Southern Westchester Dermatology, P.C.
Ellen D. Teplitz, M.D.
Dermatology and Dermatologic Surgery
Diplomate of The American Academy of Dermatology
The Annual Newsletter - 2007
There are several new products and devices that have come to the market over the past year.
Thanks to significant improvements in laser technology, cutaneous laser surgery has become the first line therapy for many dermatologic conditions.
The Ultrapulse C02 laser can
resurface the skin for removal of wrinkles, chicken pox scars, acne scars, precancers and benign skin tumors. These lasers are less destructive to the surrounding tissues, which result in faster healing time, and decreased incidence of pigmentary alteration and scarring.
This laser is excellent for upper lip wrinkling (smoker's lines), eyelid crepiness and darkening, and chapped sun damaged lips.
The Q Switched ND: Yag laser
is excellent for the treatment of pigmented lesions such as freckling, lentigines (sun spots), and tatoos. It is excellent for the removal of lentigos of the mouth, blue nevi and the nevus of OTA. Melasma, a common pigmentary alteration seen during pregnancy, hormonal replacement and birth control usage, may respond to this laser.
Please note that not every brown spot should be "zapped" by a laser. Melanoma and it's precursors should be ruled out before any procedure is implemented. Widespread use of these devices by estheticians, nurses and physician assistants or medical physicians untrained in dermatology should proceed with caution.
utilize pulses of light to selectively heat and destroy abnormal blood vessels. The type of vascular lesion treated will determine the best type of laser to use. Fine telangectasias on the face from sun damage, rosacea, connective tissue disease and hypertension respond best to pulsed dye lasers. Considerable downtime is needed as a result of dark purpura. The KTP laser is an excellent alternative due to the lack of purpura and therefore, faster healing. Deeper lesions such as spider angiomas, hemangiomas, venous lakes and spider leg veins respond to the long pulse ND-Yag laser with variable pulse widths. Contact cooling is concurrently used to allow for safe and effective treatments.
Intense Pulse Light & Photo-rejuvenation Devices:
These devices have been around for a few years, originally developed to treat leg veins. IPL improves lentigos (sunspots), broken blood vessels, and ehances collagen formation in the dermis. A series of treatments are required with little down time.
A new use for IPL is to treat inflammatory acne vulgaris and actinic keratosis (precancers). Placing a topical solution of amino levulinic acid (photo enhancer) on the treated area with "blue light" activation alters the structure of the skin. Oil glands diminish in size, and precancerous cells burn away. Long-term studies are needed to prove efficacy and safety without deleterious effects.
Laser Hair Removal
is accomplished through follicular unit destruction. The use of new super long pulsed lasers that propagate thermal damage targeted to the deep, amelanotic stem cells are essential to ensure follicle destruction. The long pulsed ruby, alexandrite and diode lasers are of similar efficacy for treatment of brown to black hair in lighter skin types.
On average, percent reduction of hair varies with the number of treatments, the anatomic sites and the energy used. Darker skin types respond best to the long pulsed ND-Yag lasers. The mean hair reduction is approximately 50% to 75% after six treatments. The best candidates are patients with light skin and dark hair since they can tolerate higher energies per treatment. Potential side effects include pigmentary alterations, blistering, scarring and crusting. Women of Mediterranean and Middle Eastern heritage with poorly defined hairlines may develop laser induced facial hair growth.
New Medical Advances in Skin Disorders
Atopic dermatitis/Eczema - The controversy over Protopic and Elidel with regard to sustained safety in children and the possible development of lymphoma is being investigated. A task force reviewed the available data and concluded that the risk verses benefit ratios of tacrolimus and pimecrolimus are similar to most conventional therapies. The reported cases of lymphoma from these topical immunomodilators are not consistent with lymphomas from systemic tacrolimus.
Mimyx is a new cream for atopic skin that contain PEA and natural skin lipids. The cream claims to reduce the inflammatory properties that cause itching.
Psoriasis - Biologic agents represent a new frontier in treatment options for psoriasis and psoriatic arthritis. Two families of drugs are targeting either tumor necrosis factor or T cell modulators. TNF antagonists include infliximab (Remicade) and adalimumab (Humira). T cell modulators include efalizumab (Rapitiva) and alefacept (Amevive). Depending upon a patient's medical history, age and type of psoriasis and arthritis involved, will determine the best biologic to use.
Systemic drug therapies are still utilized for extensive psoriasis. Cyclosporin, methotrexate, and Soriatane (acitretin) are effective and safe when used correctly.
Localized psoriasis - responds to Dovonex, Tazorac, topical steroids and coal tar. A novel formulation that combines a Class II steroid and Dovonex called Taclonex is a highly effective topical medication. It is applied once a day. The steroid foam technology seen in Luxiq and Olux foams are preferred for hair bearing areas of the body.
Genital wart prevention - human papilloma virus is a common virus that effects at least 50% of sexually active people during their lifetime. The new vaccine Gardasil is now recommended for girls and young women ages 9 to 26. It may help protect against HPV types 6, 11, 16, 18 that cause genital warts, precancerous vulvar and vaginal lesions and cervical cancer.
Hair loss and balding: Androgenetic alopecia (familial balding) affects males and females alike. Propecia blocks the conversion of testosterone to 5 dihydrotestosterone which decreases the miniaturization of hair follicles. This drug cannot be used by women or children. Women can be treated with cyproterone acetate and spironolactone which is also used for hirsutism Topical minoxidil is still the topical treatment of choice for genetic balding. It is now available in a 2% and 5% foam preparation.
Special skin care products for cancer patients undergoing chemotherapy and radiation therapy - dry, itchy, flaky skin, sores and burns are common problems plagued by patients undergoing chemotherapy and radiation. Antioxidants, vitamin-based products, hydrating oil-based moisturizers and anti-bacterial ingredients are incorporated into a skin care regimen that Dr. Teplitz will provide for you.
Foot Care - as we age, feet bear many insults from ambulation. The skin thickens, cracks and dries which can be painful. Kerol (42% urea) redicloths provide an abrasive backing that smoothes dead skin and simultaneously provides hydration with urea. Glytone Ultra Heel and Elbow is a 30% glycolic acid which also smoothes rough, thickened skin.
Acne Vulgaris treatments
Differin and Tazorac - are second generation retinoids (Vitamin A derivatives) which target abnormal keratinization thus allowing the skin to shed it's top layers. This unplugs the oil glands and hair follicles - the key in controlling acne. Women who are pregnant should avoid these drugs.
Retin A Micro .1% and .04% gels - incorporate microsponge technology allowing the active retinoic acid to remain in the epidermis. It is now packaged in a premeasured pump for guaranteed freshness and moisture.
Topical Antibiotics: Duac is a new combination drug of clindamycin gel and benzoyl peroxide similar to benzaclin gel. The formulation is not drying and leaves little residual film on the skin so makeup can be smoothly applied.
Compliance is a big factor for treating teenage acne. Medications in foil packaging are en vogue. Plexion cloths, Rosula NS towelettes and Evoclin foam are examples of novel packaging and easy transportability.
Systemic Antibiotics - a new tetracycline derivative called Solodyne concentrates into the oil glands and requires a lower dosing with minimal side effects when compared to traditional tetracycline derivatives.
Anti-androgen therapy can play a significant role in maintaining the control of acne vulgaris. This works in females over the age of 25 with acne distributed on the chin, jawline and neck. Hormonal evaluation should be performed if acne is associated with hirsutism, female baldness, infertility and abnormal menses. Birth control pills namely Orthotricyclen, Desogen and Demulen are best. Yasmin, a new birth control pill that contains drospirenone, a similar compound to spironlactone was recently introduced for both acne and hirsutism. Spironlactone and Tagamet are still good alternatives for these conditions.
Acne and Pregnancy. Women who are undergoing fertility procedures or women who are in the first trimester of pregnancy should use topical erythromycin for antibacterial therapy and fruit acids for comedone control. It is important to undergo a series of glycolic acid peels and acne surgery to control the acne. Topicals such as Retin A, Tazorac and Differin, and oral antibiotics should be stopped as quickly as possible.
Treatment of Acne Scars - the ice pick and boxcar scarring from post inflammatory acne is challenging to correct. A new technique utilizing 95% trichloroacetic acid (TCA) applied to each scar for six treatments at six week intervals stimulates collagen and elastin fibers in the treated areas. This is a simple, safe and cost effective method for acne scar treatment.
New Medical Therapies for Skin Preservation and Rejuvenation
Vitamin Therapy has been around for a long time but delivery into the tissues has been a limiting factor. Now acrylate copolymer or "sponges" target the upper layers of the skin and increase absorption without irritation.
Vitamin C (L-Ascorbic Acid) or its derivative Magnesium Ascorbyl Phosphate (Mag C) maximizes the production of collagen formation and retards melanin production in the skin. It retards the "darkening" and crepy wrinkling we all get as we age. The new formulations are excellent for the eyelids where crepiness and darkening are most evident.
A new formulation targeting eyelid puffiness and darkening designed by `Prescribed Solutions" incorporates hesperidin methyl chalcone, dipeptide-2 and palmitoyl tetrapeptide-3. These ingredients are found in hylexin, touted as the new eye cream wonder for
eyelid puffiness. We add vitamins C, K, E, and A along with elastin and collagen to the formulation for improvement in texture and elasticity of eyelid skin. It is an excellent product to use after eyelid surgery.
Triluma: A compound of hydroquinine, hydrocortisone and tretinoin designed to clear "The mask of pregnancy". It is also excellent for the discoloration from sun exposure and damage.
Carac Cream - treats solar keratoses (precancers) with Efudex in a novel delivery system which concentrates the drug in the epidermis. Less drug is needed for comparable results.
Alpha Hydroxy Acids (AHAs) - the glycolic acid home products in conjunction with other medications and the in-office fruity peels have become the main adjuvant for acne vulgaris, rosacea, solar keratosis, keratosis pilaris and sun damaged skin. They work beautifully in dark skinned patients who pigment easily after breakouts.
Lactic acid (a milk source) at 5% and 10% concentrations are excellent for skin rejuvenation and exfoliation. It is less irritating than glycolic acid and designed for the sensitive, older and more mature fragile skin.
Alpha lipoic acid: Reduced to dihydrolipoic acid, active within the cell membrane is shown to prevent UV mediated cell damage. It helps diminish fine lines and wrinkles.
DNA Repair Enzymes. A novel approach for repairing sun damaged DNA in skin cells will be added to sunscreens in a lotion form. The DNA repair enzymes (T4 endonuclease V and photolyse) are placed into liposomes and delivered into the skin cells. Hopefully these enzymes will significantly reduce the annual incidence of actinic keratoses, squamous cell carcinomas, and basal cell carcinomas.
Peptide therapy - these molecules are groups of amino acids that either stimulate fibroblasts or act on specific enzymes that inhibit muscle contraction and decrease the "pull" on the skin. The data to support these claims are soft but they are being added to many expensive creams. Palmitoyl pentapeptide-3, palmitoyl tetrapeptide-3 and oxido reductases (rice and soy peptides) are the most common peptides incorporated into creams.
Antioxidant therapy - There is a flurry of new skin creams that contain antioxidants which act as "scavengers" for free radicals that damage skin cells. Idebenone, found in Prevage, COQ10, and green tea extract are the most popular antioxidants available.
Human growth factors - such as epidermic growth factor, vascular growth factor and beta 1 growth factor, along with Ferulic acid, reverse sun damage and enhance photoprotection more than eight times that of green tea and Vitamin E. This unique mix of ingredients will be incorporated into many cosmeceutical lines in the near future.
Minimally Invasive Medical and Surgical Techniques for Anti-Aging
Botox: The use of Botulinum Toxin Type A to prevent frowning and motion wrinkling is very effective around the eyes and forehead. The toxin has been used for years in patients with strabismus and neurological spasmodic disorders. It must be injected between 4-6 months.
It is beneficial in the treatment of sweaty palms and axillae. Diminished sweating will last 7 - 12 months after the treatment.
Botox can make the eyes appear more open by injecting each lower eyelid. Asian women are attracted to this since it make the eye shape more rounded.
It is now administered into the upper and lower lips to decrease the "pucker lines" around the mouth. It can affect articulation of certain words and sipping of liquids.
Consumers should be aware of Botox treatments for bargin basement prices and only undergo treatments with credentialed physicians. The botulism toxin is also manufactured outside the country and quality control is questionable. Several individuals recently developed botulism from foreign Chinese botox and not Allergan's product.
Reloxin (Dysport) - botulinum toxin type A poised to be the first rival to Allergan's Botox. There are subtle differences between the two products. Reloxin (Dysport) produces a broader relaxation effect, and, therefore, obtains a larger area of wrinkle reduction. Other slight differences include quicker and longer lasting results in select patients. FDA approval will increase competition and likely reduce prices of Botox to consumers.
Soft Tissue Augmentation
Cosmoderm and Cosmoplast - from human cloned skin cells. This is replacing dermalogen and does not require skin testing.
Calcium hydroxylapatite - (Radiesse) - a new filler that promotes the formation of fibroblasts, collagen, elastin and glucosaniinoglycans into the deeper dermis to fill defects resulting from surgery, medications and trauma. It acts like an "implant" which contours the skin for 12 - 18 months. It will be used for deep furrows in the nasolabial folds, the lower mouth, cheeks, and chin areas.
The hyaluronans: Perlane and Restylane are used for tissue augmentation that include thin lips, deep wrinkles and deep folds. These products last longer than collagen but require local anesthesia and oral blocks for administration. Juvederm is a new product similar to Restylane that was recently approved by the FDA.
Chemical Peels: Chemical peels still play a role for skin rejuvenation. I like to use these in combination with C02 laser resurfacing in areas that are less sun damaged or wrinkled. In this kind of combined procedure, part of the skin is resurfaced with the laser (usually the upper lip, chin and eye area); then the TCA 35% is applied to the dermarcation areas. There is also combined tightening and leveling effect achieved over the whole face.
The 70% glycolic acid peel - is an excellent alternative treatment for extensive solar keratoses (sun spots) along with liquid Efudex applied at the same time. Several treatments are needed monthly throughout the year.
Sclerotherapy for leg veins: This procedure is used to remove fine spider veins of the lower extremities. A new technique called "foam sclerotherapy", whereby adding air to the sclerosant enhances vein wall destruction. You now need less concentrated amounts of sclerosing agent with this technique.
Other services provided by the office:
Microdermabrasion: This is a new popular procedure added to the practice. It is a "gentle sandblasting" of the skin. The aluminum oxide crystals abrade the skin which removes the stratum corneum. A series of 4-6 sessions performed 1 or 2 weeks apart can improve acne scars, fine wrinkling and sun damaged skin. There is no down time or anesthesia required. Ask Barbara Minisolo, the licensed esthetician for more details.
Electrolysis: Electrolysis is a very popular mode of permanent hair removal performed in the office. Barbara Minisolo has expanded her hours and offers other services which include skin facials, hair waxing and light fruity-acid peels.
Cosmetic Tattooing - "permanent makeup" a new service offered at the office for individuals who would like permanent definition of their features, which includes the eyebrows, eyelids and lip borders. It is an excellent option for older women who have difficulty putting on make-up daily. It is also used to camouflage skin defects from skin cancer surgery. Ask for Ann Richar and she will discuss the procedures with you.
Dr. Teplitz and her staff are available to discuss any of these treatment modalities with you. Be aware that there are many procedures being offered at spas, salons and even physicians' offices performed by nonphysicians or physicians who are not trained in dermatologic medicine. There has been an alarming increase in the number of patients seeking corrective treatments due to complications from laser surgery, chemical peels and Botox injections. Lawsuits have been brought for permanent burns, scars and skin discolorations. Being treated by non-physicians or physicians outside their field of expertise can result in misdiagnosis, delayed treatments and inappropriate usage of techniques. "Consumers Beware" and be cautious.