Our very own Dr. Benjamin Barankin has written his 7th book in Dermatology. His latest book, Pocket Guide Dermatology, is intended for all physicians who deal with skin issues (e.g. family doctors, pediatricians etc), dermatology nurses, medical students and residents. The book deals with common and important cases, such as: acne, rosacea, psoriasis, skin cancers, various skin infections, and more!
Melasma, one of the most stubborn skin condition commonly seen by dermatologists and skin experts today. This type of hyperpigmentation appears in dense patches, often in a symmetrical pattern that is usually seen on the cheeks, forehead, upper lip and chin, and occasionally on other sun-exposed areas, such as the arms and chest. Melasma is more common in women with darker skin, but may also affect lighter skins as well.
The cause of melasma is still not fully understood, but many different factors have been implicated in this skin condition. Genetic factors can play a role in the formation of melasma within certain ethnicities, Asian and Hispanic being more prone to the condition. In addition to genetics, hormonal activity seems to be the most suggested reasoning for the occurrence of melasma. Pregnancy, contraceptives, hormone replacement therapy or hormone treatments can all be responsible for hormone fluctuation.
For some patients, cessation of hormone-altering medications and the normal rebalancing of hormones after pregnancy can cause melasma to fade on its own. This is known as transient melasma. For others, unfortunately, their melasma is known as persistent and can stay pronounced indefinitely. There have been many studies suggesting that the use of gentle, topical home care products and professionally applied treatments is the best way to treat melasma. Placing patients on a daily care regimen with products that include a variety of the following ingredients will help suppress the formation of excess melanin through multiple mechanisms of action, delivering faster, more beneficial treatment outcomes:
• Hydroquinone can be either synthetically produced or naturally found in certain foods.
• Arbutin, which is naturally found in blueberries, pears, bearberries and wheat
• Kojic acid, naturally found in soy and mushrooms
• Retinoids represent the family of vitamin A. They are synthetically produced and suppress the activity of tyrosinase, decrease the quantity of melanosomes and inhibit melanosome transfer into keratinocytes. Not only are retinoids melanogenesis inhibitors, they also boost cell turnover, which helps accelerate the lifting of hyperpigmented cells. Retinoic acid is an effective topical ingredient, but can be too stimulating for some. Retinol is an effective alternative that is much less irritating and converts into retinoic acid within the skin. A stabilized pure retinol at 0.5% can be beneficial, as pure retinol provides faster results than a retinol complex and, when blended with calming and soothing ingredients, induces minimal irritation.
• L-ascorbic acid (vitamin C) can be synthesized or naturally found in citrus fruits.
• Lactic acid is naturally found in milk and sugars.
• Azelaic acid can be found in many grains and castor beans.
• Phytic acid, naturally found in various grains and seeds
The use of antioxidants and calming and soothing agents can help in the treatment of melasma as they prevent inflammation in the skin and therefore reduce the incidence of excess melanin formation.
A broad-spectrum sunscreen with a minimum SPF of 30 is needed for patients experiencing melasma. The reactivity of skin prone to hyperpigmentation and melasma is exacerbated by UV-induced inflammation. Choosing a physical sunblock over a chemical sunblock also helps by repelling rays rather than absorbing and dispersing then. All sunscreens must be applied 30 minutes before sun exposure and reapplied every 2 hours, or after swimming or perspiring, for maximum protection.
Along with a gentle daily care regimen, adding professional treatments can provide a more beneficial outcome. Performing a series of gentle, superficial blended chemical peels containing a combination of lower percentage acids that also contain melanogenesis-fighting ingredients is an excellent way to accelerate the treatment of melasma. Low percentage blends of TCA and lactic acid help to gently remove dead surface cells without causing unwanted inflammation in the skin. This creates the perfect canvas for corrective products to penetrate deeper in the skin to treat the unwanted pigmentation. Modified Jessner’s solutions enhanced with melanogenesis inhibitors, such as kojic and citric acids, are also effective options for treating melasma. Cream-based retinoid treatments are effective when addressing melasma as well, since the inflammatory risk is so low.
Overtreatment of melasma is quite easy and will cause a worsening of the condition. Anything that causes heat or friction in the skin can stimulate an increased deposit of excess melanin at the site of trauma. This has been demonstrated in many studies assessing the use of intense pulsed light, laser, microdermabrasion and high percentage chemical peels to treat melasma.
Another mechanical treatment that has shown added benefits in melasma treatment is micro needling. Micro needling (Dermaroller) has grown exponentially in recent years. This treatment provides an effective physical method of enhancing transdermal delivery of topical ingredients for various skin conditions without causing heat on the skin. Microneedling can be performed with a roller, or pen, which is covered with multiple tiny needles. The needles range in length and can penetrate into the skin up to 2 mm. This not only stimulates collagen production, but also facilitates the penetration of corrective products through the epidermis. It creates minor trauma to the skin, creating less risk of complications, and is generally more cost-effective than comparable laser therapy treatments. However, this treatment method can still trigger an inflammatory response, leading to a worsening of the pigmentation if too much trauma is induced. Using a shorter needle gauge will limit the depth of penetration and decrease the risk of further pigment formation.
Although frustrating for both patients and the skin health professionals working to treat it, melasma can be successfully treated. It is important to note that patients prone to hyperpigmentation and melasma will always be susceptible to recurrence. It is wise to have these patients remain on a continuous regimen containing melanogenesis-suppressing ingredients. A combination of year-round daily care with several pigment-inhibiting ingredients, consistent broad-spectrum sun protection and regular, professionally applied, gentle chemical peels can provide immense improvement of this stubborn condition.
~ Sheri Roselle, Medical Esthetician at Toronto Dermatology Centre
Did you know that the treatment of plantar warts (bottom of foot) and genital warts are covered by OHIP?
There are many types of warts, they are caused by the human papilloma virus (HPV) of which there are over 100 viral strains that have been identified. Warts can be on the bottom of feet (plantar), on the hands and elbows and knees (common warts), or even on the face (flat warts). Warts are contagious by touch/contact, and can be transferred to oneself and to others. Many warts can go away on their own with time, but unfortunately others will hang around. Plantar warts are particularly stubborn to treat because with each step you take, they burrow in deeper into your skin making treatments less effective. The sooner you treat a wart, the more likely it is to respond quickly and with fewer treatments.
Various treatment options exist, including liquid nitrogen, bleomycin injections, home acid applications (over the counter and stronger ones by prescription).
Lasers are an important component of a cosmetic medical practice. They treat many skin conditions, such as hyperpigmentation, acne, telangiectasia (blood vessels), aging skin and many other conditions that are not easily treated by typical facial treatments. Patient education on pre- and post-laser care will optimize results and increase the patient’s satisfaction with their provider and their finished look.
Patients with pigmentation disorders, such as solar lentigo, photo/sun damage, post-inflammatory hyperpigmentation and melasma, can achieve significantly better results if they take care of their skin at home. Most pigment disorders can be treated easily with visible light laser or intense pulsed light (IPL or BBL), except in the case of melasma. There has been success treating melasma with fractionated erbium laser treatments and other modalities, and several treatments are typically needed.
When treating patients with pigment disorders, home care is critical. Topical agents containing pigment-lighteners should be used at home for four to six weeks before treatment with continued use until the desired outcome is reached. Some popular pigment-lightening ingredients include hydroquinone, which many professionals consider to be the most effective pigment-lightener on the market. If a patient develops sensitivity or is looking for alternative treatments, the ingredients kojic acid, ascorbic acid (vitamin C), azelaic acid, licorice root and arbutin, as well as many others, can be used with good, although slower results. These ingredients work by suppressing the activity of the melanocytes, which are the cells in the skin that produce pigmentation to protect it from irritation, inflammation, acne, hormonal conditions and photo damage. Those with darker skin have more active melanocytes; therefore it is an absolute necessity to pre-treat darker skin types so the risk of complications is decreased. Along with pigment-lighteners, sunscreen is an absolute must. If the proper sunscreen is not used before and after treatments, patients increase their chances of undoing the results they have obtained or increasing their existing pigmentation.
For patients with rosacea or vascular issues, IPL or BBL, or visible light lasers are the most effective treatments. Light therapies are attracted to color and cannot differentiate between tanned skin and target colors; therefore, patients must use a topical high-quality broad-spectrum sunscreen before and after treatments. Zinc oxide is often preferred because it is a physical sunscreen with anti-inflammatory properties. Topical vitamin C and vitamin K could also be used to achieve favorable results. Vitamin K decreases the pooling of blood under the skin commonly associated with telangiectasia, and vitamin C has been shown to strengthen capillary walls, therefore decreasing the chances of further damage. Care for these patients is simple compared to other skin conditions that are treated with lasers. Always remember, less is more with these skin types. It is imperative to educate the patient about the importance of wearing sunscreen on a daily basis and about ways to avoid further damage. The patient should also be aware of triggers that will cause breakouts.
Mature skin that is characterized by fine lines, wrinkles or increased laxity benefit most from ablative laser treatments. One of the most popular and effective treatments available today is the fractionated Profractional laser. Care for the patient’s skin after treatment with the Profractional laser is critical, because it can affect the healing process and the results. Patients with darker skin should be prepped with pigment-lighteners before and after these treatments in order to prevent the possibility of adverse reactions, such as hypopigmentation and hyperpigmentation. The patient must also be taught the importance of keeping the skin occluded with an ointment recommended by the treating physician. Along with a gentle cleanser, this ointment is the only product that should be used for the first two days following a deep ablative laser treatment.
The main purpose of these treatments is to create a wound response in the skin so more collagen will be produced. If the skin doesn’t have a healthy environment to generate this collagen, patients may not achieve optimal results and it can increase the likelihood of complications. The skin heals best in a moist environment; therefore, after the initial healing period, hydrating agents including hyaluronic acid and emollient moisturizers should be used. Peptide-rich products may also be applied to aid in the healing process.
Lasers may also be used in the treatment of acne, which occurs because oil glands are stimulated to produce more sebum. In addition to this overproduction of sebum, dead skin cells accumulate in the excess oil. This excess buildup of skin cells and oil acts as a breeding ground for Propionibacterium acnes, which is the bacterium that worsens acne. Laser light in the red to blue spectrum may be effective at killing this bacteria and decreasing the inflammation associated with it. The laser works not by heat, but by activating a protein to destroy P. acnes and the surrounding inflamed acne lesions. Lasers alone or photodynamic therapy, a process where lasers are used in conjunction with a topically applied solution, have proven highly successful. Photodynamic therapy utilizes a topical drug called Metvix to photosensitize the P. acnes bacteria, making them more susceptible to laser light. Proper product use during this treatment is essential. Gentle cleansers, sunscreens containing zinc oxide and hydrating agents, such as hyaluronic acid and vitamin B-5, should be used.
It is important to not only have the patient’s skin prepped properly, but also to care for the skin after these treatments. Along with any medical treatment, using the wrong products will not only hinder the results, but can also cause serious complications. Education is the key to achieve the best outcome, and the ultimate gratification comes when satisfied patients obtain great results.
Our dermatologist Dr. Anatoli Freiman discusses skin cancer and dangers of tanning in Elle Canada magazine. Dr. Freiman recommends giving yourself regular exams – inspecting the body for changes in moles or the sudden growth of sores or skin discolorations. See your doctor for regular checkups if you are high risk (people with fair skin that burns or freckles instead of tans; blondes and red heads; those with many moles and people with a history of sun exposure or family history of melanoma). Dr. Freiman also suggests minimizing sun exposure between 11 a.m. and 3 p.m., wearing a hat and sunglasses, and sporting a broad-spectrum sunscreen of at least SPF 30.
The recent August 2015 issue of the Journal of the American Academy of Dermatology had 2 interesting findings of note to our patients:
1. 15.5% of patients with psoriasis have undiagnosed psoriatic arthritis
2. Patients with rosacea are more likely to have dyslipidemia (e.g. high cholesterol) and hypertension, as well as coronary artery disease. Some data even suggests that oral tetracycline type antibiotics may lower the incidence of vascular events.
