Southern Westchester Dermatology, P.C.
Ellen D. Teplitz, M.D.
Dermatology and Dermatologic Surgery
Diplomate of The American Academy of Dermatology
The Annual Newsletter - 2012
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, 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. Several new CO2 lasers have been recently approved for facial rejuvenation utilizing a fractional system.
The Fraxel laser ablates a fraction of the skin in a grid like pattern. They can also be safely used around the neck, hands and chest. This allows for less anesthesia, more rapid administration and faster healing than traditional CO2 laser resurfacing. These fractional designs might be the answer for upper lip wrinkling, eyelid crepiness and darkening around the eyes.
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.
Tattoo removal will soon undergo a revolution thanks to reabsorbable micro encapsulated tattoo ink (Freedom-2). The ink is placed into micro encapsulated spheres which can erase the tattoo in 1 or 2 treatment sessions.
Vascular lasers 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 enhances 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.
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.
Radiofrequency (RF) induces dermal heating and inducing collagen remodeling and wound contraction. This enhances the appearance of mild to moderate skin laxity. Thermacool and Thermage have reported efficacy in the treatment of laxity along the periorbital and jowls areas. Infrared light (Titan) can also induce collagen contraction and improve skin laxity. It can be used in all skin types and multiple sessions (3 to 5) are needed for optimal results.
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.
Community acquired methicillin resistant staphylococcus aureus (CA-MRSA) is growing in numbers. It is commonly carried through nasal passages, armpits and groin skin. People who develop skin abscesses should be cultured and the abscesses should be drained. If CAMRSA is clearly identified, antibiotics including clindamycin, doxycycline and rifampin are usually sensitive.
Clorox bleach baths along with altabax or bactroban cream are cheap and easy methods to avoid recurrences of this skin
Nail Salon infections including fungus, viral warts, and atypical mycobacterium are commonly spread by shared instruments, porous implements such as nail files and pumice stones and pedicure foot spas. To avoid such infections, bring your own surgical instruments and nail files, A void shaving 24 hours before a pedicure. Ask the salon if they use EP A registered hospital disinfectant between each client and clean the plumbing tub with bleach to remove the mycobacterium and biofilm.
Observations implicating psoriasis as another risk factor for strokes, myocardial infarctions, obesity and diabetes have been established. Elevation in blood pressure, glucose and lipids are more prevalent in patients with severe psoriasis. Metabolic syndrome and psoriasis have been linked together by activated T cells which release a cascade of cytokines which are present in both entities.
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.
The laser comb, a red light emitting diode may stimulate hair growth and increase hair density. Light sources may provide a new stimulating method in this elusive field.
Treatment for advanced metastatic (spreading) melanoma
The FDA recently approved Zelboraf (a.k.a. vemurafenib) for melanoma tumors that have a particular gene defect. The drug blocks the function of the defective V600E BRAF gene which is present in 40-60 percent of melanoma tumors. The drug slows or stops the uncontrolled cancerous cell growth associated with the gene defect. It is taken orally.
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.
As we age, feet bear many insults from ambulation. The skin thickens, cracks and dries which can be painful. Hydrofoam (40 urea) and Salkara (salicylic acid 6) are foams that provide an elegant way to soften and debride thick dead skin and nails. Glytone Ultra heel and Elbow is a 30
glycolic acid which also smoothes rough keratotic 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. Differin gel is now formulated at a higher concentration. The .3% gel is prescribed for patients with extensive comedone formation.
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.
Acanya gel, a new combination drug of clindamycin phospate (1.2) and benzoyl peroxide (2.5), similar to Duac and Benzaclin, has an innovative delivery system without irritation. It is excellent for sensitive skin in dry, cold environments.
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 playa 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 have been approved by the FDA that specifically improve mild acne include: orthotricyclen, estrostep, Y AZ and Yasmin. The latest controversy implicating drospirenone, the agent in both Y AZ and Yasmin is causing an increased risk of thromboemboli formation compared to existing OCP's remains to be investigated.
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.
New Medical Therapies for Skin Preservation and Rejuvenation
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 aging skin.
Zyclara cream is a new topical cream for the treatment of visible or palpable actinic keratoses (precancers). The active ingredient imiquimod is used in a pulse dosing regimen of 2 weeks on, 2 weeks off, and 2 weeks on. This allows for greater tolerability and less reactivity of the skin.
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.
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.
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, COQ1O, and green tea extract are the most popular antioxidants available. Coffee berry extract (Revale) derived from coffee and resveratrol derived from red wine are both excellent and powerful antioxidants for the skin. These compounds are found in many creams for anti-aging and rejuvenation.
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.
New Sunscreen Agents
Several new compounds have been added to sunscreens to block UVB, UV Al and UV A2. PABA, Padimate 0, cinnamates, salicylates, and Octocrylene
all block UVB. The newer UV A blocks include Avobenzone and Ecamsule. Recent confounding reports of implicating ingredientstn sunscreensoxybenzone and palmitate, a form of Vitamin A, as carcinogenic is unproved. These ingredients have been in cosmetic formulations for years without any
adverse health effects reported. The most important factor for effectiveness is appropriate application of the sunscreen. At least 1 ounce (30cc) is needed to cover the entire body surface. It should be applied every 2-3 hours. No study has ever shown that sunscreens lead to Vitamin D
deficiency. The safest way to obtain Vitamin D is through diet and supplements. The recommended dose is 1,000mg daily. When used along with insect repellents, the sunscreen enhances the absorption of Deet.
Minimally Invasive Medical and Surgical Techniques for Anti-Aging
Mineral Cosmetics and Make-up
A booming product concept for the facial cosmetic market which contains medical trace minerals such as bismuth oxychloride, titanium dioxide
and zinc oxide. Other ingredients octyl hydroxy sterate benzoate which is blended one (a silicone derivative) suspends the minerals. They create a natural cover-up and sunblock. These products conceal defects, resulting from acne, laser and peel procedures. They are non-comedogenic and water resistant.
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.
A new application for Botox toxin type A includes minimizing pore size and decreasing sebum production. Intradermal injections affect a receptor that influences sebum production. It also exerts a force on the arrector pili muscle, which causes contracture of the muscle and decreases pore size.
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.
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.
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.
Soft Tissue Augmentation
Calcium hydroxylapatite - (Radiasse) - 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.
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.
Sculptra (Poly L Lactic acid) is a new dermal volumizing filler ideal for enhancing areas that are concave, depressed or atrophic to restore youthful contours. It usually requires 2 to 3 injections.
Peels still playa role for skin rejuvenation and sun damage control. Trichloroacetic acid in varying concentrations is an effective method for removing sun damaged skin cells. Coupling this acid with keratolytics such as salicylic acid or lactic acid allow for deep penetration into the dermis. The dehydration and sloughing of skin cells along with the stimulatory effects of collagen and elastin production in the dermis, provide marked rejuvenation. The side effects are less severe and post op care is more manageable compared to other treatment modalities.
Glycolic acid peel series
Utilizing varying concentrations of glycolic acid provides a more subtle and gradual improvement in the quality and texture of the skin without the substantial down time. The series can be implemented in 3 to 4 week intervals. Indications vary from acne vulgaris, acne rosacea, seborrhea to fine wrinkling and sun damage. People who develop precancerous actinic keratoses favor this modality since they are not left with unsightly redness and crusting which are common side effects in other treatments for pre cancers.
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.
Other services provided by the office
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 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.
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.