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How Dermatologists Use Lasers and Other Light-Based Devices

Rocket projected onto the Washington Monument during the celebration of the 50th anniversary of Apollo 11.

As we celebrate the spectacular achievement of the moon landing 50 years ago, we can reflect on the technological advances that have had an impact on dermatology. In the half century since Dr. Leon Goldman pioneered the medical application of lasers, they have become integral to state-of-the- art dermatology practices. So how do dermatologists use lasers and other light-based devices?

Uses for Laser, Light and Energy-based Devices

Remove unwanted hair

Lasers remove unwanted hair from the face and body by targeting the pigment of the hair and damaging its follicle so that hair growth is slowed. In order for lasers to be effective, the hair must be treated while in its “active growth” phase. This is why multiple (usually six to eight) treatments, spaced four weeks apart on the face, and as much as eight weeks apart on the body, are needed to achieve good results. The same lasers are also effective for excessive sweating or hyperhidrosis. Note: Only specific lasers are appropriate for darker skin types, and those with tanned skin should avoid the treatment.

Do away with those age spots

Sun damage and aging can result in unwanted brown spots, called lentigines, on sun-exposed areas such as the face, chest and hands. Those spots can successfully be treated with Q-switched lasers and IPL (Intense Pulsed Light) devices. Several treatments may be required to achieve optimal results.

Treat redness and broken blood vessels

Lasers are effective at treating skin redness from conditions such as rosacea as well as benign vascular growths such as angiomas and broken blood vessels that can occur from sun damage. The treatment works because lasers at certain wavelengths can target hemoglobin that is found in blood. Typically one to a few treatments may be needed for optimal results. It is important to use a broad-spectrum sunscreen after the treatment.

Banish those breakouts

Lasers and light-based devices can successfully treat mild to moderate acne. While conventional methods to get rid of acne include topical and oral medications, such as antibiotics and retinoids, the use of photodynamic therapy can be effective in achieving long-lasting clear skin. Photodynamic therapy combines the use of a photosensitizing chemical that is absorbed both by the oil glands and the bacteria that produce acne – followed by a light source or laser to activate the chemical. This results in shrinkage of the oil glands and killing of the bacteria.

Refresh and rejuvenate

A newer generation of devices today allows for skin resurfacing that removes the top layer of skin to eliminate signs of aging and photodamage such as fine lines, wrinkles, crepiness and brown spots as well as reducing enlarged pores – all with minimal downtime.

Soften the look of scars

Lasers can improve the appearance of scars – whether they were caused by acne, trauma or surgery. Some devices – like the pulsed dye laser – can help reduce the redness associated with scars. Fractional resurfacing lasers can successfully improve a scar’s texture and tone. Depending on which device is used, there may be a period of downtime following the treatment and a need for several treatments.

Take care of that ‘turkey neck’

With age comes a loss in collagen, which can result in loose skin on the neck and under the chin – affectionately known as “turkey neck.” Fortunately, there are non-invasive technologies that utilize ultrasound and radiofrequency to stimulate collagen production – resulting in skin tightening and lifting. These treatments also can be used for wrinkles on the décolletage, that crepe-paper look on the upper chest.

Rethink the ink

Fortunately there are options for those 20 percent of people who experience tattoo regret. Q-switched lasers have been used for decades to heat up and destroy the tattoo ink particles, usually over multiple treatments. Newer technology using ultra-short bursts of energy can achieve the same results in fewer treatments.

If you think one of these treatments could be right for you, contact us to schedule a consultation. Located in Chevy Chase, MD, our dermatology office serves the greater Washington D.C. area.

Choosing the Right Sunscreen

I love France! The food, the wine and …  the sunscreen! This week I’m writing about two of my favorite topics in one blog post: Sun Protection and the South of France!

The weather report from the outside world to us office-dwellers is that it’s been wonderful out there: sunny and not as humid as a typical Washington summer. That helps explain why I am being asked constantly for a recommendation for the best sunscreen. There is of course another reason for needing guidance: there are so many sunscreen options available. Standing in the aisle at CVS trying to pick the right one hasn’t been made any easier with the recent headline: “Sunscreen enters bloodstream after just one day of use, study says…”

That health alert was but a blip in the news cycle, but it was important and I am glad that my patients are still asking about it. The study, published in the medical journal JAMA, showed that four sunscreens when applied in maximal use scenarios (four times daily, on 75% of the body) resulted in measurable amounts of the chemical sunscreen agent passing through the skin to the bloodstream. It sounds alarming, but the study stopped short of looking at the health impact of the discovery and thus additional studies are underway. It’s important to note that all of the chemicals identified in the study are FDA-approved and have been in use for many years, without showing any harm. Likewise, there is strong evidence that regular sunscreen use helps reduce the risk of cancer and premature skin aging, so there is no justification for abandoning sun-safe behavior.

So, what should we slather on in the meantime?

Getting to that answer involves a quick look at the science behind how sunscreens work. There are two general classes of sun protection agents that differ in their method of action. SunSCREENS are those that rely on active chemical agents (with names like oxybenzone) that absorb harmful UV radiation and release its latent energy as heat on the skin surface. This was the class included in the study.

SunBLOCKS work entirely differently. They employ extremely fine-grained minerals, zinc oxide and titanium dioxide, to provide a physical barrier at the skin surface. These inert minerals reflect or scatter the radiation, preventing the rays from ever reaching the skin. In days past, they were the magic in the greasy white paint lifeguards smeared on their noses. Today, these minerals have been refined and formulated in to sheer creams, lotions and sprays that are invisible when worked in to the skin and pleasant to the touch.

Okay, let’s talk about France! 

American dermatologists and others interested in the topic have known for years that you can buy a much wider array of UV-stopping products in Europe. Why is that? This answer requires a brief look at government regulation. European consumer product rules are focused on the accuracy of manufacturers’ claims, which in the case of sunscreens and blocks is about their ability to stop or absorb UV rays. In the US, the Food and Drug Administration assesses manufacturers’ claims of efficacy. However, the FDA is concerned with potential toxicity of the same chemicals within the human body and environment, thus setting a higher bar of regulation. Meeting the FDA’s testing requirements takes considerable time for which many European manufacturers do not have the appetite. Several European brands have cleared this high bar, though, bringing a few sunscreen formulations to the US that have been used in Europe for years. In the meantime, there are many more choices available throughout Europe.

All this explains why on a recent sunny weekend in the south of France an American dermatologist (moi) was SLOWLY browsing a wide array of sun screen products in a charming pharmacy. Even for me, the process was daunting!

So at last, my best sun protection product advice: when reading a product label, be it in France or CVS, use sunblocks that rely on zinc oxide or titanium dioxide and have an SPF 30 or higher. These active ingredients have not been found to cross in to the blood stream, they are non-toxic, they stop UVA and UVB from reaching your skin and some formulations have become so sheer that you don’t even notice you have them on. These “physical” sunblocks are widely available. For years, my office has only carried sunscreens that have fewer chemicals and rely on non-reactive ingredients. If you are heading to the south of France or the south side of your neighborhood pool, you can pick them up on your next visit, or call and we can ship to you.

Helping Armenia’s Angels Smile

I just spent one of the most rewarding weeks of my career in Armenia.  I was a member of a delegation from the “Face of Angel” nonprofit organization started by Drs. John Poochigian, Christine Avakoff and Lilit Garibyan in 2019, whose mission is to establish state-of-the art medical laser clinics in Armenia and train Armenian physicians how to use these lasers to treat patients with life-altering birthmarks and severe scars.  I accompanied Drs. Lilit Garibyan and Rox Anderson of Mass General Hospital, Harvard Medical School who organized this trip.  In 2013 they teamed up with Dr. Christine Avakoff and Dr. John Poochigian to establish two clinics in the capital city of Yerevan – Arabkir Hospital and the Armenian-American Wellness Center.  These facilities provide high quality medical care through the use of lasers to anyone in need, regardless of economic status.  The laser equipment was donated by Candela Laser Corp and Quanta Laser companies.  

Our mission was to help as many patients as possible, as well as train local doctors in the use of the advanced laser devices in managing debilitating scars and vascular anomalies. We were fortunate to also have on the team Branko Bojovic, M.D., chief of plastic surgery at Shriners Hospitals for Children, Boston.  Over four days, our team treated dozens of pediatric and adult patients and trained the leading local plastic surgeons.

Our time spent with patients and families was always touching.  It was common for an entire extended family – perhaps eight or nine members – to accompany a child who was being treated. One of the Armenian doctors explained that when a youngster made the trip from the countryside, in addition to the parents it was customary that aunts, uncles, siblings and a trusted elder would also be part of the entourage.  These children were very well looked after!

Some of the children had been treated before and were returning for follow-up.  The results were frequently profoundly positive.  The mother of a young girl who had undergone laser surgery the year before for a large birthmark on her face said her daughter’s life had been absolutely transformed. She described 9-year-old Lianna as having been extremely shy, to the point of being unable to look anyone in the eye or to make friends.  She was overjoyed that her daughter, who smiled at me with beautiful eyes, was now bubbling over with enthusiasm for school and her classmates.

Armenia is an ancient nation, in 301 AD becoming the first in the world to adopt Christianity as its state religion. Once a part of the former Soviet Union, this country of 3 million people, 98% of whom are ethnically Armenian, declared independence in 1991. Although it had been one of the most developed and economically robust of the former Soviet republics, it suffered a dramatic drop in Gross Domestic Product (GDP) after independence. While the literacy rate is close to 100%, the economic situation is tenuous but improving. Per capita GDP rose from $886 USD in 1993 to $4200 in 2017.

Medical resources in Armenia are generally very limited but physicians across the country are well-trained and enormously dedicated to elevating the care of their patients.  I learned a great deal from them as I did from my fellow members of our very collaborative delegation.  It was inspiring to be a part of this mission to improve the lives of patients whose injuries and birthmarks have significantly diminished their quality of life. In order to accomplish its mission of establishing fully functioning and sustainable medical laser clinics in Armenia, the “Face of Angel” organization is planning to take more lasers to the country and organize more trips to train and teach Armenian physicians. The team encourages those interested in  supporting these plans to contact  lgaribyan@mgh.harvard.ed 

The “Face of Angel” organization is truly life-changing for all those it has touched and I am indebted to its founders for allowing me participate and give back.

 

Early Detection Just Got VERY High Tech

FotoFinder Automated Total Body Mapping Studio

“Early detection” is something I talk about a lot.  That is for good reason: skin cancer is not only the most common form of cancer in the United States, it is also the most curable – that is, IF it is detected early.  This is why I talk just as much about the importance of regular full body exams.

May is Skin Cancer Awareness Month, so this is an especially good time to mention a powerful new early detection tool I’ve just added to my practice:  FotoFinder.  This breakthrough technology is truly one of the most impactful medical devices I have seen in my career.

FotoFinder combines the very best photographic equipment and German robotic engineering in a way that superbly augments the dermatology professional during full body exams.

Here’s how it works: The computer-controlled machine captures highly detailed photographs of the entire skin surface and merges them into a comprehensive Total Body Map.  It then employs artificial intelligence to meticulously compare current skin conditions to earlier “baseline” images.  If it “sees” new moles, or even minute changes in existing moles, it automatically flags them for detailed follow up by the professional.  The mapping and analysis process take just 20 minutes.  It is amazing technology that will greatly advance early detection of skin cancer.

Baseline: FotoFinder Total Body Map

Follow Up: Updated Body Map, with moles highlighted for further examination

When I saw this sophisticated device in action, I knew immediately I need to bring this to our patients.  The Dermatologic Surgery Center of Washington is the first and only practice in the Washington, DC region to install this significant advancement in the science of early detection.

Since we installed the system in January, I am often asked who should consider FotoFinder early detection technology?  If you can answer yes to any of these questions, I recommend we discuss if FotoFinder is right for you:

  • Do you have a history of melanoma or other skin cancer?
  • Do you have a family history of skin cancer?
  • Do you have many moles – more than 50?
  • Do you have large moles – 2 inches in diameter or larger?
  • Do you see changes in a mole or have new moles?
  • Do you have a history of a severe, blistering sunburn as a child or adolescent?
  • Do you have very light skin?
  • Are you exposed to strong sunlight on a regular basis?

Skin Cancer Awareness Month is a great time to make an appointment with one of our talented dermatology professionals for your next full body exam – and create your baseline Total Body Map with FotoFinder.

Click here to make an appointment online or call us at 301-652-8081.

 

All the photos used are courtesy: FotoFinder Systems, Inc.

Progress Being Made in the Dermatology Field

The annual American Academy of Dermatology meeting took place in DC in March and I was thrilled to serve as faculty along at the Live Injection Course. My colleagues – leaders from around the country- and I demonstrated injection of fillers and toxin to a packed audience. This came right after our office hosted the International Peel Society workshop in which visiting dermatologists learned state-of-the-art peel techniques. Best part of all of this was how much I leaned from my colleagues!

The AAD meeting is the largest assemblage of dermatologists anywhere and it was full of cutting-edge research from around the world.

What We Learned

In the war on melanoma, continued progress in melanoma immunotherapy has vastly improved survival rates. Future melanoma treatment may consist of personalized therapy in which a vaccine is created based on the specific antigens most expressed on an individual patient’s tumor. In this way the patient’s immune system is encouraged to recognize and attack his or her own melanoma cells.

We also learned a lot about a new class of medications called “JAK” (Janus Kinase) inhibitors. These agents are game changers for alopecia areata, atopic dermatitis, vitiligo and psoriasis. These are systemic medications, taken by mouth, but even the topical cream version has been shown to be effective in children with alopecia areata.

And for melasma, the difficult to treat darkening of the skin, there was encouraging news. Tranexamic acid in pill and topical form along with a new agent reduce the pigment that is so resistant to treatment.

Progress is being made on nearly every front in our field!

Older woman's hands on keyboard, aging hands

What Can Be Done For Aging Hands?

Did you know that your hands can reveal your true age, well before other areas of the body begin show signs of aging? While aging of the hands typically begins by age 50, with the first signs being discoloration and age spots, hands can start to age sooner if individuals are frequently exposed to the sun without the proper protection. By age 50-60, people also tend to lose volume in their hands, making veins and tendons more prominent and further contributing to aging hands. The good news is there are treatments available that can slow or reverse some of the signs of aging hands. Treatments can be tailored to the individual, depending on their specific concern:

Age spots:

Pigment-specific lasers are used to treat dark brown spots on the hand by delivering a beam of light that penetrates the skin surface. Following treatment, brown spots appear darker for about a week and then will scab, fall off, and turn pink as the skin begins to heal. One to two treatments are usually needed before improvement is noted. Results can last for years as long as proper care is taken to avoid sun exposure to these areas.

Topical retinoids and bleaching creams, like hydroquinone, can also be used to diminish the appearance of dark spots. They can be used either alone, or in combination with lasers, to reduce the appearance of age spots.

Volume loss:

Injecting fillers into the back of the hand is a quick, in-office procedure that can be achieved by using a non-allergic product called calcium hydroxylapatite. Results are immediate and can last for 1-2 years.

Applying a lotion or cream after washing your hands helps to trap water in your skin, and can provide a temporary plumping effect.

Rough, scaly patches:

If you have fair skin and spent a lot of time in the sun, you may notice rough spots or patches on your hands. These rough patches may be actinic keratoses (AKs), which are pre-cancerous growths that need to be evaluated and treated by a dermatologist. Liquid nitrogen (cryotherapy) can treat the individual AKs, while topical medicated creams or photodynamic therapy can treat the entire area at once.

Wrinkly “crepey” skin:

Applying sunscreen to your hands every day can prevent wrinkly skin on your hands. To treat wrinkles that are already there, your dermatologist may recommend a lotion containing retinol or glycolic acid or light chemical peels.

Radiofrequency treatments, which use heat directed deep into the skin, can help tighten loose skin. Most people only need 2-3 treatments on their hands to see results.

Brittle nails:

Brittle, aging nails typically present as lines running lengthwise on your nails, appearing like ridges. You may also notice that your nails peel or break easily. Certain activities such as cleaning with harsh chemicals or spending a lot of time with wet hands, can cause brittle nails, so it is important to wear rubber gloves when cleaning and doing dishes.

It is also important to moisturize the hands regularly with a urea- or petrolatum-containing moisturizer, preferably after every hand washing and before bed.

The nails reflect overall health. Changes in nail color or shape can signify a systemic problem that should be evaluated by a dermatologist.

Follow up:

It is important to follow up with your dermatologist after your treatments to help maintain your results as long as possible. Sun protection is essential at all times, and can be achieved by using a broad spectrum water-resistant sunscreen with SPF 30 or higher and reapplying regularly throughout the day. UV-protective driving gloves are also helpful in blocking out the sun’s harmful rays.

References:

American Academy of Dermatology. “What can make my hands look younger?” Available online at: https://www.aad.org/public/skin-hair-nails/anti-aging-skin-care/younger-looking-hands

American Academy of Dermatology (August 2012). “Busy moms deserve a hand: Dermatologists offer tips to prevent premature aging of the hands.” Available online at: https://www.aad.org/media/news-releases/busy-moms-deserve-a-hand-dermatologists-offer-tips-to-prevent-premature-aging-of-the-hands

 

Frequently Asked Questions Regarding Infini Wrinkle Reduction

Infini is a technology developed for surgical scar improvement that can also enhance and rejuvenate aging skin, providing consistent results and low downtime.

One of the many benefits of Infini is that it can be used at any time of the year and on any skin. Infini does not directly affect the epidermis. It is a non-invasive procedure that addresses both post-operative scars and the skin laxity such as wrinkles and textural changes that are a consequence of sun exposure.

Q: What is this procedure good for?
A: Overall skin rejuvenation; fine lines and wrinkles, improving tone and textural changes- especially “crepey skin”, sagging skin, acne scarring

Q: What parts of the face/ neck can it improve?
A: Brows, crows feet, upper lip, neck and chest

Q: How does it work?
A: Energy delivered into the skin stimulates the natural growth of collagen and elastin—natural  “scaffolding.”

Q: Why is radio-frequency an important addition to microneedling?
A: The radio-frequency delivered via gold-plated microneedles is a powerful stimulant for new collagen production.

Q: What preparation is involved?
A: Application of a topical numbing cream in the office for approximately 2 hours

Q: How long is the procedure?
A: About 30 min

Q: What is the downtime?
A: There is redness and swelling for approximately 48 hours, which may take up to a week to resolve. Make-up may be applied after 48 hours

Q: How quickly will I see results?
A: It takes a few weeks to begin to see results. Improvement continues over a period of up to 6 months

Have questions or want to make an appointment at Dermatologic Surgery Center of Washington? Click here to contact us.

Immunotherapy for Melanoma

Melanoma is by far the deadliest skin cancer but recent advances in cancer treatment have significantly improved the prognosis.  More than one million Americans are living with melanoma. It is estimated that 91,270 invasive melanoma cases will be diagnosed in 2018, with invasive melanoma projected to become the fifth most common cancer in men and the sixth most common cancer in women in 2018.[1]

Melanoma is more likely than most cancers to spread to the brain, and once it gets there, fewer than 20 percent of patients survive within one year with traditional treatments.[2]  However, newer options utilizing the body’s own immune system hold promise for helping patients with advanced-stage melanoma.  You may have read about the recent Nobel Prize winner, Jim Allison from MD Anderson Cancer Center.  His discoveries laid the ground-work for a life-saving new treatment for melanoma.

Immunotherapy works by harnessing the body’s own immune system to recognize and destroy cancer cells more effectively. Within our immune system, there are regulatory molecules called immune checkpoints, which work to keep the immune system in a balanced state (homeostasis). Tumors from cancers like melanoma take advantage of this regulatory mechanism to avoid being eliminated by the immune system. [3]

A specific group of immunotherapy drugs, called checkpoint inhibitors, work by inhibiting these immune checkpoints to release the brakes and unleash a much stronger immune response to the tumor. While these drugs do not help everyone, they have demonstrated excellent results thus far and are an important part of the initial treatment plan for patients with advanced melanoma.

 

 

[1] American Academy of Dermatology. Skin Cancer; Incidence Rates. Available online at: https://www.aad.org/media/stats/conditions/skin-cancer.
[2] Grady, Denise (Aug 22, 2018). Immunotherapy Drugs Slow Skin Cancer That Has Spread To The Brain. The New York Times; A16.
[3] Grady, Denise (Aug 22, 2018). Immunotherapy Drugs Slow Skin Cancer That Has Spread To The Brain. The New York Times; A16.

what-is-your-skin-cancer-iq

Test your skin cancer IQ

Skin cancer is the most common cancer in the United States, and it is estimated that one in five Americans will develop this condition in their lifetime. Skin cancer is triggered by mutations or defects in DNA, leading to cells growing out of control to form malignant tumors.

Back to School Rash

I love September! To me, Back-to-school means clean notebooks, new horizons and the memory of a fresh box of Crayolas. My excitement is just another in a long list of quirks that my children find perplexing and irritating. I somehow haven’t completely transmitted the enthusiasm my own parents had for the start of the school year.

My dad, a college president who saw the potential student in almost everyone, looked upon the beginning of the semester like a child anticipates Christmas morning. His own education was a transformative gift, and he never got over his wonder and gratitude. My mother excitedly planned first-day-of-school outfits and staged multiple photos, but one year she got a little ahead of herself. As she pulled out of the elementary school driveway, having dropped me and my brothers off at the front entrance, the custodian waved down her speeding station; the first day of school wasn’t until the NEXT day. I get it; summer vacation can get too long when you have three kids underfoot.

In the wonderful world of dermatology, the fall also brings particular skin conditions. One of these back-to-school rashes is hand, foot and mouth disease.

Hand, foot, and mouth disease is a viral infection that causes sores in the mouth and a rash on the hands and feet. It is common among children under the age of 5, particularly in daycare settings, as it spreads by close contact with infected people. It’s not usually serious, and nearly all people recover within 10 days without medical treatment. (1)

Symptoms of Hand, Foot and Mouth Disease

● Fever
● Poor appetite
● Sore throat
● Rash – Small red bumps or blisters on the palms, soles of the feet, and sometimes the knees, elbows, buttocks, and genital area.
● Painful sores in the mouth

Symptoms typically appear 3-6 days after the initial infection (incubation period), with fever as the first sign, followed by a sore throat. (2)

Transmission

Hand, foot, and mouth disease spreads through contact with infected individuals’ nasal secretions, throat discharge, saliva, stool, or respiratory droplets after a cough or sneeze. It may also spread through contact with blisters on the skin.

Infected individuals are typically most contagious during the first week of illness, but the virus can remain in the body for weeks after the signs and symptoms are gone, resulting in further transmission. Some people, particularly adults, can pass the virus without showing any signs of the disease. Outbreaks of the disease are common in the summer and autumn in the United States and other temperate climates. (3)

Treatment for Hand, Foot and Mouth Disease

There is no specific treatment for hand, foot, and mouth disease. Symptoms, such as fever, can be managed with over-the-counter analgesics, like Ibuprofen or Tylenol. It is important that infected individuals drink plenty of fluids to stay hydrated, particularly if fever is present. Complications of hand, foot, and mouth disease are rare, but may include viral meningitis or encephalitis. High fevers not relieved with analgesics, headache, stiff neck, or back pain warrant further evaluation by your physic.

 

 

 

(1) CDC (June 28, 2018). Hand, Foot, and Mouth Disease. Accessed online at:
https://www.cdc.gov/features/handfootmouthdisease/index.html .

(2, 3) Mayo clinic (July 26, 2017). Hand, Foot, and Mouth Disease . Accessed online at:
https://www.mayoclinic.org/diseases-conditions/hand-foot-and-mouth-disease/symptoms-causes/syc-20353035 .