body, the protein will not continually be produced.

2. Botox is injected very superficially into the skin. It does not reach the bloodstream sufficiently to cause the symptoms associated with botulism.

3. The amount required to cause symptoms of botulism is approximately 100 times the amount injected into the skin.