Isotretinoin (Accutane®)

Isotretinoin, formerly known as Accutane, is the most effective medication for the treatment of severe acne. Other medications may or may not help severe acne or moderate versions that can be unresponsive, but isotretinoin is known to clear up most people’s acne. Around 80% of those who use isotretinoin are cured of their acne. Isotretinoin pills remain the most efficacious treatment for severe acne as well as many cases of more moderate acne that are unresponsive to other treatments.  Some other conditions such as rosacea and folliculitis may also be treated with isotretinoin.

Isotretinoin is a version of high dose vitamin A that blocks processes in the body that lead to acne, such as shrinking the skin’s oil glands, reducing acne-causing bacteria on the skin, and changing the way that you shed skin cells. One course of treatment takes about 5-7 months on average; the course of treatment can take less time or a bit more depending on the individual, as dermatologists tailor the treatment to each patient. It is a medication that is usually given after other acne medicines or oral antibiotics have been tried without successful treatment of breakouts. This is a medication that requires monitoring so monthly check ups with your dermatologist are required while on this medication.

What is Mohs surgery?

Mohs surgery is a specialized treatment for skincancer treatment on delicate skin areas or “high real estate areas” of the body like the face. Mohs surgeons are dermatologists who have performed additional fellowship training to become experts in Mohs micrographic surgery. Fellowship-trained Mohs surgeons are highly skilled in all aspects of this technique, including surgical removal of the tumor, pathologic examination of the tissue, and advanced reconstruction techniques of the skin.

It is a very precise, highly detailed method whereby the skin cancer is excised and then stained and examined under the microscope immediately. Repeated saucer-shaped layers of tissue are removed and examined until no more skin cancer can be microscopically visualized in the sample.

Mohs is scheduled with the understanding that the patient may be spending the entire day in the office depending on the number of levels necessary to clear the tumor. General anesthesia is not required for Mohs micrographic surgery. Most of these procedures are performed with the patient in the waiting room awaiting the verdict from the Mohs surgeon. The procedure uses frozen sections of skin that are then stained with special dyes. The dyed frozen pieces of skin are examined under the microscope and a tumor map showing the sites of any residual cancer cells is drawn by the Mohs surgeon. The process permits an examination of the entire tumor’s margins simultaneously while the patient is waiting in the office. If more cancer cells are seen under the microscope, tissue is removed at the site of involvement. Each skin layer that is removed is called a “level”. If no more cancer cells are seen at a particular level, then it is deemed “clear” (no more tumor) and the surgeon can begin on closing the excised area. Some tumors that appear small on clinical exam may have extensive invasion underneath normal appearing skin, resulting in a larger surgical defect than would be expected. It is therefore impossible to predict a final size until all surgery is complete. Cure rates typically exceed 99% for new cancers, and 95% for recurrent cancers.

By removing only tissue where cancer is known to be present, the technique combines a very high cure rate with excellent preservation of normal skin. Once the cancer has been fully removed, the surgeon will determine the type of repair for the best cosmetic result. The surgeon may refer patients to another physician for wound closure, may close the wound immediately, or may let the wound heal on its own.

Parabens in products

Parabens are used in pharmaceuticals and skin care products as antifungal agents. In fact, parabens are the most widely used preservatives in the cosmetics industry. They’re often used in makeup, hair care products, moisturizers and shaving products. There are several types of parabens, the most common being methylparaben, probylparaben and butylparaben. They are used to maintain the integrity of the product, as they protect against the growth of fungus and bacteria, and have been used in products since the 1950’s. Yet while they do lower the chance of you developing a skin infection from a compromised product, they can still be irritating to some people’s skin.

The controversy comes from when in the 1990s, parabens were found to be xenoestrogens ― agents that can mimic the body’s natural estrogen. Additional sources of exogenous estrogen has been linked to organ system toxicity, reproductive and fertility problems, birth and developmental defects, and hormone disruption. As a result, experts in many countries have recommended limits on paraben levels in cosmetic products. What’s more, watchdog organizations worry that if parabens can be stored in the body, over time they could have a cumulative effect and pose a health risk.

This remains controversial, as other studies have shown parabens to have a very weak estrogenic effect and it is unknown if cumulative effects could pose a health risk. Currently the USDA and WHO consider the chemicals safe at low levels, as the amount of parabens in any product is typically quite small.

There’s reason to be mindful, but no reason to have an all-consuming concern about these chemicals. If it helps you rest easy, use a paraben-free body lotion. Today there are a number of formulas available from paraben-free brands. Epionce® is a botanical based brand created by a board-certified dermatologist that is completely paraben free.

Different types of acne scars

A scar is the body’s natural way of healing and replacing lost or damaged skin. A scar is usually composed of fibrous tissue and can form for many different reasons anywhere on the body. The look and feel of the scar and the composition of a scar may vary – sometimes appearing flat, lumpy, sunken, colored, painful, or it can be itchy. The final look of a scar depends of many factors, including the skin type and location on the body, the direction of the wound, the type of injury, and age of the individual.

We don’t know why some patients with acne scar very badly and others don’t. Even patients with mild acne can develop scars, while there are patients with severe acne that don’t get scars. Picking at or popping acne lesions can definitely increase the likelihood that you could get scars from your acne.

Acne scars can be classified as many different types: atrophic, hypertrophic, or dyspigmented scars. Atrophic scars look like little indents or dimples in the skin and may be further classified as icepick (deep and narrow), rolling (broad with sloping edges) or boxcar scars (broad with sharp edges).

On the other side of the spectrum, hypertrophic scars are thickened raised acne scars. Discolored acne scars are sometimes referred as post-inflammatory hyperpigmentation (brown discoloration) or post-inflammatory erythema (red discoloration). The treatment of acne scars is dependent on the type of scars you have.

There are many different types of treatments for acne scars including: lasers, steroid injections, chemical peels, dermabrasion, microneedling, and fillers. Speak to your dermatologist about which treatment type would be best suited for you.

Acne and IUDs

Acne is listed as a side effect of IUDs that contain progesterone, specifically the Mirena and Skyla implants. This is because this hormone is an androgen that can over-stimulate your oil glands and contribute to acne. What causes the acne is the hormone imbalance caused by more progestin in the body and not enough estrogen to balance it out. However, it is not a certainty that any type of birth control actually causes acne directly, just that certain ones will not help with it if you’re prone to outbreaks. If you were taking the birth control pill right before switching to an IUD and find that you start breaking out, more often than not that is behind what is going on with your skin.

Medications such as spironolactone can help counteract the effects that the IUD has in the skin and can control IUD-related breakouts. Originally formulated to treat hypertension and a few other cardiovascular conditions, spironolactone is a drug that can also help with hormonal acne at lower doses. It works as an anti-androgen (therefore only given to female patients) by blocking the entry of androgen hormones into cells. Overall, it limits the hormonal fluctuations that can lead to breakouts. While spironolactone has been used for hormonally regulated breakouts for over 30 years, it is considered off-label use for acne.

Skincare pre and post gym

Pre-gym: Before heading out to the gym, cleanse the skin with a mild, non-irritating cleanser if you’re wearing a heavy base layer of makeup, and apply a lightweight, oil free moisturizer. Tinted moisturizer or mineral powder are fine to wear if you choose. Applying an oil-free formula is perfect to use pre-workout, as it won’t cause the skin to feel greasy, yet will work to hold water in the skin while you perspire. As much as it might feel like it, sweat sessions are not exactly quenching your skin with moisture. Moisturizer is especially important to apply because sweat evaporates water out of the skin, leaving it dehydrated unless protective steps are taken.  If you’re headed outdoors to exercise, use a moisturizer with a sunscreen of at least 30 SPF, remembering to protect your neck, décolleté and arms as well as the face.

During the workout: The machines at the gym may be great for your body, but the sweaty hands of your fellow gym rats mean that they’re also repositories of a lot of germs. Make sure to stay hydrated throughout exercising, to replenish the moisture you are losing as you sweat. During exercise, try to avoid wiping your face with your hands – instead use a towel and pat your face dry.

After You’re Done: A big mistake people make after a workout: being too aggressive with their skin. Resist the urge to over-scrub: even the most killer spin class doesn’t call for major exfoliation. Skin is extra sensitive following a workout, so make sure to gently cleanse your face and avoid applying other products as too many products could irritate the skin and cause redness. Refrain from lounging in your sweaty exercise gear and remove clothing as soon as possible and hit the shower. The dirt and sweat from your clothing will sit on your skin, blocking your pores and potentially causing breakouts.

Do I need to worry about the sun in the winter?

Even when we don’t feel the heat outdoors the sun’s strong ultraviolet (UV) rays can harm the skin year-round, making our skin just as prone to the chances of developing skin damage or skin cancer in the winter months as in the summer months. No matter how thick those overcast clouds look in the winter, up to 80 percent of the sun’s rays can still penetrate them. UVA are always present, as they can penetrate clouds, glass, resulting in premature aging and increased risk of skin cancer. UVB rays, on the other hand, vary in intensity and season and damage the more superficial layers of the skin, resulting in sunburns and skin cancer.

For those spending much of their winters on the slopes, it is important to be aware that the combination of higher altitude (UV radiation exposure increases 4 to 5 percent with every 1,000 feet above sea level) and the UV rays reflected by the snow puts skiers and snowboarders at an increased risk of sun damage. Fresh snow reflects nearly 80 percent of UV radiation, and UV rays can bounce off frozen water, increasing exposure as you can be hit by the same ray twice. At high altitudes, thinner air allows for the passage of even more light.

What you can do:

  • Use a broad-spectrum sunscreen with an SPF of 30 or higher whenever you spend extended time outdoors. Apply 30 minutes before hitting the slopes.
  • Apply sunscreen liberally and evenly to all exposed skin –most skiers and snowboarders do not use enough.
  • Remember that the skin on your lips and eyes are thinner than on the rest of your face. Use a lip balm and an eye cream infused with sunscreen to get both protection and moisturization.
  • Use a moisturizing sunscreen with ingredients like lanolin (in Aquaphor) or glycerin, as dry winter conditions can be particularly harsh on the skin.
  • Be sure to cover often-missed spots under scarves or helmets: the lips, ears, around the eyes, and on the neck, the underside of chin, scalp and top of hands!
  • Carry a travel-sized sunscreen and lip balm with SPF in it with you on the slopes. Re-apply on the chairlift, especially after a long, snow-blown run, or when warming up in the lodge.

If possible, try to ski early in the morning and later on in the day, before 10 AM and after 4 PM typically is when the level of UV light is lower, avoiding the most intense sunlight.

Chemical sunscreens vs. physical blocker sunscreens

Regardless of which type of sun protection you choose, there are benefits to regular use. Numerous studies that have shown that regular use of sunscreen has anti-aging effects. In a recent study in Australia, researchers compared skin aging in 900 men and women from Australia over the course of four years. They found that those that used sunscreen daily, had an undetectable increase in skin aging.

According to the FDA, sunblock with SPF 30 is the safest way to go. Anything above SPF 30 is not usually necessary as it has little incremental benefit and below 30 is not effective enough.

Physical sunscreens: use physical UV filters by deflecting or blocking the sun’s rays. Suggested for those with heat sensitive skin (like those with rosacea and redness) since it deflects the heat and energy given off by the sun away from the skin, as well as those who are acne-prone as they seem to be less likely to be pore-clogging. Common physical sunscreen ingredients include titanium dioxide (TiO2) and zinc oxide (ZnO)– these are both broad spectrum protectors, meaning they protect against both UVA and UVB rays

Pros: Physical sunscreens tend to be better tolerated by most skin types because they are not absorbed in the skin.

Cons: Physical sunscreens tend to leave a white cast or white streaks after application and don’t offer as much UVA protection compared to chemical sunscreens. Physical sunscreens are also a bit thicker so they may be more difficult to apply.

Chemical sunscreens: Chemical sunscreens work by absorbing the sun’s rays so that the skin doesn’t absorb the rays. Some chemical filters can scatter sun rays, but still mostly just absorb them. Common broad spectrum filters used include oxybenzone, octinoxate, avobenzone, and homosalate.

Pros: Pros include its ability to defend the deeper layers of skin-including collagen fibers and other tissue-against the aging effects of UVA rays; and it prevents penetration by the UVB rays responsible for tanning and sunburn

Cons:  Rubs off more easily and must be frequently reapplied.

Since they each have their pros and cons, many of today’s sunscreens contain both physical and chemical UV filters.

What Do Acne Scars Looks Like?

Acne scars come in all different shapes and colors.  There are scars that are discolored, scars that are raised, and scars that are indented.  A dermatologist can offer you a variety of treatments to help improve your scars.  Discolored scars may be red, brown or white and the coloring can be improved by using fading creams, laser treatments or chemical peels.  Raised scars, also known as hypertrophic scars or keloid scars, are usually first treated with a special type of injectable medication to flatten them.

Indented scars, also known as atrophic scars, come in a wide assortment of shapes and may be specifically referred to as icepick scars, boxcar scars, or rolling scars.  All of these different types of indented scars can be treated using a wide variety of methods.  Laser treatments, microneedling, and filler injections are just some of the options for treating indented scars.  Since there are so many scar treatment options available, be sure to see a dermatologist that is an expert in acne scar treatment to get the best possible outcome for your skin.

Types of acne scar treatments available:

  • Lightening creams
  • Chemical peels
  • Pulsed dye laser treatments
  • Intralesional steroid injections
  • Fractionated non-ablative laser treatments
  • Fractionated ablative laser treatments (also known as carbon dioxide laser treatments)
  • Radiofrequency treatments
  • Filler treatments
  • Microneedling


Do I Need An Intense Pulsed Light Treatment And What Is It?

Intense pulsed light treatment (IPL) is a laser-like treatment that is designed to improve:  brown spots, red spots, and signs of aging. Some people refer to an IPL treatment as a photofacial or photorejuvenation.

There are many different types of IPL devices and these treatments can be performed at a dermatologist’s office. An IPL treatment takes about 10 minutes to perform. It will feel like little hot pinches on your skin. Sometimes patients are given a numbing cream to apply to their face for 20 – 30 minutes prior to the treatment to lessen any discomfort. During the treatment the patient’s eyes are covered with special goggles because the light emitted from the IPL machine is extremely bright. Immediately after the treatment the skin will be slightly pink and may feel like a mild sunburn.

For the next few days after the treatment your face may be pink and/or slightly swollen.  Any brown spots or brown discolorations that you had on your skin will be slightly darker for about 5 – 7 days after the treatment.  One week after the treatment you will notice that your skin is glowing, has a smoother tone, and a more even color.   You should use caution when doing an IPL treatment in the summer as you should not have a tan when you get an IPL treatment.  Make certain that your treatment is being done in a dermatologist’s office to ensure the safest treatment with the best results.

An Intense Pulsed Light Treatment Can Treat:

  • Brown spots also known as sun spots
  • Red spots and broken blood vessels
  • Signs of aging