Ask the Doctor

I've read about treatments which use blue light or LED light to treat acne. Can you tell me more?

There are several devices which are approved for treating acne with light sources. It appears that these lights can have an effect on a bacteria on the skin called Proprionobacterium Acnes. This bacteria does play a role in acne and several of these lights have proven to be moderately effective for inflammatory acne which is mild to moderate. However, many advertisements for these treatments imply that this is the end of your acne and do not tell you the whole story. Acne is more complex that just a bacteria on the skin. The light treatments have not been studied with regard to the other causes of acne such as oil, plugged follicles, etc. The light treatments will temporarily decrease the population of P. Acnes on the skin, but they do not eradicate it. This is an organism that is found on everyone's skin and it will "come back." Presumably, so can your acne. Based on studies I have seen so far, the light treatments are potentially an additional treatment which can be used - not necessarily a replacement for creams, washes, or even pills for acne. At least, I cannot see how this can be claimed, based on the available studies in the medical literature at this time. I would expect that you would need periodic treatment with the light on a regular basis to prevent the acne from coming back.

One thing that is certainly not stressed in advertisements for these treatments is that insurance will probably not cover it. You need 2 or 3 treatments a week for 4-5 weeks, but the actual regimen varies with different lights and in the different studies. So even if it is only $40 a treatment, it will be expensive. Keep in mind that whatever the price, there are no studies of how effective these devices are over a long period of time. Most of the studies have been short and look only to compare the results at 2 months or less with conventional treatment. Just because a device is approved by the FDA does not mean that it is 100% effective or permanent.

Because of the relative newness of this treatment modality and the out-of-pocket expense for the patients, we have decided not to purchase one of these lights for our office at this time. There are many effective topical creams and oral medications which *are* covered by insurance and have minimal side effects and will work well for the majority of patients. Our CoolTouch laser has also been approved for the treatment of acne recently.

V. Angeloni MD

I had a miscarriage about 4 months ago. About 2 weeks after, my skin broke out with cystic acne that continues to be a problem. My questions are is there any treatment that is safe to use while trying to conceive and is this normal with significant hormonal changes such as a miscarriage?

Stress and some hormonal changes may precipitate acne or make it worse than it was. While actively attempting pregnancy, some drugs are off the acne treatment list because of concerns for the fetus. So, commonly used medicines like tetracycline antibiotics, accutane, and topical retinoids like Retin-A are avoided. Some oral antibiotics and topical antiacne drugs may be used while attempting conception or while pregnant. See your family doctor or dermatologist to discuss this further.

V. Angeloni MD

hi, I'm 24 and my face is peeling I have use multiple kind of creams but
they don't work what's wrong with me?

This is a case where there are many possible explanations, but without an exam, I really can't say for sure... Some people will develop a problem called seborrheic dermatitis which causes redness and scaling usually around the nose, sometimes between the eyebrows and/or in the eyebrows. It can also show up in the scalp, behind the ears or in the ears, but it doesn't have to be in all these areas. You can try and treat this with nonprescription medications such as 1% hydrocortisone cream applied twice a day for a week or two. Dandruff shampoos used on the hair and on the problem areas may cut down on flare ups of the dermatitis, as this is something that isn't cured, just controlled.
Other possibilities include having an allergic reaction to something you are using on your face, having sensitive skin which is irritated by soaps, or using retinoid creams which can be irritating. Your family doctor should be able to diagnose seborrheic dermatitis, but if that isn't the problem, then you should try to see a dermatologist.

V. Angeloni MD

I Am a 30 Year Old woman who had cellulitis not once but 3 times within 3 years. The first year it hit right in my bikini area and was very painful and i had to take a antibiotic. Then last year i got it again in the same spot.. and Now this May i am just getting over it again in the same exact spot and i do not shave or anything. So why am I still getting it again in the same area always?

It would be very unusual to get cellulitis in the same area. It is possible that there could be a small cyst there that ruptures periodically, causing a lot of redness, tenderness, and pain which could be mistaken for cellulitis. However, recurrent eruptions in the "exact same spot" more strongly suggest herpes. When the eruption is present, a scraping and microscopic exam could confirm this diagnosis, as could a viral culture. If it only occurs once a year, then it might be useful to have a blood test to look for the antibody to the virus (HSV-2 antibody test). Since this is contagious and can be transmitted sexually, you should see your family doctor or a dermatologist for further evaluation and testing as soon as possible.

V. Angeloni MD

This winter I have had terribly chapped lips. I have tried every kind of chapstick available and none have seemed to help. Is there something you can recommend?

There are no prescription lip balms for this. Chapped lips are the result of low humidity, lip licking, cold and wind. Putting on lip balm once or twice a day will not correct the problem if you lick your lips numerous times during the day. The constant wetting and drying damages the skin and disrupts the protective barrier function of the skin. You should avoid licking your lips, but this can be almost an "unconscious" reflex when your lips are dry! Every time you lick your lips, you should put on some vaseline or lip balm. There are several other over the counter products which you could try. Some have alpha-hydroxy acids which can be more effective for some people. Plain old vaseline (available in a convenient small dispenser for lips) is usually very effective if used frequently. If the problem persists, consider seeing a dermatologist as this can be related to eczema or could be an allergic contact dermatitis.
V. Angeloni M.D.

I am a 56 year old women who is considering some form of facial skin rejuvenation procedure, but am unsure what the difference between the results are. Both the Pro-Light and the Cool Touch Laser sound good and both say they reduce wrinkles, but how do I know which procedure would give me the best results?

The Cool Touch laser is intended solely as a wrinkle treatment and there is a considerable amount of literature regarding the effectiveness of this modality. It does not treat brown spots, freckles, or broken blood vessels.
The ProLite is a flashlamp device which can treat freckles and blood vessels among other things and that is its primary indication. The effect on pores and wrinkles has been noted in a few studies.

Which one is best for you? We really need to see what kind of wrinkles/problems you are interested in treating to say for sure. Call to set up a free consultation. Also there is a question/answer lower down on this page which gives additional information on various wrinkle treatment options.

V. Angeloni M.D.

I'm 29 years old and wondered if there is anything I can do at home to help minimize the appearance of mild acne scarring? Most of my scars are red/brown scars where the blemishes were and are relatively smooth. Or is there a relatively inexpensive procedure that can be done by a dermatologist? Do most insurance pay for acne related procedures or is this considered cosmetic?

Skip down a few questions to the one that asks about the "Cool" laser and possible use for acne scarring. If your "scars" are relatively smooth, they may not be scars at all. When some acne lesions resolve, they may leave some coloration in the skin which tends to fade slowly. So if the main color that remains is red, it is called postinflammatory erythema; if the main color is brown, then you have postinflammatory hyperpigmentation. The erythema will resolve spontaneously as will the pigmentation, but you must be patient. If your acne is not well controlled, you will develop new spots before the old ones fade, so as some are vanishing, new ones are forming, maintaining the status quo (i.e., too many spots!). You should see your primary care physician (if your insurance requires this before seeing a specialist) or a dermatologist to get a handle on your acne. Medications such as Retin-A can help control your acne and might also help lighten up the dark spots more quickly and most insurances will cover this medication if it is used for acne (and not just for wrinkles). Some scars can be reddish brown initially, but if they are smooth, the appearance will improve when the redness and pigmentation fades. Lasers and other treatments will not make a significant impact on scars that are already flat or flush with the skin surface.

V. Angeloni M.D.

I am a female and each summer when I am in the sun my upper lip gets a dark mask, where the skin is darker than the rest of my face. I have noticed this on a friend of mine also. Can you tell me what causes this and how it can be treated? I have tried all kinds of sunblocks for my face but nothing seems to work. Thank you.

This is a very common condition in women known as melasma. It frequently occurs during pregnancy, sometimes occurs in women on oral contraceptive pills, and also in women who have done neither of these things. This will darken in the summer. Nonprescription treatments use hydroquinone and these are commonly called "bleaching creams" (e.g. Porcelana). The prescription medications used also employ hydroquinone, but in higher concentration and sometimes with other agents which speed the fading process (alphahydroxy acids, retinol, Retin-A). These creams may take 2-3 months to work. In addition, even though some of the prescription "fading creams" contain sunscreen, it is very important to wear a high SPF sunscreen (SPF 45 or higher) during the summer months, especially if you are out for several hours, reapplying the sunscreen every 60-90 minutes. Note that this condition is not "cured" by the fading creams and sun exposure will cause the pigment cells in the affected areas to darken more rapidly than the surrounding skin. Periodic use of fading creams and _religious_ use of sunscreen will be necessary to minimize the problem. The prescriptions creams are quite effective.

V. Angeloni MD

Could the "cool" laser be used for other applications besides wrinkle
treatments? I am 48 and have numerous acne scars as well as skin tags
and benign sebaceous adenomas. Could this new "cool" technology be used either to remove scars or skin growths over time?

Scarring from acne presents several variations which often need different approaches. The CoolTouch laser has been used in patients with acne scarring, but it requires more treatments than used to treat wrinkles. Some types of acne scars will not respond well to the CoolTouch laser. It is important to keep in mind that the CoolTouch will improve the appearance of the scars but will not "erase" them. You'd need to have a consultation with a dermatologist to determine which treatment options would work best in your case.

Acne scars come in three basic varieties: 1) rolling scar 2) ice pick scar 3) Boxcar scar
The rolling scars are like "rolling hills" where there is soft depression in the skin. This is probably caused by fibrous bands pulling the skin down and this type of scar would respond to needle subcision (cutting the fibrous bands with a sharp needle fanned out under the skin) followed by injection of filler substances to lift up the skin. Ice pick scars are very small but deep scars that look like a hole made by an icepick. The depth of these scars eliminates dermabrasion or even laser as effective treatments. These are typically treated with "punch excision" which means you cut out the scar and the hole with a small cookie cutter and then suture it closed. You essentially replace a deep scar with a flat scar which is flush with the skin. In many cases, this procedure is followed by dermabrasion or laser ablation to blend in the "new" scars which were created by the punch procedure. The boxcar type scar is a shallow, steep walled scar. This type of scar responds best to dermabrasion or laser treatment using a CO2 laser. The CO2 laser is an ablative laser which basically vaporizes the top layers of skin. This procedure is associated with significant "downtime" since you will take about 9-12 days for the facial skin to heal and it is possible that the skin will remain red for several weeks or months. CoolTouch laser does not have this downtime and redness phase since it is a nonablative laser, but it isn't as effective as CO2 laser for this type of problem. Some superficial types of acne scars may also be improved by microdermabrasion or various chemical peels.

Sebaceous hyperplasia is a common problem. This can be treated with various modalities including needle hyfrecation (a type of "cautery") or liquid nitrogen, or laser. The diode laser would be preferable in this condition if you are interested in just treating the sebaceous hyperplasia. CO2 laser used to treat acne scarring would also smooth out sebaceous hyperplasia lesions at the same time, but it is usually not used just to treat isolated lesions of sebaceous hyperplasia.

Skin tags are very common and lasers will probably never replace the old standards here -- sterile scissors or liquid nitrogen.

Note that all of these treatments would be considered "cosmetic" and insurance may not pay for either the evaluation of these problems or the procedure to treat them.

V. Angeloni MD

I am 26 years old and have dark circles under my eyes. They seem to be inherited and not a result of lack of sleep. Because I am fair-skinned, they are especially noticable and make-up and concealer do little to hide them. I'm tired of people asking me if I had a late night! Is there anything I can do?

You're right, this is an inherited condition. It seems to be autosomal dominant inheritance and it is called familial periorbital hyperpigmentation. It is also sometimes called periocular or periorbital hypermelanosis. Camouflage makeup can be helpful in this condition, but it is difficult to conceal. I recently saw an article in a Dermatology "newspaper" that mentioned someone experimenting on this with a laser. This was a small preliminary study, so don't go looking for someone to do this for you. The problem here is that lasers can produce hypopigmentation as a side effect of resurfacing to get rid of wrinkles, but this is somewhat unpredictable. So there isn't an easy fix for this problem at this time, but don't despair, there are better lasers and treatments coming out every day.

My husband and I are trying to get pregnant. If we succeed, is there a way to prevent/reduce stretch marks while pregnant? Any tips on how to care for all skin (not just face) to increase elasticity, etc. when pregnant would be appreciated!

I'm just a dermatologist, but I am pretty sure that you will have an easier time getting pregnant than your husband. ; ]

Stretch marks are common and seem to be due to a combination of genetics, hormones, and distension. Some women get very large during pregnancy and get no stretch marks whatsoever (don't you just hate them...), and others develop stretch marks regardless of their size . Cocoa butter or topical vitamin E don't seem to help a bit with the appearance of the stretch marks but might help them to feel a little better. Studies have been done using pulsed dye lasers with the results reported to range from minimal or no improvement to mild-moderate improvement. Since most stretch marks slowly improve by losing their initial purplish color and fading to a silvery or flesh colored appearance, it can be difficult to discern whether lasers or other treatments are making a dramatic difference. Some people have used the CoolTouch laser on stretch marks and reported some improvement also. Retin-A has been studied as well and again the results range from "no improvement" to mild or moderate subjective improvement. The term "subjective" improvement here usually reflects improvement perceived by the patient which was not necessarily confirmed by objective observers (i.e., physicians conducting the studies) or by scientific evaluation of the skin surface or microscopic examination. Note that all these treatments would not be covered by insurance since you are treating a "cosmetic" problem...

Just as one cannot produce stronger fingernails by eating gelatin, there is no specific diet or topical regimen which can increase skin elasticity. Cosmetic products which purport to help your skin because they contain collagen or elastin really have no chance to get into your skin and build up your collagen or elastic fibers. Collagen and elastin molecules are too large to penetrate into the skin. Eat a well balanced diet and take your prenatal vitamins.

Vincent L. Angeloni MD

I'm 31 and have fine lines between my brows and am noticing the start of lines coming in around my mouth/cheeks. I also seem to be losing firmness in an area on my neck. I'm interested in any techniques that could reverse and/or prevent further "damage" in addition to my regular daily routine. What are the best ways to be more aggressive with wrinkle reduction and prevention?

The most important part of wrinkle prevention is sunscreen. Use at least an SPF 15, and if you are very fair and burn easily, I routinely recommend an SPF 30 or higher. This is the most cost effective way to reduce the formation of future wrinkles. Please go to our patient information section and download the file on Skin Cancer prevention for more information regarding sunscreen use. If you smoke, QUIT. Smoking also damages the skin and causes excessive wrinkling. The combination of smoking and severe sun damage can predispose you to the development of large blackheads and whiteheads along the cheekbones when you are older (>50). If you go to a commercial tanning booth and you don't want to stop, learn to like your wrinkles — you're going to have lots of them. Otherwise, use a self-tanning cream or lotion to give yourself some color without increasing your chance of skin cancer or wrinkles.

There are several other things you can do to improve fine wrinkles. I can't really tell you which of the following would be best to use in your case, since I haven't had a chance to evaluate your wrinkles. However, I have categorized the treatment options depending on the type of damage you have...and listed the relative cost of the options discussed .($ = inexpensive, $$ = moderately expensive, $$$ = expensive) This list is also geared toward the shallow wrinkles a 30-something year old would have. Deep wrinkles and severe sun damage and solar elastosis are not considered in this list.

Fine or mild wrinkles, mild freckling or sun spots:

Retinol ($, non-prescription) is something that theoretically gets converted into a Retin-A like molecule within the skin. This can improve mild wrinkling. Not very irritating, slow onset of action.

Kinerase ($-$$, nonprescription but available only through a doctor's office) is a very tolerable product even for those with the most sensitive skin. It can improve fine wrinkles but the onset of action is rather slow, like the retinol products and the amount of wrinkle reduction might be on the lower end of the scale.

Retin-A or Renova ($-$$, prescription only) is also useful for mild wrinkles, sun freckles, etc. It can be irritating and will cause exfoliation. Onset of improvement is about 4 months or longer which is quicker than the products listed above. Also reverses some of the damage from sun and can help acne.

Alphahydroxyacid peels ($-$$) are a type of "lunchtime" peel which can freshen and tone up the skin and fine wrinkles. Usually given as a series of peels over several weeks. No downtime.

Topical Vitamin C ($$) has been shown in some studies to cause improvement of wrinkles and perhaps will prevent further sun damage.

Beta-peel ($$) is a salicylic acid peel which usually causes a little more peeling that alphahydroxyacid peels. The Beta Peel can fade freckles and improve fine wrinkles as well as whiteheads and blackheads - salicylic acid penetrates into pores much better than the alphahydroxyacids.

Microdermabrasion ($$$) is a procedure which smooths the skin by shooting a fine stream of abrasive particles at the skin and simultaneously sucking away the particles and debris. This can smooth wrinkles, fade freckles and sun spots with essentially no downtime. Several treatments will be needed to acheive results and periodic touch ups may be required.

Slightly deeper wrinkles:

AccuPeel ($$-$$$) a trichloroacetic acid peel which is safe and effective but will result in some noticeable peeling a few days after the procedure.

Obagi Blue Peel ($$-$$$) also a buffered trichloroacetic acid peel which also has some peeling associated. Can be tailored to be deeper or more superficial, depending on your needs/cosmetic desire.

CoolTouch laser ($$$) is a new non-ablative laser that gradually reduces wrinkles over a period of 4-6 months with NO downtime. This new laser technology stimulates collagen production beneath the surface of the skin, softening wrinkles by 20-80%. This is a slow gradual process, and it does not treat surface pigmentary problems like age spots or freckles, but these can be addressed with some of the other products listed above.

Wrinkles due to overactive facial muscles:

These would be wrinkles which develop between the eyebrows and those around the lateral part of the eye (crows feet). These can be treated with BOTOX ($$-$$$) which relaxes those muscles and thereby improving the wrinkles. This is one of the most popular cosmetic treatments and it is very safe and effective.

If you are young and your wrinkles are not very deep, the lines between the brows can be dramatically improved with BOTOX by preventing the contraction of the muscle that "crinkles" the skin and causes the wrinkle. This can be used in combination with a retinoid to get a gradual improvement in the wrinkle if some persists after the BOTOX.

The neck problem you mentioned ("losing firmness") is one that is difficult to deal with. Currently there is research being done with lasers and some peels for the neck region, but there isn't a treatment which is consistently yielding fantastic results in this area. If you are developing very loose skin under the chin and neck area or jowls, this can be addressed with a neck/facelift done by a plastic surgeon, but usually this kind of droopiness isn't seen in 31-year-olds. If the skin on your neck has a pebbly "chicken skin" appearance at this age, you should see a dermatologist to rule out Pseudoxanthoma Elasticum, a rare genetic skin problem. (Really rare, so don't stay up at night worrying about this).

Vincent L. Angeloni MD

Question: My son is thinking about going on accutane for severe acne, how much of a risk is depression and suicide with this drug?
Accutane is a drug which is very effective for severe acne which cannot be controlled with other medications. It has a long track record and has been around since the early 1980's and millions of patients have been treated with the drug. There have been very few reports which have described any increase in depression among patients who have been treated with this drug. In fact, in many studies, patients were happier since their acne was so much better. Depression was added to the list of warnings for accutane about 3 years ago. Recently a politician's son committed suicide while he was on accutane and this has received considerable attention in the media. There remains no scientific evidence of an association between accutane and depression or suicide. While there are anecdotal case reports of small numbers of patients who became depressed, larger studies have not been able to confirm an association. About 4 weeks after the news media publicized this controversial issue, a larger study was reported in the medical literature with over 7,000 patients which did not demonstrate any association between accutane and depression. Further research needs to be done, and we cannot ignore the fact that people on accutane might have problems with depression. Since depression can happen in the general population, and since patients with severe skin problems (like acne) have an increased rate of depression, it is possible that some patients will be depressed while they are taking accutane. Thus, while our patients are on accutane, we watch carefully for signs of depression and ask that family members monitor the situation as well. If your son is feeling "blue", tearful, doesn't feel like getting out of bed, we will address his depression and consider stopping the accutane if the situation warrants it.

Vincent L. Angeloni M.D.

Question: I read about the use of aromatherapy for hair loss and since I am a 68 year old woman with thinning hair, I wonder if this would be helpful for my condition.
The Des Moines Register column entitled "Your Body" contained information on aromatherapy for hair loss which needs to be corrected. First, credit should be given where credit is due. The aromatherapy article was not originally from Health Magazine as reported by the Register, but can be found in The Archives of Dermatology, volume 134, November 1998, pages 1350-52 and is entitled "Randomized Trial of Aromatherapy; Successful Treatment for Alopecia Areata."

Please note that this was a small study, and although randomized, it has yet to be confirmed by subsequent larger studies. It isn't unusual to get a small preliminary study which shows promising results but subsequent studies may not report such successful outcomes.

The Register column also reports aromatherapy as an effective treatment for hair loss, but fails to mention the actual diagnosis of the disease that was treated. The original study considered the effect of aromatherapy only on alopecia areata, and there is no way that you can extrapolate these results to mean that aromatherapy works for all different types of hair loss. Hair loss has multiple causes which can be difficult for the casual observer to sort out. A dermatologist can help determine the exact diagnosis so that the correct therapy can be instituted. You need to rule out other causes of hair loss (thyroid diseases, anemia, etc.) and have a better idea of what the actual diagnosis is before you start treating yourself.

The Register column reports the hair loss in the study was a "rare autoimmune disorder." Alopecia areata is not a rare disorder, and, as the original article in the Archives of Dermatology states, it is found in 1% of the population. The newspaper also mentions that the investigators in the article reported it as useful for other hair loss problems such as postmenopausal hair thinning. I could not even find one sentence where the words "postmenopausal thinning" were mentioned in the original article, so it is more likely that the reporter from Health Magazine was actually the one doing the speculating. One male patient who participated in the study had modest improvement of his male pattern balding. The authors wisely chose not to speculate at all about this observation. The only accurate, scientific statement that can be made regarding the use of aromatherapy for male pattern balding based on the anecdotal report of this one patient is that this result should be viewed with a healthy amount of skepticism until it is confirmed or refuted by studies with larger numbers of patients.Taking this one step further, even if a treatment works for male pattern balding, you cannot assume that it will also work in women with postmenopausal thinning. A perfect example of this is Propecia® (finasteride) which is effective for men with inherited male pattern balding, but is totally ineffective for hair loss in postmenopausal women.

Vincent L. Angeloni M.D.