ANTI-AGING SKINCARE FAQ ver. 4.1, October 2004

This FAQ may be reproduced if it is referenced as the Anti-Aging Skincare
FAQ, version 4.1, posted to alt.skincare.

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Anti-Aging Skincare Frequently Asked Questions, Version 4.1
Revised October 2004
Posted to alt.skincare
Author code 91587355


CONTENTS:

1. Introduction
2. What is the anatomy of the skin?
3. What factors affect skin health and aging of the skin?
4. What are Retin-A (tretinoin) and retinoids?
5. What is retinol?
6. What is copper peptide?
7. What are alpha-hydroxy acids and skin exfoliation?
8. What other topical treatments are available?
9. What is skin resurfacing?
10. What are nonablative treatments?
11. How can I treat excessive skin oil?
12. How can I treat scars?
13. How can I treat visible capillaries?

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1. Introduction

Most people start seeing aging effects in the skin by their late 30s. Over
the years you may also accumulate scars from cuts, scrapes, and burns. This
FAQ answers common questions about how to slow skin aging and improve the
appearance of aged or scarred skin. The information applies to both men and
women. It does not cover cosmetics, injected fillers or Botox (botulism
toxin). It does not cover plastic surgery procedures, except for skin
resurfacing and scar revision. Rather, it deals with products and medical
procedures that can improve skin structure. It is based on a review of
medical research, dermatology textbooks, popular skincare books, Internet
consumer reviews and personal experience.

The pharmaceutical information and product brand-names are for customers in
the USA. Products with the same active ingredients are obviously available in
other countries. Brand-name products from the same company will often have
slightly different names in different countries. If a generic version of a
prescription product is available from your pharmacist, it is simply
identified by the active ingredient name. For example, the active ingredient
in the brand name product Retin-A is called tretinoin. Generic versions
usually cost much less than brand-name products. Prices for the products
mentioned in this FAQ, in USA dollars, were current as of the revision date.
The information on importing prescription products into the USA under the
FDA regulations should not be considered legal advice and should be used only
at the reader's own risk.

This FAQ does not constitute professional medical advice. Most internal
medicine specialists and general practice physicians can provide you with
basic medical skincare information, but for specialized advice and procedures
you should consult a dermatologist or a nurse or physician-assistant who
specializes in dermatology. Plastic surgeons also understand skincare and do
procedures such as resurfacing and scar revision. The information about
medical professionals and cosmetologists in this FAQ applies to the USA.


2. What is the anatomy of the skin?

The outer layer of the skin is the epidermis, and the next layer is the dermis.
The epidermis, which is generally less than a millimeter thick on the face, is
constantly being regenerated as surface cells are shed. As epidermal cells
are pushed to the skin surface, they become flattened, and a hard protein
called keratin is formed in them. The thicker dermis under the epidermis
contains collagen and elastin fibers that give skin its elasticity. The pores
contain fine hairs and secrete sebum (skin oil) to keep your skin moist.
Sweat glands open onto the skin surface to cool the body in high temperatures.
Both the pores and sweat glands are sources for new cells that spread out on
top of the dermis to form the epidermis. The appearance of your skin is
governed by the condition of both the dermis and epidermis.

As we age, changes occur in the structure of the skin that affect its
appearance. The dermis becomes less elastic and the epidermis becomes
thinner. Because of these changes, wrinkles and fine lines develop, pores
appear larger, and the surface texture becomes more coarse. Dynamic wrinkles,
which are caused by making various facial expressions over the years, become
more prominent. Discolorations also often appear. Some of these changes are
cause by intrinsic cellular aging, but most are caused by extrinsic damage
from sun exposure (called photoaging or photodamage). Solar ultraviolet light
damages all types of cells in the skin and can also cause skin cancer.
Dark-skinned people usually have much less photoaging because the melanin
pigment in their skin partially blocks sunlight from reaching the lower
dermis. The best-looking skin most people have is in areas without much sun
exposure - under the arms, on female breasts or on the rear. Note that you
probably haven't been using any special cleansers or expensive skincare
products on these areas, and the skin there still looks like a baby's.

The dermis can also be damaged by injuries. If a wound penetrates deeply into
the dermis, thick, uneven scar collagen can form as the wound heals. This
produces a raised scar. If a wound causes significant tissue loss in the
dermis, a pit or depressed scar may form. Burn scars can have an irregular
appearance with both raised and depressed areas.

While the condition of the dermis is reflected in wrinkles, lines and scars,
the condition of the epidermis affects the surface texture of your skin.
Generally, the best appearance is produced by a thick epidermis. A thicker
epidermis also tends to minimize the appearance of pores and depressed scars.
However, if the epidermis grows abnormally or is excessively dry, the skin
can appear rough or scaly. At the other extreme, stripping off the upper
epidermal layers with excessive scrubbing or over-use of cosmetic acids can
temporarily produce an uneven surface texture and increase the size of the
pore openings. Scraped or burned areas sometimes have a thinner epidermis,
even after complete healing.

You should not expect the texture of the epidermis to be porcelain-smooth.
The openings of the pores and sweat glands cause small indentations, and
there are small ridges covering the surface. Many people have a false sense
of how smooth adult skin should appear because they see models and
celebrities who seem to have perfect skin in magazine photos, on TV and in
movies. Only children or people who have generally avoided sun exposure have
this type of skin. Most close-up magazine photos are touched-up to smooth
skin texture, and both men and women wear a lot of makeup on TV and in the
movies. (There is a Net site with candid photos showing that many
celebrities have the same skin problems as everyone else.) Even politicians
and news-people wear a lot of makeup on TV. Special camera lenses, filters,
lighting, and digital image processing help to hide wrinkles and rough skin.
A recent magazine article and companion network news report had an interview
with a famous actress who showed exactly how her skin was "cleaned up" for
magazine photos with computer software. Remember too, that after about age
50, many celebrities have facelifts, which stretch the skin and make the
surface appear smoother than normal (often unnaturally smooth, with a
stretched appearance ).

Based on skin anatomy, we can say that a true anti-aging skincare treatment
will produce one or more of the following effects:

1. Prevent or repair damage to collagen and elastin in the dermis;
2. Promote the growth of new collagen and elastin;
3. Repair other damaged cells in the dermis;
4. Promote epidermal growth to thicken the epidermis; or
5. Smooth the epidermal surface.

There are scientific methods to determine if a substance or procedure has any
of these effects, and research in this field is ongoing. However, despite
advertising claims, most skincare products sold today, such as cleansers and
moisturizers, don't produce any significant effects in skin structure. The
"special" ingredients advertised in some of these products (such as vitamins,
proteins, and plant extracts) generally don't penetrate into the lower
epidermis or dermis, so they can't improve collagen or elastin. Any
improvement in appearance they produce is confined to the upper epidermal
cell layers and is usually temporary. Because of this, you will generally
find that inexpensive cleansers and moisturizes work just as well as expensive
products. (We will cover the products that do affect skin structure below.)


3. What factors affect skin health and aging of the skin?

Scientific research has identified a variety of factors that affect extrinsic
and intrinsic aging of the skin. Many of these factors are controllable by
simply modifying your behavior and diet. This section covers ways to prevent
skin aging, and the following sections cover ways to treat it.

Avoiding sun damage is the most effective thing you can do to prevent aging
of your skin. The sun is a huge nuclear fusion reactor, producing not only
visible light and heat, but also intense ultraviolet (UV) light that can
damage your skin. Sunlight is the major cause of extrinsic skin aging because
it damages collagen and elastin, and produces abnormal changes in other cells.
Doctors call aging due to sun exposure photoaging, that is, aging produced
by light. While photoaging is usually described as a cosmetic problem, it is
also a serious health concern since it can lead to skin cancer.
Unfortunately, apart from dermatologists, many healthcare providers don't
warn their patients adequately about the risks of sun exposure.

Everyone is susceptible to photoaging, even people with dark skin. Though
more skin pigment reduces sun damage, the intensity of sunlight and cumulative
exposure will eventually cause photoaging in people of all skin colors. In
light skinned people, tanning is actually the body's defensive response
to sun exposure, producing more melanin (skin pigment) to protect the skin.
However, this is a very weak defense, and tanning doesn't adequately protect
the skin from sun damage.

The majority of visible skin aging occurs in the face, because it is
regularly exposed to the sun. If a person were able to avoid sun exposure
their whole life, their face would have few wrinkles and discolorations, even
in old age. Some old people who have had little sun exposure look remarkably
youthful. The body of a 60 year-old person who exercises regularly and eats
right can look as good as that of an average 40 year-old; the same could be
true of our faces if we avoided sun exposure. So if you want healthy skin,
you need to stay out of the sun, or cover up with clothes, a brimmed hat, and
a broad-spectrum UVA/UVB sunblock. This is very important for children and
teenagers too, because sun damage is cumulative. Don't use tanning beds;
they are only slightly better than baking in the sun. (Despite what tanning
salons say, any wavelength of UV light that causes your skin to tan also
damages the skin.) If you go swimming, use a beach umbrella when you are out
of the water. If you wear very light-weave clothing in the summer, you should
apply sunblock underneath, because the fabric may only partially block the
sunlight. Wear good-quality UV-blocking sunglasses, since sunlight can damage
your eyes and the delicate skin around them. Also ask your optician for
UV-blocking lenses if you wear clear prescription glasses.

In this FAQ, I use the term "sunblock" to refer both to products that reduce
UV light exposure by reflecting or blocking it (such as those containing
titanium dioxide and zinc oxide) as well as chemical sunscreens that absorb
UV light. Either of these products work well, however some dermatologists
prefer the products with titanium dioxide and zinc oxide because they are less
likely to cause any irritation.

Modern sunblocks are true anti-aging products because they prevents sunlight
from damaging your skin. However, older "suntan lotions" didn't do a very
good job of blocking UV rays, so many middle-aged and older people have skin
photodamage, even if they used these products in their youth. Today there are
all sorts of very effective sunblock products available from very light gels
for daily use, to thick waterproof creams for swimming. (Avoid daily use of
sunblocks containing alcohol, which can irritate your skin.) Look for a
sunblock that is labeled for both UVA and UVB protection. (UVA and UVB
refer to different wavelength ranges of solar ultraviolet light.) It is best
to buy brands that have an expiration date printed on the label or bottom of
the bottle, since most sunblocks lose potency over time. If you wear makeup,
try to find a product line that incorporates sunblock in its products .

Follow the the directions on the sunblock label. Most sunblocks require a
number of minutes before they start working, and you need to reapply them
after a certain period of time. Some sunblocks may stain clothes, so you
should apply some to a similar scrap of fabric and let it sit overnight to
check. If you are going to be in the sun for an hour or more, you should use
sunblock with a sun protection factor (SPF) of at least 15. Higher values
will allow you to stay in the sun longer, but they also expose your skin to
higher concentrations of the various sunblock chemicals - some of which may
irritate your skin. SPF ratings are a measure of how long the sunblock lasts
on your skin, not a measure of "blocking power." So higher SPF values are
appropriate if you are going to be in the sun for many hours and don't want
to apply more sunblock later. However, if you sweat a lot, you should apply
more sunblock after an hour or two no matter what the SPF value.

You should use sunblock on all exposed areas of skin when you are outside.
Some people forget to apply it to their hands, ears, and neck. You should
also use sunblock lip-balm for your lips, which are very susceptible to sun
damage. Be sure to cover your nose well with sunblock, because its angle
causes it to receive more intense sunlight during mid-day. (The worst
photoaging many people have is on top of their nose.) Sunblock should be used
year-round and also on cloudy days, because even diffuse sunlight causes
damage. People who live at high altitude should always use sunblock and cover
up as much as possible when outside because the intensity of UV light is
higher there. High-altitude areas have higher skin cancer rates. Mountain
climbers and skiers should shade or cover their faces as much as possible
with brimmed hats, wrap-around sunglasses or goggles, nose shields (see
www.bekogear.com), or facemasks.

It is becoming less fashionable for light-skinned people to have a dark tan
because of its association with skin damage. However, if you want a tan,
today there are many self-tanning lotions that will temporarily dye light skin
to various shades of brown. They are much better than older products that
produced an orange color. Note that these are not sunblocks, and the dyed
skin doesn't provide any sun protection. However, they should be used
sparingly, because the active chemical in them, dihydroxyacetone, could be
harmful to your skin in high concentration.

If you smoke, quit. This includes marijuana and other smoked drugs as well
as tobacco. Doctors say smokers have much worse skin than non-smokers. The
toxins in all types of combustion smoke damage skin cells and diminish blood
flow to the skin. A medical study showed that smoking was strongly correlated
with a much higher incidence of facial wrinkles.

Limit your consumption of alcohol. A medical study showed that heavy alcohol
consumption was strongly correlated with a variety of skin diseases and blood
vessel abnormalities. Heavy alcohol consumption has adverse effects on
nutrition and immune functions, which also affect the skin.

Don't use illicit street drugs. They may contain contaminants and toxins
that can damage your organs, including your skin.

There is scientific evidence that diet influences intrinsic aging of the
body, including the skin. Healthy immune and cardiovascular systems may
prevent skin abnormalities. Both of these systems are improved by a diet rich
in fruits, vegetables, low-fat protein, unsaturated fats and low in simple
carbohydrates, sugar, and saturated fats. One recent medical study confirmed
that healthy skin appearance was correlated with a diet similar to this. You
should also avoid processed foods with "partially hydrogenated vegetable
oil" or "vegetable shortening" (called trans fats) in the ingredients list;
they can clog your arteries. (Liquid vegetable oils, such as olive oil,
canola oil, and soybean oil are better for you than trans fats.) Trans fats
are in many processed foods sold at grocery stores including many brands of
margarine, peanut butter, cookies, crackers, pastries, and bread. Avoid junk-
food like chips, candy, and sodas.

Animal studies indicate that cellular aging processes may be slowed down by
restricting your daily caloric intake. It is theorized that caloric-
restriction lowers the production of free radicals (unpaired electrons) and
reduces circulating blood glucose, both of which can damage cells. This is
another reason to eat more fruits and vegetables, and reduce your consumption
of simple carbohydrates and sugar, which are high in calories and increase
blood glucose levels. Simple carbohydrates include foods made from refined
grains like sugary breakfast cereals, cakes, white pasta, and white bread.
Foods like this which significantly increase blood glucose levels are said to
have a high "glycemic index." You can find lists of foods and their glycemic
indices on the Net and in some diet books.

Vitamin and mineral supplements that contain the recommended daily
allowances (RDA) provide necessary nutrients for skin health. The RDA levels
are based on numerous scientific studies. However, large doses of supplements
well above the RDA can be harmful, particularly for people with certain
diseases or pregnant women. Despite what you may have seen in advertising,
scientific studies have not shown that high doses of vitamins and minerals
above the RDA prevent disease or slow aging. You can find lists of the RDA
online for both vitamins and minerals. The labels on supplement products list
the percentages of the RDA. There are products available that contain the
full RDA for most vitamins and minerals, so you only have to take one pill per
day. If you eat a good diet of mostly fruits, vegetables, low-fat protein,
and some whole-grains, you will get most of the RDA in your food; so you may
only need to take a pill once per week to get all the nutrients you need.

Moderate exercise strengthens the cardiovascular system, which is important
for skin health. If you have a sedentary job, try to do some sort of vigorous
aerobic exercise for at least 30 minutes, three times a week. Simply walking
at a brisk pace for 45 minutes, five days a week can give nearly the same
benefit. Moderate strength training with weights two days per week is also
beneficial. For anti-aging benefits, exercise should not be continued to
exhaustion. Scientific studies have found that very strenuous exercise
greatly increases the production of free radicals and may accelerate other
aging processes in cells. Elite endurance athletes and bodybuilders don't age
any slower or have fewer wrinkles than people who exercise moderately, and
in fact, they may age faster.

You should also get in the habit of checking your skin periodically. There
are many types of growths and discolorations that can develop on the skin
with aging. Check your skin all over with a hand mirror every few months.
Look for any odd bumps, discolorations, or changes in a mole. Many people
dismiss all developing marks on their skin simply as "age spots". While most
growths are benign, some are skin cancer. Your doctor can give you a brochure
showing the most dangerous types of lesions to look for; there are also
pictures on various dermatology websites. A quick appointment to have your
regular doctor or a dermatologist check a spot could save your life. While
all skin cancers must be removed surgically, usually this is inexpensive and
relatively painless if it is caught very early while it is still small. If
you wait even a few months, some types of skin cancer can kill you. Even with
a benign growth, waiting until it gets larger will result in a larger scar
when it is removed. If you have it removed early, usually there will be
only a tiny scar after healing.

Your doctor can also explain the various types of benign lesions to you and
recommend treatments. Benign, raised growths can be removed surgically and
the skin stitched if necessary. Benign, flat discolorations can be treated
with bleaching creams, alpha-hydroxy acids, retinoids (such as Retin-A),
freezing, curetage (scraping), or resurfacing (chemical peeling, dermabrasion,
or laser). Low-concentration hydroquinone bleaching creams and alpha-hydroxy
acids can be purchased without a prescription at most drug and discount
stores. You can alternate nightly use of both products. However, you should
see a doctor first to make sure the spots are benign. He or she can also
prescribe stronger bleaching creams and Retin-A or you can alternate use of
a strong prescription bleaching cream and an alpha-hydroxy acid. You must use
a sunblock when outside during the day while treating dark spots, and in the
future, or they may show up again.


4. What are Retin-A (tretinoin) and retinoids?

Currently, the most-studied topical anti-aging treatment is prescription
tretinoin (with brands Retin-A, Retin-A Micro, Renova, Avita, or generic).
Tretinoin is also called vitamin A acid or retinoic acid; but it is a
different chemical from regular vitamin A - one form of which is called
retinol. A prescription is required for tretinoin because it produces
significant changes in the structure of the skin. Tretinoin was developed
many years ago and is often prescribed for acne because it reduces sebum
build-up in pores; but a large number of peer-reviewed medical studies done
since the early 1980s also show that tretinoin can also improve fine lines,
skin texture, and uneven pigmentation. Tretinoin may also improve the
appearance of large pores and some scars. It is has been shown conclusively
that tretinoin acts to improve collagen in the dermis, thicken the epidermis,
and smooth the skin surface. The effects are modest with most people, but a
few people achieve significant improvement. For medical studies, see for
example "Treatment of Photodamage with Topical Tretinoin: an Overview",
Journal of the American Academy of Dermatology, 36(3 Pt 2), S27-36, 1997 Mar;
"Short- and Long-Term Histologic Effects of Topical Tretinoin on
Photodamaged Skin," International Journal of Dermatology, 37(4), 286-292, 1998
Apr; "Treatment of Photoaged Skin With Topical Tretinoin," Skin Pharmacology,
6 Suppl 1(), 78-82, 1993; and "Topical Tretinoin Improves the Appearance of
Photo Damaged Skin," Australasian Journal of Dermatology, 35(1), 1-9, 1994
(abstracts available free online using the medical index Medline at the
National Library of Medicine, www.ncbi.nlm.nih.gov and at many other medical
websites).

Tretinoin and related chemicals, called retinoids, are some of the most
important discoveries in dermatology. In addition to tretinoin, other
retinoids are available for treating various skin conditions including
adapalene (brand-name Differin) and tazarotene (brand-names Avage and
Tazorac). Adapalene is used for acne, and tazarotene was originally
used mainly for psoriasis and acne. Currently, there are no published medical
studies on adapalene as a treatment for photoaging, but tazarotene has
been shown to be effective for this, though it may cause more irritation than
the tretinoin. See for example, "Tazarotene Cream for the Treatment of
Facial Photodamage," Archives of Dermatology, 137(12), 1597-1604, 2001; and
"Efficacy of 0.1% Tazarotene Cream for the Treatment of Photodamage: A
12-Month Multicenter, Randomized Trial," Archives of Dermatology, 138(11),
1486-1493, 2002 Nov (abstracts available on Medline). Results indicate that
improvement with 0.1% tazarotene is comparable to 0.05% and 0.1% tretinoin.
Tazarotene may work better than tretinoin for some people. Tazarotene is not
yet available as a generic in the USA, and the brand-name products Avage and
Tazorac are more expensive than generic tretinoin. Other studies may be
done to compare the effectiveness of tazarotene to tretinoin for photoaging.
You can do a combined search on both words using Medline to check for these
studies.

Ortho Pharmaceuticals has published before-and-after photos from the tretinoin
medical studies online and in magazine ads that show significant improvement
in fine lines and discoloration for some of the test subjects. However, these
probably show the best results; most people will have less improvement. In
the clinical trials, which lasted from six months to one year, approximately
65% of the test subjects had some noticeable improvement in fine lines and
discolorations, and 51% had improvement in skin texture. While the
improvement was modest with most test subjects, nearly all showed
improvement to their skin under microscopic examination. Net reviews of
tretinoin are almost all positive, though people with sensitive skin often
complain of peeling and irritation when using the higher concentrations. The
results of the medical studies and anecdotal evidence from doctors over the
years show definitively that tretinoin is an effective topical treatment for
moderate photoaging. However, it is not a wrinkle cure, and it cannot stop or
reverse the aging process.

Initially, there was some controversy about tretinoin. It's effects were
wildly exaggerated in the media, sometimes with help from doctors. Then the
initial manufacturer got into trouble with the FDA in the USA for
promoting tretinoin as a prescription wrinkle treatment before it had been
approved for that use. Also, many people experienced irritation with some
forms of tretinoin. Because of all this, you don't read nearly as much in
the media today about tretinoin. Another problem is that now only one brand
of tretinoin cream called Renova can legally be advertised in the USA as a
treatment for photoaging, though all forms contain the same active chemical.
(This is an unfortunate consequence of FDA regulations.) However, doctors
can also legally prescribe any other brand of tretinoin for general skin
improvement, though this is called an "off-label" use if you don't have acne.

Most of the studies showing skin improvement with tretinoin have been done
with a 0.05%-concentration formula. However, many people find that regular
0.05% tretinoin cream initially causes peeling and redness. They often give
up on tretinoin because of this. To avoid this possibility, it is best to
start out with a tube of 0.025% cream. Initially, apply only a tiny amount to
your face at night and check for peeling and redness the next day. You can
use moisturizer during the day if necessary. Work your way up gradually
to no more than a pea-size amount nightly for the whole face. Apply it
evenly by first dabbing your forehead, cheeks, and nose. You can also
apply a small amount to any other areas that have received a lot of sun
exposure such as your ears, neck, chest, back, arms and hands. (Apply it
only lightly to the ears or you will get a lot of peeling.) You can apply it
to the fine lines around your eyes, but be careful not to get any in your eyes
or it could irritate them (flush them with water if you do.) It is very
important not to use tretinoin during the day because exposure to light,
especially sunlight, will decrease its potency. You should apply it at least
a half-hour before sleeping so it is fully absorbed and won't rub off on your
pillow. Don't apply other products to your face at the same time, since they
could inactivate the tretinoin.

The regular tretinoin creams are appropriate for most people because they are
very light, and don't contain oil. However, if you find the 0.025% cream too
irritating, you can try Ortho's 0.02% or 0.05% Renova brand products, which
are thicker, emollient creams for dry or sensitive skin. If you have no
problems with the regular .025% cream, your doctor can next prescribe the
0.05% cream. People with more skin oil may be able to use the 0.1% cream or
0.1% Retin-A Micro, which is a special time-release formula usually used for
acne. There is also a 0.025% gel that is more potent than the creams.
The gel does not spread as easily as the creams, and it contains a significant
amount of ethyl alcohol (or ethanol), which can be irritating. The gel
usually works better than the creams to treat acne and clogged pores.
A very potent 0.05% alcohol-based liquid is also available, but most people
find it too irritating, and it is easy to accidently spill it.

Remember, you must be patient with tretinoin. While microscopic changes start
immediately, it takes about three to six months before you will see any
visible improvement in the mirror. After six months, typically you will start
to see that deep wrinkles are reduced slightly in depth, fine lines around
your eyes are less noticeable, and your skin will feel smoother and firmer
when you wash your face. Maximum results are achieved after 12-24 months of
nightly use (depending on concentration), and after that you only need to
apply it two or three days per week for maintenance. If you stop using
tretinoin, the skin will gradually regress. You may want to take before-and-
after, close-up photographs of your face to check your progress. People who
don't do this often greatly underestimate their results, because the
effects of tretinoin are gradual and generally modest. The gradual nature of
its effect may be one reason why tretinoin is not used by more people. Even
if you are one of those people who does not see significant improvement in the
mirror, tretinoin will improve your skin on a cellular level, and can slow
down the development of lines, wrinkles, and discolorations in the future.
Doctors have found that some people achieve better results using tretinoin
and cosmetic acids on alternate nights (discussed below).

With a prescription, you can buy a 45 gram tube of generic tretinoin (0.025%
gel or 0.025%, 0.05%, 0.1% cream) at pharmacies for between $50 and $75. This
is obviously very expensive, but a 45 gram tube will last at least three
months. Only a pea-sized amount is used for the whole face. 20 gram tubes
cost between $25 and $40. Some generics and foreign brands may be available
in 60 gram tubes. Usually, the larger tubes are a better value per gram.
Note that the other effective retinoid, tazarotene, currently costs about $60
for a 30 gram tube. Prices on tretinoin vary widely at pharmacies, so call
around for quotes when you get your prescription. Mail-order pharmacies may
be less expensive. (Check the consumer websites for recommended mail-order
pharmacies.) The Avita brand and generics cost less, but some pharmacies
may only carry one concentration in a generic. The Ortho Retin-A, Renova,
and Retin-A Micro brands are more expensive. If you are on a low budget, get
a prescription for a large tube of the highest-concentration 0.1% generic
cream and use only a water-drop-sized amount for your face. You can spread it
easier by moistening your face first with a little water. You can make the
tube last a whole year this way.

It is possible to buy tretinoin over the Net or by mail from foreign sources
at much lower cost than in the USA, but beware that you could get product
of dubious quality. There are some reputable Canadian and British mail-order
pharmacies which have low prices and quality brands. There is more risk of
counterfeit products or shipping losses when buying from countries others
than the USA, Canada, and Britain. You can check various consumer websites
for Canadian and British pharmacy recommendations. Some of these
pharmacies also have websites. Depending on the pharmacy, you will have to
mail or FAX them your prescription, or simply give them your doctor's name
and address. Beware however, that anyone can set up a P.O. box or website
and call themselves a pharmacy, so check them out first. With any mail-order
pharmacy you should use a credit card, rather than a check or money order, to
protect against fraud. (You can contest the charges on your credit card if
your order is not sent.) Also, never use any mail-order pharmacy that asks
for your social security number. It is not required by any law and could be
used fraudulently.

Some pharmacies in Mexico also sell various brands of tretinoin without a
prescription. However, there have been cases of counterfeit pharmaceutical
products being sold in Mexico, so examine the box and the tube carefully. All
the printing should be clear, and obviously words should not be misspelled.
Unless it is a generic product, both the brand-name and the generic name
"tretinoin" should be on the tube and box. The concentration (0.025%, 0.05%,
or 0.1%) should be printed on box and tube. There should be an expiration
date stamped on both the box and the end of the tube. The tube should be
made of metal, not plastic, and should be sealed under the cap. There should
also be a detailed instruction sheet inside the box. In Mexico, it is best to
only buy brand-name tretinoin products made by major USA and European
pharmaceutical companies, rather than generics. Beware that even if you
follow these guidelines, you could still get bogus products in Mexico.
You should also know that on rare occasions, Mexican police have illegally
stopped USA citizens leaving Mexican pharmacies with various medications and
asked for cash "fines". (Any trip to Mexico carries some risk.)

Under FDA regulations, it is legal to import a "90 day personal supply" of
some types of prescription medications purchased in another country across any
border if you declare it, and it is clearly labeled with the generic
medication name. This includes importation by shipment or personal-carry.
Technically, the regulation applies only to the importation of drugs that
are not available in the USA. However, Customs inspectors usually allow
both shipping and personal importation of tretinoin and other topical skin
medications. Three or four large tubes would probably be O.K. More than
this could be confiscated at the border, but the inspectors may not care
much about illicit skin cream. Be aware however, that there is always a
small chance of confiscation of pharmacy shipments or personally-carried
tretinoin. Importation of pharmaceuticals is a controversial issue, and the
law may change to make the regulations less restrictive or more restrictive.

If you bring the tubes in personally, according to the regulation you should
carry with you a signed statement (that is, signed by you) stating the
following:

"I declare that the items I am carrying are for my personal use only under
the June 1988 "FDA Pilot Guidance Scheme" and that they are not for
commercial resale. No beneficial or therapeutic claims have been made
against any product. The amount does not exceed a three month supply,
and they are used with the consent of my physician."

You must also write on the statement the name and address of your personal
doctor who knows that you are using tretinoin. It is also a good idea to
carry one of your doctor's business cards and a photocopy of your
prescription with you just in case there are any questions at the border,
though this is not required by the regulation. (Write "copy" on the
prescription photocopy so the border inspectors know you are not trying to use
it as an original.) Let your doctor know in advance that you may buy your
medication from a foreign pharmacy to save money. By the way, don't try to
use this method to import any controlled substances, growth or sex hormones,
anabolic steroids, or injectable medications. If you do, you could be
arrested by federal or state officers.

All tretinoin made by major pharmaceutical companies should have a potency
expiration date stamped on the box or the end of the tube. Be sure the
expiration date is at least six months away since one large tube may last you
this long. Obviously, if you buy a few tubes at one time, you will want
an expiration date a couple of years in the future. Tretinoin cream has a
shelf-life of about three years from the date of manufacture, and the gel
about two years. Keep the tube capped, since exposure to air and light can
inactivate tretinoin and cause some of the other ingredients to evaporate.
Also store the tube at temperatures under 80 F, or it will degrade faster.

Unless you have tretinoin prescribed for acne, insurance companies usually
won't pay for a doctor's visit or a prescription. You can obviously pay for
a skincare consultation with your regular doctor or a dermatologist, but you
can save money by simply having your doctor give you a prescription at your
next insurance-covered visit.

If you have extra money, also ask your doctor for a prescription for a small
30 gram tube of 0.05% or 0.1% tazarotene cream or gel (Avage brand cream or
Tazorac brand cream or gel), and compare it to tretinoin on different sides of
your face. It costs about $60. Some people may get slightly better results
with tazarotene. The Avage brand is FDA-approved for treating facial
photoaging, while Tazaroc is approved for treating acne and other skin
conditions; but the active ingredient tazarotene is the same in both brands.
Avage and Tazaorac cream have nearly identical ingredients, so you can check
the pharmacies to see which one costs less per gram. Tazorac also comes in a
gel, while Avage is currently only available as a cream. Avage and Tazorac
cream are emollient-type creams containing mineral oil, similar to Renova,
made for people with dry or sensitive skin. People with more skin oil or
acne should use Tazorac brand gel. Unlike tretinoin gel, Tazorac brand gel
only has a small amount of alcohol and spreads easier. Doctors can legally
prescribe either brand of tazarotene for treating photoaging. With any form,
you should initially use tazarotene very lightly since it may cause
irritation and peeling. If you get the higher concentration 0.1% product,
start by applying only about a water-drop-sized amount to your face at first.
Tazarotene seems to absorb slowly, so be sure to apply it at least a half-
hour before sleeping or it could rub off on your pillow. Some internists and
general practitioners may not yet be familiar with tazarotene as a treatment
for photoaging, so you may want to show them copies of the medical paper
abstracts on tazarotene listed above. You can also print out consumer
medical information on both Avage and Tazorac from the Net.

If you go to a dermatologist, be sure to also ask for free tretinoin and
tazarotene samples; they often have small tubes to give away to patients.
Since tretinoin is now considered a routine skincare product, your regular
doctor may also be willing to call in a prescription to your pharmacy without
an exam. Some clinics can also schedule a lower-cost consultation with a
nurse practitioner or physician-assistant who can give you a prescription for
tretinoin. Always be sure to ask that the prescription specify the maximum
number of refills, so you can simply go back to the pharmacy when you need a
new tube. When you run out of refills, often you can get the doctor's office
or clinic to call the pharmacy to authorize more without having to pay for
another visit.

Tretinoin has a good safety record. It has been used daily by thousands of
acne patients without significant reported problems. Animal skin tests
suggest that topical tretinoin application is safe, though some studies have
indicated that it may make the skin more susceptible to UV light damage. On
the other hand, there are only a few small-sample, multi-year human safety
tests, so the specific risks of using it daily for many years are unknown.
For this reason, it is prudent to decrease application frequency after 12
to 24 months (depending on the concentration you are using) to two or three
times per week - which is all that is needed anyway for maintenance. Because
of its effect on pigment cells, tretinoin will also lighten your skin
slightly. With some people, it will significantly lighten freckles after
about a year. You should not use tretinoin if you are pregnant or may become
pregnant. (An excess of vitamin A and related compounds in the body may
cause birth defects.) Don't apply any other medications or moisturizers to
your skin over tretinoin. As previously mentioned, tretinoin should be
applied only at night because light decreases its potency. When using
tretinoin, you must use a sunblock during the day when outside, because of
the possibility of UV light sensitivity. (You should be doing this anyway.)
Similar cautions also apply to the other retinoids such as tazarotene, so be
to read the instructions and safety cautions that come with the tube.
Author code 91587355


5. What is retinol?

Retinol is the name for a form of vitamin A. This can be confusing because
the word "retinol" sounds like the tretinoin brand, Retin-A. Retinol is not
nearly as effective as tretinoin, but medical studies have shown that
stabilized forms of retinol do have some positive effects when applied to the
skin. The studies show that if the retinol penetrates, some may be converted
by enzymes in the skin to small amounts of tretinoin, thereby producing
similar effects such as improved collagen and a thickened epidermis. See
for example, "In Vitro Metabolism by Human Skin and Fibroblasts of Retinol,
Retinal and Retinoic Acid," Experimental Dermatology, 7(1), 27-34, 1998 Feb
(abstract available on Medline). Retinol can produce a modest reduction in
fine lines and a somewhat smoother skin surface. Many retinol products are
also inexpensive, so you can experiment with them without spending a lot of
money. Net reviews of retinol products are generally positive, but reported
results are usually quite modest and very gradual.

Many drugstores and supermarkets have non-prescription retinol products like
Neutrogena Healthy Skin Anti-Wrinkle Cream (regular and SPF 15),
Alpha-Hydrox Night ResQ, and St. Ives Anti-Wrinkle. These are non-greasy,
light creams that are usually applied at night. They cost about $14 for 30 to
40 grams. The Neutrogena products are widely available at drugstores and
supermarkets, and Wal-Mart also has a less expensive store-brand called
"Equate Anti-Wrinkle" for about $8 with similar ingredients.

Most retinol products are inexpensive compared to prescription tretinoin,
and the medical studies indicate they can potentially improve your skin
appearance. However, retinol products are less effective than those
containing tretinoin. One dermatologist has written that currently-available
retinol products are 5-10 times weaker in effect that 0.05% tretinoin. While
the medical studies on retinol used concentrations of 0.5% to 1%, most
retinol products don't list the retinol concentration. This is silly, but it
is a common practice with cosmetics companies because it allows them to skimp
on active ingredients and avoid competition with other brands. Also, one
well-known skincare expert has written that she is skeptical that the
concentration of retinol in most products is comparable to that used in the
studies. So unless you find a retinol brand with the concentration listed,
you can't compare the potency of the products with those used in the studies.

The instructions included with some retinol products say you can see results
in a matter of weeks, but since tretinoin takes months for visible results,
this is probably not true. In fact, based on the suspected low retinol
concentration in most products, you might have to use it for a few years to
get the same noticeable effect as with only six month's use of tretinoin.
Because of this, there may not be any long-term cost savings over generic
tretinoin.

Don't confuse retinol products with other skin creams that say "multivitamin"
or list various other vitamins. Vitamins have to be in certain chemical forms
to penetrate into the dermis or cause any significant biological effect, and
most skin products do not contain these vitamin forms. In addition, unlike
retinol and tretinoin, there is no conclusive evidence yet that other types of
vitamins permanently improve the dermis or epidermis. (There have been a few
positive studies on special forms of vitamin C, but the evidence for
beneficial effects is meager.)

Retinol products are safe for continuous use because they are equivalent in
effect to very low-concentration tretinoin creams. However, some brands
may have other irritating ingredients, so start by using only a small amount,
and see how your skin reacts. Like tretinoin, the directions on most of
these products say they should be used only at night, but supposedly
Neutrogena's SPF 15 version can be used outside during the day. As with
tretinoin, you should use sunblock when outside. You should not use retinol
if you are pregnant or may become pregnant. (An excess of vitamin A and
related compounds in the body may cause birth defects.)

Retinol products do degrade over time and lose potency after about three
years. Unfortunately, most products do not have expiration dates stamped on
the tubes. Since products can sometimes sit in warehouses and on store
shelves for up to two years, it is best to only buy one tube at a time.


6. What is copper peptide?

Copper peptide has been shown in a number of medical studies to promote
healing of the skin. A few studies have also suggested that it can improve
collagen in the dermis. (See the Net addresses below for references.) It may
have some value as an anti-aging skin treatment. There are some positive
Net reviews of copper peptide, with some people reporting smoother skin
texture or improvement in some types of scars. However, others report only
a slight effect. Currently, the positive medical evidence for copper peptide
as a treatment for photoaging is not nearly as extensive as for tretinoin.

Copper peptide products are available without a prescription. Some copper
peptide products are sold at high-end department stores, but they are usually
very expensive. Neutrogena makes a low-concentration copper peptide product
called Visibly Firm Night Cream that costs about $17 for 50 grams. It is
available at many drug stores and supermarkets. You can check
www.neutrogena.com for more information on this product. (Note that some
Neutrogena boxes have a stamped expiration date that indicates a shelf life
of about three years, but other boxes have no date.) The scientist who
originally developed copper peptide skin treatments has medical studies and
extensive product information at www.skinbiology.com and www.skinbio.com.
You can order his products online or by mail, and the prices are reasonable.
His products are generally a better value than the Neutrogena product or those
at department stores because they have a higher concentration of copper
peptide.


7. What are alpha-hydroxy acids and skin exfoliation?

Low-concentration alpha hydroxy acids (AHAs) and salicylic acid (called
cosmetic acids) are chemicals promoted to improve signs of photoaging such
as rough skin surface texture, fine lines, and uneven pigmentation. Home
use of cosmetic acids originally became popular because they provide quick
results on areas of rough skin by peeling off or exfoliating the upper layers
of the epidermis, exposing smoother skin underneath. In addition, numerous
medical studies have also shown that use of low-concentration cosmetic acids
results in improvements to the structure of the epidermis and the upper
dermis and modest improvements in skin texture and fine lines. They may
also stimulate the growth of collagen. See for example, "Epidermal and Dermal
Effects of Topical Lactic Acid," Journal of the American Academy of
Dermatology, 35(3 Pt 1), 388-391, 1996 Sep; and "Topical 8% Glycolic acid
and 8% L-lactic Acid Creams for the Treatment of Photodamaged Skin: A
Double-Blind Vehicle-Controlled Clinical Trial," Archives of Dermatology,
132(6), 631-636, 1996 Jun; (abstracts available on Medline). Net reviews of
cosmetic acids are generally positive, though some people with sensitive skin
report significant irritation.

Note that these acids are more than cosmetic in their effect, but the phrase
"cosmetic acid" has become common. You may also hear the invented term
"cosmeceutical" applied to acids, retinol, and copper peptide - that is,
products which have some effect on skin biology, but don't require a
prescription.

There are a variety of cosmetic acid products available for home use. Acid
concentrations are typically listed as 2% to 20%, though concentrations are
calculated differently among different manufacturers. (The important
specification is actually pH or acidity, but manufacturers rarely list this.)
Most AHA products contain either glycolic acid, malic acid, or lactic acid.
Salicylic acid is sometimes labeled a "beta hydroxy acid," indicating a
different chemical structure than AHAs. It is also used in some acne
medications. Unlike AHAs, salicylic acid is toxic at high concentration and
more caustic, so most salicylic acid products for home use contain
concentrations below 7%. Too much salicylic acid applied to the skin can
cause salicylism, which is characterized by headache, dizziness, and ringing
in the ears. (By the way, salicylic acid is not aspirin, that's
acetlysalicylic acid, a different chemical.)

Cosmetic acids are available as creams, lotions, and gels on the shelf at
specialty cosmetics stores and most drugstores for less than $15. Some
dermatologists, plastic surgeons, and cosmetologists sell the higher
concentration products (above 10% for AHAs) in their offices, but prices
are usually higher than in stores. One popular, reasonably-priced AHA brand
is Alpha Hydrox, in the red boxes. It is available at many drug and discount
stores. Alpha Hydrox has 10% glycolic acid products in cream, lotion, and
gel formulas (see www.neotericcosmetics.com; click on Alpha Hydrox.) The
products are water-based, and can be diluted with distilled water if
necessary. The most potent product is the Alpha Hydrox Oil Free Formula gel;
it costs about $11 for 30 grams. Some drug and discount stores also sell a
store-brand 8% AHA lotion or cream for about $6.

Light skin exfoliation can also be done using abrasive pads or cleansers.
These products are sold in various abrasive textures in the skincare section
of drug and discount stores. They can help smooth the epidermis if you have
areas of rough skin. However, unlike cosmetic acids, abrasives simply remove
the top layers of the epidermis and have little effect on the dermis. The
coarser products may also cause redness and irritation to normal skin because
the pads pull and stretch the skin, and the abrasive particles can scratch the
epidermis. So try the mildest pads or cleansers first. Also be sure to use
sunblock during the day when using abrasives, since thinning the upper
epidermis can make your skin more susceptible to sun damage.

Cosmetic acids and abrasive pads or cleansers can be used regularly if you
have abnormally rough skin due to overgrowth of the top epidermal layers. If
you have chronically rough and dry skin, you should also try various
moisturizers including special urea-based moisturizers like Carmol 20,
available from pharmacists. (A higher strength, Carmol 40 is also available
by prescription.) However, despite what some advertising says, people with
normal skin should limit their use of cosmetic acids and abrasives. The upper
epidermis provides an important environmental barrier and protection from UV
light, so removing it every day for the rest of your life with acid or by
scrubbing doesn't make sense. FDA studies have confirmed that AHAs make
the skin more sensitive to solar UV light damage (though the effect is
reversible when use is discontinued). Also, some doctors have raised
questions about the safety of long-term cosmetic acid use. The continuous
cell turnover that they produce could potentially accelerate some intrinsic
skin aging processes. You should also know that there are Net reports of
AHA use preceding the development of rosacea, which is sometimes triggered
by skin irritation. If you have a family history of rosacea, you should
probably not use cosmetic acids.

With cosmetic acids, one reasonable and safe strategy for skin improvement
would be to use a cosmetic acid nightly for three to 12 months (depending on
concentration), and then discontinue use or apply it only only occasionally.
Remember, cosmetic acids should not be used continuously. Another very
effective initial strategy recommended by some doctors is alternate use of a
cosmetic acid and tretinoin. See for example, "Retinoid Therapy: Compatible
Skin Care," Skin Pharmacology and Applied Skin Physiology, 12(3), 111-119,
1999 May-Jun (abstract available on Medline.) While this study used tretinoin
at night and acid during the day, it is best to only apply the products on
alternate nights to reduce sun-sensitivity. This combination strategy is
believed to be more effective than using either product alone. Application
frequency or concentration of the products may have to be reduced if you get
irritation, peeling or redness. In any case, after about 12 months, decrease
application of the tretinoin to twice per week, and discontinue use of the
acid, or apply it only occasionally. Whatever schedule you use with cosmetic
acids, if your skin looks red and irritated during the day, simply decrease
the application frequency, use a lower-concentration product, or dilute it
with distilled water. When using AHAs daily or alternating with tretinoin,
most people will need to limit concentration to 12% or less. If you use this
strategy with salicylic acid, select a product with a concentration under 5%
to avoid potential toxicity. Higher-concentration salicylic acid products
usually aren't practical for long-term use anyway, because they often cause a
lot of crusting and peeling of the skin.

AHAs and salicylic acid produce different effects on pore appearance.
Contrary to some advertising, AHAs are not a treatment for large pores and do
little to dissolve sebum-keratin plugs in the pores. In fact, peeling off the
upper epidermal layers with AHAs may temporarily make your pores look
slightly larger. Salicylic acid, on the other hand, can help dissolve sebum-
keratin plugs that clog pores. That is why it is used in some acne
medications like Neutrogena's Clear Pore Treatment (with 2% salicylic acid).
There is some research suggesting that the ability of salicylic acid to
penetrate into pores may make it more effective than AHAs of comparable
acidity for treating photoaging. If you have a problem with clogged pores,
you can use the combination strategy of alternating nightly use of 2%-4%
salicylic acid and tretinoin. The 56 gram, 2% Neutrogena Clear Pore Treatment
Gel is the most widely available salicylic acid product in drugstores and
supermarkets; it costs about $7 (look in the acne treatment section). You can
find other products with 3% or 4% concentration at specialty cosmetics stores
or on the Net. Avoid salicylic acid products that have alcohol listed first
or second in the ingredients list, indicating a high concentration. It can be
very irritating. (Note that in prescription medicines like tretinoin,
ingredients may be listed in the opposite order from non-prescription
products, that is, from lower to higher concentration.)

You should only use cosmetic acids at night, since they cause sun sensitivity.
It is very important to always use sunblock when outside while using
cosmetic acids, or you will defeat any benefits you gain by allowing more sun
damage. Don't apply cosmetic acids with any other products since the acids
can react with other chemicals. Be careful not to get any acid in your eyes.
The first time you try a cosmetic acid, do it on a night when you won't have
to work the next day; otherwise, you could wake up with a very red face.
Start out with a low concentration, or dilute the acid and work your way up to
full concentration gradually. Also, stand next to a sink when you apply the
acid so you can flush your eyes and face with water if you get any in your
eyes or if your face starts to sting badly. (There may be an initial mild
stinging sensation, but it should subside quickly.) Also be aware that
cosmetic acids may lighten your skin slightly with long-term use. Women who
are pregnant or may become pregnant should not use salicylic acid because of
the possibility of salicylism, and AHA use should be limited to low-
concentration formulas.


There are some sources for high concentration AHA and salicylic acid
products, but they may not be safe for general home use. These are similar
to the solutions used by doctors for light and medium chemical peels.
However, using high concentration acid solutions without specialized knowledge
is very dangerous. Some of these products may not be medical-grade and might
contain impurities or toxins that could damage your skin. Some high
concentration solutions can only be left on the skin for a short time and
then must be quickly washed off or neutralized with a base solution to prevent
burns, scarring, and possible infection. It only takes minutes for some
solutions to penetrate through the thin epidermis into the dermis and cause
permanent scars. They can also cause permanent damage if they get into your
eyes. So unless you have specialized medical knowledge on how to use high
concentration acids, only use AHA products under 20% concentration or
salicylic acid under 7% available from reputable stores or from cosmetologists
and doctors. If you want to get light or medium resurfacing, have it done by
someone with experience. Don't risk scarring your face.

Most cosmetic acids are not stamped with expiration dates, but manufacturers
say they start to degrade after about three years. It is best to only buy one
tube at a time to assure potency.


8. What other topical treatments are available?

There are many other non-prescription topical products for sale in stores or
on the Net that claim to improve skin health. Most are simply cosmetic
products that may temporarily improve the appearance of the upper epidermis
without affecting skin structure. Recent network news programs have reported
that many of the expensive skincare products sold at department stores are
simply moisturizers and contain no ingredients proven to improve skin
structure. The ingredients were similar to those in products that you can buy
at drug or discount stores for under $10. They also found that sales people
at the department stores often made false claims, and some also offered a
bogus skin examination to promote their products. While it may not be
illegal, a lot of skincare advertising is simply deceptive. Advertising can
make all sorts of vague claims about skin improvement so long as it doesn't
claim the product affects the "structure or function" of the skin. Many
people believe the advertising and waste money buying ineffective skincare
products. Unless you can confirm that the claims made for a product's
ingredients are supported by medical studies published in peer-reviewed
medical journals (like those listed on Medline), you shouldn't expect any
permanent effect on your skin.

There are also some topical non-prescription products on the market that have
been tested in a few preliminary medical studies. They may improve skin
structure in some way, but the evidence is not definitive. This group
includes products containing special Vitamin C formulations, alpha-lipoic
acid, green tea, palmitoyl pentapeptide, epidermal growth factor, and
furfuryladenine (Kinerase and Kinetin). Generally, the claims made for these
products include delivery of antioxidants into the dermis, smoothing of the
epidermis, or improvement of collagen and elastin.

These products are more expensive than retinol, copper peptide, or AHAs, and
many are more expensive than prescription retinoids. Before you spend a lot
of time and money on these products, you should have some assurance that they
actually work. Most of preliminary studies on these products are not
double-blind, or only use a small number of subjects, so the results are not
considered conclusive or even statistically significant. In fact, positive
results in small-sample studies with no control group can be due to the placebo
effect, where some improvement is reported even with skin creams that have no
active ingredients. (In the tretinoin clinical trials, approximately a third
of the
large control group seemed to have some improvement in fine lines and skin
texture after using only sunblock and an inactive cream for 24 weeks.) There
are also no long-term tests yet on any of these products. So unlike retinoids
and cosmetic acids, dermatologists do not yet agree on their effectiveness,
biochemical action, or safety. Net reviews from users of these products are
all over the map, with some people reporting improvement and others reporting
no effect at all. Some of these products may work, but unless you are wealthy
and have money to spend experimenting, it is better to wait until there is
more scientific proof of their effectiveness and an understanding of how they
affect skin cells.

We can anticipate new chemicals will be discovered in the near future that
can treat photoaging, improve skin structure, and slow the aging process.
These chemicals will be tested by medical researchers and physicians, and the
results will be reported in medical journals. So if you hear about a new skin
product or want to investigate any of the products mentioned above, you can
check for medical studies using the Internet medical index Medline (available
free on many websites such as the National Library of Medicine,
www.ncbi.nlm.nih.gov with short study abstracts). Do a combined search on
the chemical name of the active ingredient in the product and terms such as
"skin," "photoaging," and "photodamage." You can also call or e-mail your
dermatologist's office to ask about new products for treating photoaging.
Beware however, if your dermatologist tries to sell you an expensive "skincare
system" with various cleansers and creams. A few unscrupulous dermatologists
make extra money selling overpriced products out of their offices.

There are also two other effective, proven topical skin treatments that
should be mentioned, if only because they are so inexpensive. There are a
variety of chemicals that have been found to improve epidermal growth after
skin abrasions. Two of these cost only a few dollars and are available at
drug stores. Both cod liver oil and zinc oxide have been found in animal
studies to significantly improve epidermal healing when compared to
unmedicated products like plain petroleum jelly. One study also found them
to be synergistic when applied together. See for example, "Improvement and
Retardation of Wound Healing: Effects of Pharmacological Agents in
Laboratory Animal Studies," Veterinary Dermatology, 10(2), 83-88, 1999;
"Topical Application of Cod Liver Oil Ointment Accelerates Wound Healing,"
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery,
34(1), 15-20, 2000 Mar; and "Enhancement of Re-Epithelialization with Topical
Zinc Oxide in Porcine Partial-Thickness Wounds," Journal of Surgical Research,
50(2), 101-105, 1991 Feb (abstracts of last two articles available on
Medline).

Cod liver oil and zinc oxide won't do anything for lines and wrinkles in the
dermis, but they may help smooth the epidermis after recent skin abrasions,
burns, and other wounds. (You should wait to apply them until new skin has
started to heal over the wound; antibiotic ointment should applied initially
to prevent infection.) There are some ointments and creams available in drug
stores that contain both cod liver oil and zinc oxide. Plain white zinc oxide
ointment is also available. These are usually in the first-aid or baby-care
sections. However, some of these products have too much fragrance for most
people because they are marketed for diaper-rash. Try to find one without
fragrance listed in the ingredients; some generic drug store-brands have no
fragrance. Cod liver oil (in capsules or bottles) is also available in the
dietary supplements section, but it doesn't adhere very well to the skin and
has a slight fish odor. It is best to use these products when you are at
home or else under a bandage, because they usually leave a noticeable film on
the skin. They may also stain clothes and bed sheets.


9. What is skin resurfacing?

Skin resurfacing is the removal of skin layers by abrasive dermabrasion,
chemical acid peeling, or laser. When the skin regrows, the skin may appear
smoother. Numerous medical studies have shown that resurfacing can
potentially reduce the appearance of wrinkles, remove benign discolorations,
improve skin texture, and improve some scars. See for example, "A Clinical
and Histologic Evaluation of Two Medium-Depth Peels: Glycolic Acid Versus
Jessner's Trichloroacetic Acid," Dermatological Surgery, 22(9), 781-786, 1996
Sep; "Manual Resurfacing and Trichloroacetic Acid for the Treatment of
Patients with Widespread Actinic Damage: Clinical and Histologic
Observations," Dermatological Surgery, 23(5), 373-379, 1997 May; "Salicylic
Acid Peels for the Treatment of Photoaging," Dermatological Surgery, 24(3),
325-828, 1998 Mar; and "Histologic Effects of the High-Energy Pulsed CO2
Laser On Photoaged Facial Skin," Plastic and Reconstructive Surgery, 99(7),
2036-2055, 1997 Jun (abstracts available on Medline).

Light resurfacing removes only part of the epidermis and can improve skin
texture and very fine lines in much the same way as long-term use of cosmetic
acids. Medium resurfacing penetrates through the epidermis to the upper
dermis. This stimulates new collagen growth in the upper dermis, eliminating
fine lines and reducing wrinkles. Even though all or part of the epidermis is
removed in resurfacing, the face has the remarkable ability to regenerate the
epidermis with cells migrating from inside the pores and sweat gland openings.
With medium resurfacing, the potential for improvement is much greater than
using topical treatments like tretinoin or cosmetic acids. Deep resurfacing
extends further into the dermis. It can remove more wrinkles, but it is
rarely done due to the high risk of scarring and loss of skin pigment. (This
FAQ doesn't cover deep resurfacing.)

Light resurfacing is usually safe, but medium resurfacing has increased risk
of scarring, pigmentation changes, and pore enlargement. Even though the
potential effect is not nearly as great, it is far safer to have one or more
light resurfacing procedures rather than one medium procedure. Net reviews
of light resurfacing are generally positive, but the effects are modest. Net
reviews of medium resurfacing vary widely with results ranging from great
improvement to permanent disfigurement. You can see many before-and-after
pictures of resurfacing at dermatology and plastic surgery websites.
(Remember though, that they don't post pictures of the complications.)
There have been a number of recent news reports about lawsuits against
doctors for causing permanent facial scarring with medium resurfacing that
penetrated too far into the skin. (As in any profession, most doctors are
skilled, but some are incompetent.)

In advertising, some doctors claim medium resurfacing can reduce the size of
pores. The effect of medium resurfacing on pore appearance is highly
variable, with some people reporting improvement, but many reporting no
change or permanent enlargement. Improvement in skin elasticity that results
from resurfacing can sometimes make pores less noticeable. However, in other
people, aberrations in epidermal healing following resurfacing can make pores
appear larger than before the procedure (more on this below). Medium
resurfacing should therefore not be used as a treatment primarily for large
pores, because it can sometimes make them worse. If you have large pores, the
combination strategy using tretinoin and salicylic acid often helps by
improving skin elasticity and reducing sebum buildup inside the pores.

No matter what your skin type, before you consider either light or medium
resurfacing, it is best to first try the tretinoin and cosmetic acid strategy
(using either salicylic acid or AHA) for about a year to see if get the
improvement you want. It can't produce the potential results of medium
resurfacing, but it will often produce better results than light resurfacing
due to tretinoin's ability to penetrate the dermis and improve collagen. It
is also less expensive and involves almost no risk. Many people with light
or moderate photoaging who have used this combination treatment are satisfied
and have saved a lot of money.

I will cover the specifics of medium and light resurfacing separately.

Medium Resurfacing:

One type of medium resurfacing called dermabrasion is traditionally done using
small motor-driven instruments with abrasive heads. However, some doctors
do dermabrasion manually with sterilized, fine-grit silicon carbide
sandpaper. While this is much slower, it allows penetration depth to be
carefully controlled by observing signs that the lower epidermis or upper
dermis has been reached. With either technique, dermabrasion is a rather
bloody procedure, so careful attention must be paid to infection control
during and after the procedure.

Medium chemical peels are usually done with a combination of high-
concentration trichloroacetic acid and either glycolic acid or Jessner's
solution (a combination of salicylic acid, resorcinol, and lactic acid.) The
acids must be carefully and uniformly applied using swabs. Chemical peels
are the most difficult resurfacing procedure to control, because the doctor
must judge penetration depth using acid concentration, application time, and
skin appearance.

Laser resurfacing is rapidly becoming the most popular method of medium
resurfacing since it is more convenient to perform than a chemical peel or
dermabrasion. It may soon replace these other two methods entirely. With a
laser, the doctor doesn't have to handle messy acids or bloody abrasives, and
can concentrate fully on controlling penetration depth. There is somewhat
less risk of infection because the heat of the laser coagulates tissue and
blood. Many doctors also believe that the laser produces some contraction of
collagen in the dermis, giving a better result than a chemical peel or
dermabrasion of the same penetration. The two types of lasers currently in
common use are the erbium YAG laser and the carbon dioxide (CO2) laser.
("Erbium YAG" means erbium, yttrium, aluminum, and garnet - materials inside
the laser.) The erbium YAG laser is preferred by some doctors because it
allows very precise control of penetration depth. See for example "Achieving
Superior Results with the Erbium:YAG Laser," Archives of Facial Plastic
Surgery, 4(4), 262-266, 2002 Oct-Dec (abstract available on Medline.) Other
doctors prefer CO2 lasers, because they believe they are more effective on
deep wrinkles. However, there are many brands of both types of laser with
different characteristics, so these are only general observations. (You can
discuss the different types of lasers with the doctors you consult.)

To understand the risks of medium resurfacing, you should think of the
procedure as a controlled surgical wound, not as a "spa treatment." For it to
be successful, penetration must be carefully controlled, and then the skin
must heal well. Excessive penetration into the dermis in an effort to remove
deep wrinkles can cause uneven, scarred skin. If this happens, the resulting
permanent scars are similar to those caused by second-degree thermal burns.
Infection following the procedure can cause scarring too. Pigment cells can
also be affected by medium resurfacing, producing uneven skin color or
permanent lightening. Medium resurfacing complications are often diminished
in consumer information, but they have been reported in medical journals and
are mentioned in most patient consent forms. See for example, "Thermal
Injuries As a Result of CO2 Laser Resurfacing, "Plastic and Reconstructive
Surgery, 102(4), 1247-1252, 1998 Sep (abstract available online on Medline).
Articles in newspapers and magazines have described some patients' poor
results with medium resurfacing including pigmentation problems and scaring
(see for example "Face Off," Elle, October 2002, p. 202).

People who have taken the oral acne drug Accutane should not have medium
resurfacing done for at least a year, since it reduces the ability of the skin
to heal and can cause scarring. Pregnant women should also not have medium
resurfacing performed due to the risk of complications, especially infection.
People who have rosacea or a family history of rosacea should not have medium
resurfacing done, since it can exacerbate or initiate the condition.

There is another little-publicized, but significant risk with medium
resurfacing. Doctors have discovered that medium resurfacing does not work
well on a significant fraction of the population and can make their skin
appearance much worse. Even if penetration is not excessive, in some people,
particularly those with large pores and a lot of skin oil, the epidermis may
not regenerate well, resulting in a much worse surface texture than before the
procedure. This is due to variations in the way new epidermal cells grow
outward from the pores and sweat gland openings. Also, the basal or bottom
layer of the epidermis, which forms new skin cells, may not return to it's
normal pre-operative state. Even though wrinkles may be reduced, up close the
resulting epidermis may be thin and have an uneven, orange-peel appearance.
The pore openings may appear larger than before with tiny fissures around
them, particularly in the center of the face. Loss of pigment can also make
large pores appear more prominent. If you have any healed abrasions or
chemical and thermal burns, you may see a similar difference in texture
compared to your normal skin. Long-term use of tretinoin may help this
problem somewhat, but the skin texture may never look smooth up close. These
serious risks of poor skin texture and enlarged pores are mentioned in some
patient consent forms and journal articles on resurfacing, but are usually not
covered in consumer information. See for example, "The Prevention and
Management of Postdermabrasion Complications, "Journal of Dermatological
Surgery and Oncology, 17(5), 431-437, 1991 May (abstract available on
Medline). Even though this is a major problem, inexplicably, some medical
textbooks on resurfacing don't discuss this risk, and many medical websites
that cover resurfacing also say nothing about it. If you have large pores and
a noticeable amount of skin oil or any acne, you should probably not have
medium resurfacing for photoaging. Instead, you should use the topical
treatments mentioned previously or nonablative treatments (see below). Don't
risk scarring your face.

No matter what your skin type or what type of medium resurfacing you are
considering, resurfacing a small test area is necessary to see how your skin
responds. There is a large variation in people's skin thickness and healing
ability, so you need to check for scarring, loss of pigment, and healing
problems. Medical textbooks recommend a test area, particularly for darker
skin, since medium resurfacing can destroy some pigment cells; this can cause
an unsightly spotted or mottled appearance. You will have to wear a small
bandage on the test area for about ten days. Allow the area to heal for about
six weeks. It should be smooth and only slightly lighter in color than your
other skin. If the pores look larger or the surface is uneven or discolored,
medium resurfacing is not appropriate. Instead, you can try very light
resurfacing or use the combination strategy of tretinoin and low-concentration
salicylic acid. Another option is to find a doctor who has a nonablative
laser, intense pulsed light source, or radio frequency device. ("Nonablative"
means that no skin is removed.) These devices may improve the condition of
the dermis moderately without burning off the epidermis. (More information on
this below.) Many doctors who do medium resurfacing will also have access to
a nonablative device.

If a doctor will not do a test area for medium resurfacing, go to another
doctor. Some doctors will assure you that the electronic power settings on
lasers eliminates the need for test areas. This is definitely not true of CO2
lasers, and questionable even with the more precise erbium YAG lasers. While
erbium YAG lasers allow close control of penetration depth, the doctor still
ultimately determines how deep the resurfacing will go. Don't risk scarring
your face.

With medium resurfacing, you can minimize risk and cost by resurfacing only
the areas where you have wrinkles or benign skin discolorations. However,
the doctor must blend the resurfaced areas with the untouched areas or
you may have a visible textural border between the two. Some doctors prefer to
do the whole face, and adjust the penetration depth as needed for different
areas. For wrinkles, the areas with the best results seem to be the sides of
the eyes, forehead, rear cheek area, and around the mouth. Note that dynamic
wrinkles in these areas, due primarily to facial expressions, will usually
reappear in a few years. Results seem to be variable directly under the
eyes and may be dependent on whether the wrinkles there are largely dynamic
or due only to photoaging; the skin in this area is also delicate and can scar
easily if penetration is excessive. (If you have large bags under the eyes,
or loose skin on top of the eyes, it must be treated with different plastic
surgery procedures.) Because everyone's skin has more oil and larger pores
on the nose and front cheeks, the doctor should resurface the skin lighter in
these areas to avoid an orange-peel texture after healing. Areas where the
skin may be stretched tight over bones, such as the top of the nose, must only
be very lightly resurfaced. The neck is usually only lightly resurfaced
because it does not heal as well as the face. These are only general rules,
and the depth of resurfacing done on different areas is dependent on your skin
type and the amount of sun damage you have. You should obviously discuss all
this with your doctor.

Depending on the type of procedure, medium resurfacing will require some
type of anesthetic during the procedure for pain. You will usually be given
topical or local (injected) anesthetic, and a sedative. The degree of
sedation will depend on the type of resurfacing to be done. Someone will
have to take you home after the procedure because you will have bandages on
your face and the sedative will make you drowsy for a while. If you have a
medium chemical peel, be sure the doctor has a large bottle of water nearby
in case any acid gets in your eyes. You also don't want to be so heavily
sedated during a chemical peel that you can't tell the doctor if this
happens. If you have laser resurfacing, your doctor should put opaque
shields over your eyes to protect them from the intense laser light.

If you do get medium resurfacing, the recovery period can be long and somewhat
uncomfortable. Any pain can be managed with mild pain medication, but you
should be prepared to look awful for at least 12 days (with swelling, red
skin, crusts forming, and peeling). You will need to stay home from work for
at least two weeks. Be prepared to take even more time off if you have any
complications. You will have to wash the skin very gently and keep it moist
with antibiotic ointment. While you may be somewhat presentable after two
weeks, the complete healing process can be slow. In light-skinned people, the
skin will be pink for many weeks and possibly a few months. With darker skin,
pigmentation may be uneven for the same time. Make-up will be needed if you
want to hide the pink color or uneven color. You must stay out of the
bright sun until your skin is fully healed. Ask your doctor when you can
resume outdoor activities and what kind of sunblock you should use since some
brands may irritate the new skin (for example, those with alcohol). In the
future you will need to always use sunblock when outside during mid-day
because the new skin may be more easily damaged by solar UV light.

Results of medium resurfacing will usually last for many years, and if you
stay out of the sun, some improvements may be permanent. You can prolong
the effects after you have fully healed by using tretinoin on the schedule
discussed above, so be sure to get a prescription from your doctor. To be
safe, cosmetic acids should probably not be used at home following medium
resurfacing. Continual removal of the upper epidermis with cosmetic acids
following medium resurfacing could accelerate some intrinsic skin cellular
aging processes. Currently, you should also be cautious about repeating
medium resurfacing, even after many years, until there is more medical
information available about the safety of multiple procedures. Multiple
procedures could potentially produce an unnatural surface texture and an
unacceptable lightening of the skin.

If you decide to have medium resurfacing, it is important to select a board-
certified plastic surgeon or dermatologist. Because of the risks of infection
and scarring, you should select a doctor just as if you were having major
surgery. First, you should check www.abms.org or the American Board of
Medical Specialties (ABMS) directory at your library. (The ABMS directory
at the library generally lists more details about the doctors' education and
training than the website.) ABMS-certified doctors have passed rigorous
exams in their specialty beyond what is required for state licensure. Some
doctors who were originally trained or certified in other specialties also do
resurfacing because it can be very lucrative in large cities. There are a few
other competing medical boards that will certify doctors to practice in areas
out of their specialty training. These doctors may in fact be highly skilled,
but it is safer to go to an ABMS-certified plastic surgeon or dermatologist
for resurfacing since they have extensive training in skin anatomy and healing
processes. Establishing a relationship with a plastic surgeon or
dermatologist is also good if you or your family need to consult them in the
future for other more serious medical problems.

If you are over age 50 and have creases, folds, sagging skin, or bags under
your eyes, you should consult only plastic surgeons. They can recommend
other surgical procedures to remove excess skin and tissue which will give
much greater aesthetic improvement than resurfacing. In these cases, it is
usually a waste of money to do resurfacing, because the improvement in
skin elasticity is insufficient. If necessary, resurfacing can be done after
other plastic surgery procedures. Some plastic surgeons will do medium
resurfacing at the same time they do other facial procedures. However, this
significantly raises the risk of complications such as infection, so it is
best to do resurfacing only after you have fully healed from the surgery.
After a facelift, you may not need medium resurfacing anyway; light
resurfacing or use of cosmetic acid and tretinoin may be sufficient. If you
are considering these other types of plastic surgery, you should do some
research online and at the library so you understand the specific procedures
and potential risks. Many plastic surgeons will give you a free or low-cost
initial consultation and discuss all your options.

Once you have identified the ABMS-certified plastic surgeons and
dermatologists in your area, you can refine your list. There are lots of
other things you can do to check doctors' qualifications. Ask your other
doctors, dentists, and friends who they would recommend. Check the yellow
pages ads under "Physicians - Surgery, Plastic and Reconstructive" and
"Physicians - Dermatology." Some doctors may also have an ad under "Skin
Care." See if the ad lists a website you can visit. Use a search engine to
do an Internet search on the doctor's name and medical specialty. You may
find titles of books or papers he or she has written. You can search the
Internet medical index Medline with their last name and initials to see if
they have written any medical journal articles. Your county may have a
medical society that publishes a brochure listing all the local doctors and
their qualifications. Ask the reference librarian at your local library what
information they have on selecting doctors. They may have reference
publications listing the best doctors in various fields. If you live a in a
large city, a local magazine may also have an annual "best doctors" issue.
Check with your state medical licensing department to see if the doctors you
find have had any disciplinary actions. You can also check with the state or
local court clerk if any malpractice lawsuits have been filed against these
doctors in your state. (Note that some suits filed against doctors are
frivolous, so you can ask to read the court files if there are only one or
two cases.) All of this will probably narrow your list down to a few doctors,
so you can make appointments for consultations. Be aware that some of the
older, prominent doctors on your list are probably going to charge more than
young doctors who have only recently obtained their board certification.
These younger doctors may actually be better trained in the latest
resurfacing techniques. Obviously, not everyone will do all this work.
However, the more research you do in selecting a qualified doctor, the less
risk you will be taking with medium resurfacing.

If you live near the doctors' offices, you can simply stop by before making
an appointment. You want to talk to the staff about the about following:
1. What type of medium resurfacing procedures they do - chemical peels,
dermabrasion or laser. Ask if they also use a nonablative device. They may
have a price list they can give you for the various procedures.
2. See if they have brochures they can give you on the procedures or a website
you can visit.
3. Ask if they do a lot of resurfacing at their office. You want to
find a doctor who does resurfacing as a regular part of their practice and is
interested in skin aesthetics. Many dermatologists concentrate on treating
skin diseases and don't do much cosmetic work.
4. Ask how much a "cosmetic consultation" to discuss resurfacing will cost
before you commit to an appointment. As previously mentioned, some plastic
surgeons will give you a free or low-cost initial consultation and price quote
on resurfacing. This is less common with dermatologists. Since doctors make
a significant profit on resurfacing, you should avoid doctors that are also
going to charge you a lot of money for a consultation.

If you don't live near the doctor's offices, alternatively, you can send a
letter or e-mail requesting the above information. A telephone call is often
less helpful because you may only talk to an appointment clerk.

Depending on the type of response you get to your initial inquiries, the
information they provide, and how much they charge, you can decide which
doctors to see. When you meet the doctors and their medical staffs, it will
be easy to tell if you like their personalities. They should be friendly and
courteous. This is very important in case there are any complications with
your procedure. You should also choose a doctor who will explain everything
to you personally . The doctor should take time to examine your face
carefully for a few minutes and then discuss the resurfacing procedure and
its risks, and answer all your questions. Some doctors will have a nurse or
physician-assistant talk to you first to give you basic information about the
procedure and take a medical history. If a doctor just has you watch a video
and gives you a five-minute sales pitch, you should choose another doctor.
Ask if the doctor is willing to do a small test area first to see how your
skin responds. (You may have to pay a small charge for the test area to be
done because it requires set-up of the resurfacing equipment.) Ask how many
resurfacing procedures of the type you are considering the doctor has done.
The doctor should offer to show you some before-and-after pictures of other
patients he or she has treated - not just printed sample pictures of someone
else's patients in a pamphlet or book. If a doctor seems insulted when you
ask about experience and qualifications, you should choose another doctor.

After your consultation, the doctor's staff should give you a written,
complete price quote so there are no surprise extra charges added later. If
the staff won't give you a firm price or tells you that you must make an
appointment for resurfacing that day, politely decline and choose another
doctor.

Full-face, medium resurfacing is expensive, and you will probably get quotes
from $800 to $3500, depending on the resurfacing method and your location.
Resurfacing on smaller areas of the face will be less. Laser resurfacing is
the most expensive procedure due to the high cost of the laser equipment.
Insurance generally does not cover skin resurfacing or nonablative treatments
unless they are to treat blemishes or scars associated with a congenital
defect, medical condition, or injury. (Check the specific provisions in your
policy and get written approval if you think you are covered.) Even with the
same treatment method, you may find that prices vary widely, so make your
decision based on the doctor's training, experience, and personality. High
prices or fancy offices don't necessarily correlate with medical
qualifications or skill. Before making a final decision on treatment, you
should also consider that the current cost of one medium laser resurfacing
procedure will buy a lifetime supply of home topical treatments such as
tretinoin, cosmetic acids, and any similar products that are developed in
the future.

Light Resurfacing:

Light resurfacing is far less traumatic and has fewer risks since it only
removes part of the epidermis. There is usually no anesthetic used and less
complex infection control. At around $80 to $200, light resurfacing is much
less expensive than medium resurfacing. Light resurfacing is usually done
with low-abrasive dermabrasion or a medium-concentration chemical acid peel
(typically glycolic acid or salicylic acid).

While a single light resurfacing procedure has no effect on wrinkles, after
the upper epidermis regenerates, it is often smoother in texture than before.
Some studies have shown that a few light resurfacing procedures, spaced a few
weeks apart are more beneficial than a single procedure and may reduce fine
lines.

Total healing time is only about two weeks, and usually you only look like
you have a sunburn for about a week. The pores will often appear slightly
larger until the skin completely heals. If you have a light chemical
peel, you may have to stay home from work for a few days because some
acid solutions will cause the upper skin layers to harden slightly and peel
off after about three days. You should stay out of the bright sun for a few
weeks, and use sunblock in the future.

As mentioned previously, if you have large pores and a lot of skin oil,
there is a possibility of epidermal healing problems with resurfacing.
Light resurfacing may make your pores and skin texture look slightly worse,
at least temporarily. So if you have this skin type, you should ask for the
lightest resurfacing available until you see how your skin responds. This
will mean fewer passes with the abrasive material or dilution of the acid. If
your skin texture looks worse after a few weeks, you should instead use the
topical treatments mentioned previously or nonablative treatments (see below).

Most people just get one or two light resurfacing procedures every few years,
but some dermatologists recommend a series of procedures over many months
for greater effect. Before you make a commitment to multiple procedures, it
is best to wait about a month after your first procedure to see how your skin
responds.

The results of light resurfacing will usually last for one to five years,
depending on the number of procedures. You can prolong the effects by using
tretinoin on the schedule discussed above, so be sure to ask for a
prescription if you go to a doctor, nurse, or physician-assistant. To be
safe, cosmetic acids should probably not be used at home following many
repeated light resurfacing procedures. Continual removal of the upper
epidermis with cosmetic acids following multiple procedures could accelerate
some intrinsic skin cellular aging processes. Also, the safety of repeating a
series of multiple light resurfacing procedures many times over a person's
lifetime is currently unknown, and the same cautions about continual removal
of the upper epidermis apply. Pregnant women should probably not have light
resurfacing done, since there is still a slight risk of infection. People who
have taken the oral acne drug Accutane should probably not have light
resurfacing done for at least nine months, since it reduces the ability of the
skin to heal. People who have rosacea or a family history of rosacea should
probably not have light resurfacing done, since it could exacerbate or
initiate the condition.

You can use the same process described previously to find a doctor that does
light resurfacing. However, light resurfacing is often done by a nurse or
physician-assistant working under the supervision of a plastic surgeon or
dermatologist. You may not meet the supervising doctor at all in this
case. If so, when you visit the office for information, you can ask the nurse
or physician-assistant for their business card and check the status of their
state license and any disciplinary actions with the state medical licensing
department.

If the doctors' offices in your area don't do light resurfacing, they may be
able to recommend a cosmetologist. Cosmetologists are usually listed in the
yellow pages under "Skin Care" and "Beauty Salons and Services." If you use a
cosmetologist, you can also visit their office and ask for a business card to
check their state licensure or private certification. Private certification
should be listed on their card, and some certifying organizations and
schools have websites with a number you can call to confirm current
certification and ask about training. With a cosmetologist, it is best to ask
for the lightest resurfacing available until you are confident with their
work. This may only be application of a low-concentration cosmetic acid, but
if there are no problems, you can then return later for a stronger peel.
Some people may think it's unnecessary to check licensure or private
certification for light resurfacing, but problems can still occur, and you
don't want to risk scarring your face.

Light resurfacing generally does not require topical anesthetic, and you
should not feel any more than a strong stinging sensation on the skin. If you
feel any intense pain, signal for them to stop the procedure and figure out
what is wrong. Even with light resurfacing, mistakes such as high acid
concentration can happen. Also, if you are having a chemical peel, there
should be a large bottle of water nearby in case any acid gets in your eyes.

If you want to get light resurfacing, beware that some doctor's offices and
many cosmetologists may try to pressure you into signing up immediately for
multiple procedures or buying other expensive "special" or "secret" skincare
treatments and products. They may try to sell you some of the unproven
products mentioned previously in this FAQ. There are all sorts of high-
profit cosmetic "skincare systems" sold by some doctors and cosmetologists.
This sort of sales pitch is more common at the spas that some doctors have
opened and with many cosmetologists. Other than the higher-concentration
cosmetic acids, you can buy similar products for much less at specialty
cosmetics stores and some drug stores. You should select a practitioner who
doesn't pressure you to buy unnecessary products and services.



10. What are nonablative treatments?

As mentioned previously, there are also nonablative lasers, non-laser
intense pulsed light (IPL) sources, and radio frequency (RF) devices used by
some doctors which are designed to stimulate collagen production in the
dermis without removing (or ablating) the epidermis. See for example,
"Noninvasive Rejuvenation of Photodamaged Skin Using Serial, Full-Face
Intense Pulsed Light Treatments," Dermatological Surgery, 26(9), 835-842,
2000 Sep (abstract available on Medline.) Most of these devices require
multiple treatments over a few months to produce a noticeable effect.
Doctors generally say that improvement with nonablative methods is modest.
Results are usually better than light resurfacing, but not nearly as
significant as with medium resurfacing. Fine lines can be reduced and
wrinkles reduced in depth. Some devices also produce modest improvement in
skin texture, discolorations, small capillaries and acne. (There are also
some specialized light treatments specifically for acne, but these are
different than nonablative treatments for photoaging.)

The advantages of nonablative methods over medium resurfacing are minimal
risk of infection and scarring, and much reduced healing time and skin
redness. The procedures may not require any anesthetic or just a topical
cream or gel. If you can't afford to take time off from work and don't want
temporary pink or discolored skin, this is an option. You can usually have
the procedure done on Friday, and return to work on Monday or Tuesday. It is
also an option for people with dark skin or those with large pores and a lot
of skin oil who could have discoloration or healing problems with
resurfacing. A series of nonablative laser or IPL treatments will cost
between $700 and $3000 depending on the device used, the number of
treatments, and the area to be covered.

Nonablative treatments are performed by the same doctors that do medium
resurfacing. A nurse or physician assistant can also do the treatments under
a doctor's supervision. You can use the same methods described previously to
find a doctors office that offers these treatments. Beware that some
cosmetologists may also advertise "high-tech" skin treatments that sound
like nonablative laser, IPL or RF, but are actually not very effective.
Effective nonablative devices are expensive, and most cosmetologists do not
have access to this equipment unless they are affiliated with a doctor's
office.

Results with nonablative devices vary widely and are dependent on the type of
device used. There are many different nonablative devices available with
brand names such as N-Lite, Cooltouch, Smooth Beam, V-Star, Aramis, EsteLux,
ThermaCool TC, and Photoderm. Some of these produce better results than
others, and there are new improved models coming out every year with
different characteristics. Some doctors have said in news stories that the
effects from nonablative devices last only about three years. Other doctors
have reported on their websites that a significant fraction of their patients
did not get any visible results with some brands of nonablative devices. So
before you commit to treatment, do some research. Do a search of the Net,
newsgroups, and Medline using the exact name of the device the doctor uses
to check for studies and patient reviews. Also ask the doctor to show you
some before-and-after photos of other patients, not just pictures in a
marketing brochure. Due to the myriad of new devices now available, it may
be prudent to wait a few years to see which devices are reported in medical
studies to be most successful.

Because of the large number of different nonablative devices, it is difficult
to generalize about their risks. Temporary skin redness is possible, and
there is still the possibility of scarring if too much energy is introduced
into the dermis. You should wait at least a month after your first treatment
to see how your skin responds before having a second treatment. There are no
long-term safety studies yet. You can check for new medical studies on these
devices by searching Medline using "nonablative" and either "skin,"
"photoaging" or "photodamage". Ask your doctor about any specific risks for
the particular device being used, including cautions for Accutane patients
and pregnant women. Doctors are currently experimenting with schedules to see
if it is safe to repeat a series of treatments after a number of years. To
help maintain results, tretinoin and cosmetic acids can be used following
nonablative treatments on the low-frequency maintenance schedule described
previously.


11. How can I treat excessive skin oil?

Skin oil, or sebum, is produced by sebaceous glands attached to your skin
pores and prevents your skin from drying out and flaking. As adolescents,
most people get a temporary increase in sebum production and some acne. This
is due to an increase in androgen (male hormone) levels in both males and
females that stimulate the sebaceous glands. However, many adults continue to
have low-level acne throughout life, and some experience an increase in sebum
as they age.

If your skin is just "shiny", but your pores are small and you don't have
acne, you don't really have a skin problem (though cosmetics companies may
want you to think so.) Just having oil on your skin is not a bad thing;
people with dry skin who must constantly use moisturizers wish they had more
skin oil. In this case, excess sebum on the surface of the skin can be
removed by simply washing a few times a day or using absorbent pads (but
avoid excessive use of alcohol-based astringents, which can irritate the
skin.)

In some people, excess sebum is a real medical problem. It can become
impacted in pores, temporarily enlarging them and leading to acne symptoms
like blackheads, whiteheads or inflamed areas. Mild cases of acne can be
treated with non-prescription topical benzoyl peroxide, which helps prevent
bacterial inflammation and causes drying and peeling of the epidermis.
Some doctors also prescribe oral or topical antibiotics. In addition to
producing an inflammation reaction, bacteria also cause chemical changes in
the pore that can contribute to the formation of a sebum plug. So in many
cases, a few-month course of oral tetracycline or other antibiotic can be
helpful. However, even if the bacteria and inflammation are eliminated,
pores may still appear larger and darker than normal due to impacted sebum.
(The dark color is due to oxidation of the sebum, not dirt.) Soaps,
cleansers, and abrasive scrubbing usually will not remove sebum that is
impacted in pores. (That's like trying to remove some clay packed inside a
pipe by washing the open end.) Excessive sebum has to be treated with topical
or oral medications.

The best topical treatments for sebum impacted in pores are prescription
retinoids like tretinoin (Retin-A, Avita, or generic), tazarotene (Tazorac
gel), or adapalene (Differin). (Tretinoin and tazarotene were described
previously as effective treatments for photoaging.) You need to go to a
doctor, preferably a dermatologist, to get a prescription for these
medications. While they don't significantly reduce sebum production,
prescription retinoids allow sebum to be shed more easily from the pores.
Over time, this can make the pore opening appear smaller, because it is not
distended with sebum. Usually, acne will get slightly worse when you first
start using retinoids, so you have to use them for a few weeks before you see
any improvement. As mentioned previously, you can treat clogged pores by
alternate nightly use of a retinoid and non-prescription, low-concentration
salicylic acid gel. A very effective strategy for treating whiteheads and
inflammatory acne is alternate use of a retinoid and non-prescription benzoyl
peroxide. Store-brand benzoyl peroxide cream or lotion in 5% or 10%
concentration can be purchased at most drug and discount stores for only
about $4 for 30 grams. The 5% concentration is usually sufficient and causes
less drying and peeling than the 10% concentration. If necessary, you can
dilute the 10% lotion with distilled water.

The different retinoids work in slightly different ways, so one may work
better than the others in your case. Generic tretinoin cream (0.025%, 0.05%
or 0.1%) or gel (0.025%) is usually the least expensive so you should try it
first. It costs about $25 for 20 grams. Most people prefer the cream form
because tretinoin gel contains a lot of alcohol, which can be irritating. The
gel also doesn't spread as easily as the cream. However, the gel may work
better for some people to clear pores. Adapalene gel (0.1%) costs more, but
usually causes less irritation than tretinoin or tazarotene for people with
sensitive skin. Adapalene only comes in a gel, but it doesn't contain
alcohol. It costs about $25 for 15 grams. Tazarotene gel (0.05% and 0.1%) is
the most expensive, but some doctors say it may work better than tretinoin or
adapalene on blackheads. It costs about $60 for 30 grams. Tazarotene gel
contains only a small amount of alcohol. Tazarotene also comes in an
emollient cream, but it isn't appropriate for acne because it contains mineral
oil. If you find one of the retinoids that works well, you can save money by
next buying a larger tube. They usually cost less per gram than the smaller
tubes. You can also save money by buying the highest concentration available
and simply using a smaller amount than normal on your face. You can spread a
small amount easier by first lightly wetting your face and dabbing the
medication on your forehead, cheeks and nose. You should also ask your
dermatologist for free samples of tretinoin, adapalene, and tazarotene. They
often have small tubes to give away. As mentioned previously, retinoids
should not be used by women who are pregnant or may become pregnant.

If absolutely necessary, large blackheads and whiteheads can be removed
manually. You shouldn't squeeze them out with your fingers or you can cause
bruising, scarring and pore enlargement. A better method is to use a wire-
type tool, sterilized with rubbing alcohol. A good brand is the Tweezerman
Skin Care Tool, sold at drugstores (or see www.tweezerman.com). However, it
is still possible to damage your skin with these tools, so follow the
directions carefully. If you can't remove the sebum with a light pressure,
wait a few days for your topical medication to loosen it. If you press hard
and crush the skin around the pore, you can badly damage the skin and even
cause the pore to enlarge permanently. Unless the spots are large and
unsightly, many doctors say that it is better simply to let the medication
remove them, rather than risk skin damage by using the tool. Retinoids,
salicylic acid, and benzoyl peroxide will usually loosen the sebum plugs in a
few days so they can be washed off. An alternate manual method for removing
blackheads with less risk is use of special adhesive pore strips (sold in the
acne-care section of stores). These have a special glue that is supposed to
adhere to sebum plugs and lift them out. This seems like a good method, but
results reported on the Net by users of pore strips are variable. Some people
say they work, but others report that they usually only remove a small number
of blackheads. They are also expensive if you use them frequently. There are
a few different brands, so you can try them to see if they work for you.

For some people, retinoids alone are insufficient to treat the impacted sebum
that clogs pores. Also, resistant impacted sebum can be an early sign of
some conditions like seborrhea, in which the sebaceous glands enlarge
abnormally, particularly in the center of the face. There are effective oral
prescription treatments that act directly to reduce sebum production by the
sebaceous glands. However, these medications can have side-effects, so you
should first try each of the various retinoids for at least three months.
If none of the retinoids work for you, and you still have persistent daily
blackheads or whiteheads, your sebaceous glands are abnormally producing too
much sebum. This is a medical problem, not just a cosmetic one, and your
doctor should be willing to prescribe oral medications. However, you may
have to search for a doctor that will take this problem seriously enough to
prescribe these. Some doctors also resist prescribing oral medications for
excess sebum because they are concerned about potential legal liability for
side-effects. (There are some patients who sue doctors even after all the
risks of side-effects are carefully explained to them.)

Sebum production is partially controlled by androgens which stimulate the
sebaceous glands. In females, chronic elevated androgen levels can lead
to acne, excess body hair, loss of head hair, and menstrual problems. Even
androgen levels that are at the upper level of the normal range can cause
excessive skin oil. A doctor can reduce sebum production in women with oral
medications that affect androgen production such as anti-androgens,
glucocorticoids, or oral contraceptives. The FDA has approved some oral
contraceptives specifically for this purpose (for example, Ortho Tri-Cyclen).
You can discuss this treatment option with your dermatologist, gynecologist,
or your regular doctor. However, it may be better to see a endocrinologist
for this treatment, since they have much more experience in performing the
required tests and prescribing the appropriate medications. An endocrinologist
is a physician who specializes in the treatment of hormonal problems. Your
regular doctor or dermatologist may not be sensitive to this problem, so you
may have to find an endocrinologist yourself. See www.abms.org for certified
endocrinologists in your area. For further information see "Medical
Guidelines for Clinical Practice for the Diagnosis and Treatment of
Hyperandrogenic Disorders," Endocrine Practice, 7(2), 120-134, 2001 Mar-Apr
(full text available on the American Association of Clinical
Endocrinologists website at
www.aace.com/clin/guidelines/hyperandrogenism2001.pdf).

In adult males, excess sebum production is usually due to increased
sebaceous gland sensitivity to androgen stimulation, rather than to elevated
androgen levels. Pharmaceutical companies are currently working on
medications that can be taken by both men and women which block the effects
of androgens on the sebaceous glands. These experimental medications are
similar in concept to prescription finasteride (Propecia and Proscar) which
blocks the harmful actions of the hormone dihydrotestosterone (DHT). (DHT
causes hair loss and prostate enlargement in men.) You can ask your
dermatologist if any of these medications have been approved, or periodically
check the newsgroup alt.skincare.acne and websites that discuss acne
treatment. If these medications can be perfected, they will revolutionize
the treatment of acne and excess sebum. In rare cases, excess sebum in males
may be due to adrenal gland dysfunction and hyperandrogenism. See for
example "Acne in the Male Resistant to Isotretinoin and the Responsibility
of Androgens: 9 Cases, Therapeutic Implications," Annales de Dermatologie et
de Venereologie (France), 126(1), 17-19, 1999 Jan (English abstract available
on Medline). This is usually discovered in men after multiple courses of the
prescription drug Accutane have failed (see below). In these cases, an
endocrinologist should be consulted. These cases require specialized
treatment and monitoring, since anti-androgen therapy can cause feminizing
effects in males.

The most potent medication available to reduce sebum production is oral
isotretinoin, brand-name Accutane, a chemical related to vitamin A. It acts
directly to shrink the size of the sebaceous glands and reduce sebum
production. Sebum production is usually permanently reduced after Accutane
is taken for a number of months. It can be taken by both men and women,
however, it can have significant side-effects similar to those of vitamin A
toxicity. The possible side-effects include birth defects in pregnant women,
ocular effects (including some reports of cataracts), effects on bones and
joints, severe headache and fluid pressure in the head, mental depression,
increased blood triglycerides or cholesterol, and a worsening of the skin
condition known as keratosis pilaris. As previously mentioned, Accutane can
also temporarily affect skin healing, so you must wait at least a year before
having any type of resurfacing procedure. Because of the possible side-
effects, doctors are generally reluctant to prescribe Accutane except for
severe inflammatory acne. However, because sebum production is significantly
reduced, Accutane also works very well on blackheads and whiteheads,
eliminating them permanently in many people. So some doctors will now
prescribe Accutane for persistent moderate adult acne. See for example,
"Treatment of Acne With Intermittent Isotretinoin," British Journal of
Dermatology, 137(1), 106-108, 1997 Jul; "Roaccutane Treatment Guidelines:
Results of an International Survey," Dermatology, 194(4), 351-357, 1997; and
"Acne Vulgaris in the Elderly: the Response to Low-Dose Isotretinoin,"
British Journal of Dermatology; 139(1), 99-101, 1998 Jul. (Note that
"Roaccutane" is one European brand-name for Accutane or isotretinoin.) You
can download abstracts of these papers from the Internet medical index
Medline and discuss them with your doctor.

While most people do not develop severe side-effects with Accutane, you must
be willing to accept their risk and not blame your doctor if you have
problems. Your doctor may have you sign an informed consent form before
prescribing Accutane and will usually want you to have periodic blood tests
to check for certain side-effects. Women who are pregnant or who may become
pregnant during treatment must never use Accutane because of the high
probability of serious birth defects. Doctors will require a woman to take
a pregnancy test and agree to abstain from sex or use birth control methods
before prescribing Accutane. Do not use tetracycline or similar antibiotics
while taking Accutane, since the combination may cause increased pressure in
the brain.

As mentioned, Accutane may also worsen the acne-like condition known as
keratosis pilaris, which produces small non-inflamed bumps of dead skin cells
and sebum on the upper arms, thighs, chest, back and rear. This is not
mentioned in medical information on Accutane, however, it has been reported
by some patients. This possible side-effect is unexpected because Accutane
has been used to treat skin disorders similar to keratosis pilaris. While
Accutane still reduces facial sebum in people with this condition, the
keratosis pilaris often appears on larger areas of the back, chest, and rear
soon after finishing an Accutane course. This can last for many months or
even be permanent. To treat keratosis pilaris, doctors recommend tretinoin,
prescription lactic acid products, glycolic acid, and abrasive scrubs to, but
the condition can be persistent and very annoying.

Accutane dosage is calculated by your body weight, however, some research
indicates that daily dosage can be reduced so long as the total accumulated
dose over the course of treatment (that is, the number of pills taken) is the
same. So you can reduce the risks of taking Accutane by starting out with
a low daily dose to see if there are any serious side-effects. Some side
effects are normal such as dry skin, chapped lips, dry nose, and dry eyes.
Often you will also see an increase in the number of blackheads or whiteheads
right after you start taking Accutane, but this is normal and stops within a
few weeks as your pores clear of accumulated sebum. Serious side-effects to
report immediately to your doctor while taking Accutane include severe
headaches, nausea, vomiting, or vision problems. If you don't have any
problems, your doctor can have you gradually increase the daily dose, and
adjust it again later if needed. To minimize side-effects, it is also
advisable when finishing a course of Accutane to taper off the dosage
gradually over a few weeks rather than stopping abruptly. This can be done
by taking fewer low-dose pills each day or taking high-dose pills only on
alternate days.

According to medical research, the majority of people who take a course of
Accutane will see a permanent reduction in sebum production of about 40%,
although their skin will not remain nearly as dry as it was during the course
of treatment. However, even though sebum and acne will be significantly
reduced, most people will need to continue regular or occasional use of
topical retinoids like tretinoin or tazarotene to keep their pores clear.
About 20% of people will relapse in the future and require a repeat course
or multiple courses of Accutane. If sebum production quickly returns to
pre-treatment levels following a course of Accutane, elevated androgen levels
should be suspected in both men and women, and an endocrinologist should be
consulted. If androgen levels are normal, and a patient relapses following
multiple Accutane courses, some doctors will prescribe a low dose of Accutane
to be taken continuously (with regular blood tests). If elevated androgens
are the cause of excess sebum, it will only be temporarily suppressed by
Accutane. This is more likely with women, so to avoid wasting money on
Accutane, all women should have androgen levels checked before starting an
expensive Accutane course. Elevated androgens in women should be treated
before Accutane is considered.

All oral treatments for excess sebum can be expensive. Insurance companies
will usually pay for hormonal treatments and oral contraceptives if a doctor
prescribes them for acne (which includes blackheads and whiteheads) or an
identified hormonal dysfunction. However, Accutane is very expensive, and
most insurance companies will not pay for it unless it is prescribed for
severe acne that does not respond to retinoids. You may have to pay for it
yourself if your dermatologist is treating you for excess sebum and mild acne.
You will also have to pay for any blood tests your doctor requires while on
Accutane.

Accutane is now available as a generic, so have your doctor prescribe it
using the generic name isotretinoin. An isotretinoin course will cost at
least $200 per month (depending on your body weight), and you will need to
take it for at least four months to prevent relapse. So compare prices at
local and mail-order pharmacies.

Prices for isotretinoin are usually much lower at Canadian and British mail-
order pharmacies than at USA pharmacies. Pharmacies in Canada and Britain
generally have isotretinoin made by Roche Laboratories and equivalent
generics, but beware that pharmacies in Mexico and many other countries
could have isotretinoin of dubious quality. There have been a number of news
reports on foreign pharmacies selling bogus expensive medications like
isotretinoin in convincing counterfeit packaging. See the cautions listed
previously in Section 4 regarding foreign pharmacies.

As previously mentioned, USA law and FDA regulations govern the importation
of prescription drugs. Whenever importing medications, the FDA regulations
limit you to a three month supply. As mentioned previously, drugs that are
also available in the USA can be confiscated by Customs agents if they
choose to strictly enforce the law. There is also an FDA policy that strongly
discourages USA importation of certain prescription drugs with potentially
serious side-effects, including isotretinoin. If an imported package
containing isotretinoin is inspected by Customs agents, it will probably be
confiscated. You may not be able to contest the charges on a pharmacy credit
card order, and you could lose the money you spent on the medication. So
check first with any Canadian or British mail-order pharmacy for their
policies on shipping isotretinoin before ordering. Usually they will say that
they can legally mail the product from their country, but they can't guarantee
that it won't be confiscated. They usually won't refund your money if a
package is confiscated.

If you cross the border yourself with isotretinoin, be sure to have with you a
copy of your prescription, your doctor's business card, and a signed statement
like the one described previously for importing tubes of tretinoin. You are
limited to importing a three month supply. Even if you have all this,
confiscation is still probable under the FDA policy.

You should always let your doctor know in advance that you will be having
your prescription filled by a Canadian or British pharmacy or be crossing the
border with your prescription, just in case Customs calls the doctor to
confirm your prescription. Tell the doctor that you want to do this to save
money. Because of the very high cost of pharmaceutical drugs in the US, many
doctors are used to their patients getting their drugs from Canada or Britain.
As mentioned previously, importation of pharmaceuticals is a controversial
issue, and the law may change to make the regulations less restrictive or more
restrictive.

If you can't afford generic isotretinoin and have severe acne, your doctor
can help you apply to Roche Laboratories or a generic manufacturer to obtain
Accutane at reduced cost under the companies' "Patient Assistance Programs."
See www.helpingpatients.org for more information.



12. How can I treat scars?

Wounds or surgical incisions that penetrate into, or through, the lower dermis
are likely to cause scars. The scars that form are classified as hypertrophic
(raised) or atrophic (depressed or flat). Keloid scars are hypertrophic scars
with especially hard and prominent tissue. Following a wound, it can take a
long time for the skin to fully heal. Non-keloid scars that form from a wound
will often become less prominent over time, but this can take many years.
Most of the treatments to minimize scars are best performed either when the
wound is closed, early in the healing process, or soon after the scar forms.
Old scars can still be treated, but there are fewer options.

In treating scars you should have a realistic goal of achieving improvement in
the skin's appearance, rather than expecting the scar to disappear. Topical
treatments generally will "soften" the appearance of scars, but they will
still be noticeable. With topical treatments you must also be patient,
because it will usually be a few months before you see any improvement. The
greatest improvement can be achieved with surgical or resurfacing procedures
performed by a doctor.

As a wound heals, you can minimize scar formation by keeping it moist and free
of infection. After the wound is cleaned and closed (if necessary), apply
non-prescription Neosporin, Polysporin, or a similar antibiotic ointment under
a bandage. For burns, you can also ask your doctor for prescription Silvadene
ointment. Gently wash every day with soap or an antibacterial cleanser, and
apply a new bandage and ointment. Don't let the wound dry out, or the
resulting scar will be worse. Don't pick off any scab that forms, let it fall
off by itself. Applying an ointment or cream with cod liver oil and zinc
oxide after the skin has started to heal over may also help the epidermis
regrow. Large burns, cuts, or lacerations must obviously be treated
immediately by a medical professional; there are many new specialized
techniques and wound dressings that can minimize scar formation in large
injuries. If you have a cut or laceration that is likely to cause a large
noticeable scar, particularly on the face, you can request that a plastic
surgeon close the wound. Some emergency-room doctors may not be as skilled
in minimizing scars. Insurance may not cover the difference in cost of a
plastic surgeon, but it is usually worth the money to have a less-noticeable
scar.

If you have a new, moderately-raised scar, daily massage of the scar using a
moisturizer or oil can help soften the stiff scar collagen. Vitamin E oil is
sometimes recommended for massaging into scars, but regular moisturizers may
work just as well. Medical studies have generally found that vitamin E oil
has no special effect on scars, but many Net posters say it has improved
their scars when rubbed in daily.

Some Net reviewers have reported success using non-prescription Mederma gel
on new, moderately-raised scars (www.mederma.com, available at pharmacy
counters). However, others have reported little effect. The active
ingredient in Mederma is onion extract, which has been shown to inhibit the
growth of collagen in test tubes (possibly resulting in a flatter scar).
Mederma costs $15 or $25 (depending on tube size). You have to use it for a
few months to see any effect. Mederma may inhibit epidermal healing when
used on new wounds, so it should only be used after the skin has healed over
the wound and a raised scar seems to be forming. Mederma doesn't work on
depressed or pitted scars. (On depressed scars you don't want to inhibit
collagen growth.) In the past, Mederma has offered a money-back guarantee,
so check the box or the instructions before purchasing, and keep your receipt.

You can buy medical-grade silicone sheets for scar treatment that are taped
over moderately-raised scars to flatten them over time (however, they won't
work on keloid scars.) They may also help flatten uneven areas from
second-degree burns. There are many medical studies that show this method
improves the appearance of new scars, though the mechanism is unknown. It
doesn't seem to work as well on old scars. It has been quite successful with
new surgical scars. See for example, "Effectiveness of Silicone Sheets in the
Prevention of Hypertrophic Breast Scars," Annals of Plastic Surgery, 37(4),
345-348, 1996 Oct; and "Effect of Four Treatment Variants on the Functional
and Cosmetic state of Mature Scars," Journal of Wound Care, 9(7), 319-324,
2000 Jul (abstracts available on Medline). You need to keep the scar covered
with this material for at least 10 hours per day for about eight weeks to see
results. The longer you use the material, the flatter the scar can become,
and some people continue for six months or more. There are a few brands of
these silicone sheets available at pharmacy counters or in the first-aid
section. The sheets are expensive, about $15 to $40 for a 1.5" x 4" piece,
but it doesn't wear out. (Rejuveness brand also has different sized face-
masks available to hold sheets against the face at night.) Some of the brands
also sell a special tape to hold the pad in place because regular first-aid
tape doesn't stick to it very well. Curad sells less-expensive small,
disposable adhesive pads called "Curad Scar Therapy" which work on the same
principle (see www.curadusa.com). Band-Aid brand and some other first aid
brands also have similar products. For facial scars, it may be easier to
use the products like those from Curad or Band-Aid rather than the silicone
pads.

Tretinoin may modestly improve the appearance of acne scars, shallow
depressed scars, uneven areas from second-degree burn scars, and some raised
scars. See for example "The Local Treatment of Hypertrophic Scars and Keloids
with Topical Retinoic Acid," British Journal of Dermatology, 103(3), 319-323,
1980 Sep (abstract available on Medline). Some Net reports claim that copper
peptide can also improve depressed and raised scars, though others report
little effect. Some people also report improvement using the combination
strategy mentioned previously for photoaging. 10% AHA or 2-4% salicylic acid
is used on alternate nights with tretinoin. This usually must be continued
for six months to a year for noticeable improvement. Thereafter, tretinoin
is used twice per week to maintain the results.

Dermatologists and plastic surgeons have many techniques available
for treating both raised and depressed scars. Laser resurfacing or
dermabrasion are often used. See for example, "Resurfacing of Pitted Facial
Scars with a Pulsed Er:YAG Laser," Dermatological Surgery, 23(10), 880-883,
1997 Oct (abstract available on Medline). (Resurfacing of burn scars should
probably be done by manual dermabrasion or with an erbium YAG laser since
precise control of penetration depth is necessary.) However, as with medium
resurfacing for treating photoaging, resurfacing of scars doesn't seem to
work well on people with large pores and a lot of skin oil. Doctors can also
treat scars by surgically removing them and stitching the skin closed or
replacing the scar with a skin graft. A skilled doctor can remove a prominent
scar and leave only a very fine, healed suture line in the skin that is much
less noticeable. Small pitted scars can be replaced with a skin graft taken
from behind the ear in a relatively inexpensive office procedure. Various
materials can also be injected under depressed scars to elevate them. You
can use the same procedure described previously for resurfacing to choose a
plastic surgeon or dermatologist to treat scars. Try to find a doctor that
does a lot of work on "scar revision," since they can offer you more treatment
options. Prices for this type of treatment vary widely, so you should consult
a few doctor for opinions and cost estimates before having any expensive
treatment.

Something should also be said about preventing scars. Acne scars can be
avoided with early, aggressive treatment. Treatments are now available that
will stop the inflamed lesions that can cause scars. If you are going to
have surgery, discuss your concerns about incision scars with your surgeon in
advance, so that he or she will close the incision (not an assistant) and use
techniques to minimize scar formation. If you have a job or hobby where you
could have injuries from flying debris, hot material or chemicals, you should
wear the appropriate protective equipment on your face and body. While safety
glasses are good for protecting your eyes, it is better to protect your whole
face with a clear plastic face shield. (These are available at some hardware
stores.) You can save a lot of time and money by preventing scars, rather
than having to treat them.


13. How can I treat visible capillaries?

Dilated capillaries or spider veins (called telangiectasia by doctors) are a
common, benign hereditary condition that usually becomes noticeable in the
late thirties or early forties. In the face, it is common to get visible
capillaries on or around the nose and cheeks, and they can appear anywhere on
the legs and ankles. Sometimes dark patches under the eyes and around the
nose are caused by many tiny capillaries showing though the epidermis.

A doctor, nurse, or physician-assistant can treat capillaries with a laser,
intense pulsed light (IPL), an electrocautery needle, or by injection of a
clotting (sclerosing) agent. These techniques cause the blood in the
capillaries to clot and seal off the capillaries, stopping blood-flow through
them.

Injections, using tiny needles, are the most effective method for the legs,
often achieving nearly complete disappearance of the capillaries. Injections
have been used successfully for many years, and Net posters generally report
good results. However, with injections, there are some risks, including skin
ulceration and scarring, formation of smaller capillaries around the injection
site, and temporary or permanent discoloration. Injections can be used on the
face, but many doctors don't do this due to the risks of discoloration and
migration of the sclerosing agent. Lasers can also be used on the legs, but
current lasers are usually only effective on very small leg capillaries.
Companies are trying to develop new lasers that are more effective for leg
capillaries.

For the face, lasers are the most useful, particularly for areas with many
capillaries (which can look like dark patches). Some medical studies have
found that IPL is also useful for this, but many more studies have been done
showing the effectiveness of lasers than IPL. A variety of different lasers
may be used to treat capillaries, including flashlamp pulsed dye type and
neodymium YAG. Both lasers and IPL can also remove or lighten some benign
dark discolorations. Net posters who have had laser treatment generally
report improvement, but not complete disappearance of all capillaries.
Some posters reported a temporary or permanent unsightly, uneven skin color
after treatment of a large facial area with many tiny capillaries. People
with darker skin can also have problems with discoloration after laser or IPL.

Electrocautery can be used on larger individual capillaries. In
electrocautery, a tiny needle is inserted into the capillary, and an electric
current causes clotting and sealing. However, while electrocautery has been
used for many years with some success, many Net posters report that
electrocautery did not work well for them and also left a small pitted scar.
So it may be prudent to try it on one small capillary first.

Prices for a single treatment session vary, depending on the size of the area
treated and the method used. A few capillaries treated with injections or
electrocautery will cost about $100, while a large area treated with a laser
can cost $500 or more. With all of these methods, a single treatment session
will usually make the capillaries less noticeable, however, often two or more
treatments are required to achieve significant improvement. It is also
probable that other capillaries will appear in the future if you are
susceptible to this condition. Obviously, treating capillaries can be
expensive, so for women, treating only prominent ones while covering small
ones with makeup can save money. There are a few brands of makeup
specifically formulated for covering skin discolorations like capillaries.
Making the life-style and diet changes described previously can also help
reduce the formation of visible capillaries.

It is best to have a doctor, nurse, or physician-assistant treat visible
capillaries, rather than a cosmetologist. The techniques require a lot of
experience and careful technique . Usually you will have to go to a
dermatologist's or plastic surgeon's office for these procedures. You can use
the same procedure described previously to choose a doctor. Nurses or
physician-assistants who do this type of work under a doctor's supervision
may have an ad in the yellow pages under "Skin Care." In some larger cities
there are also doctors who specialize in phlebology (treatment of vein
diseases). Phlebologists who do cosmetic work on capillaries may have an ad
indicating this under the subheading "Veins" in the physician section of the
phonebook or under "Skin Care." As with other doctors, you should check the
certification of phleboligists at www.abms.org.
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Author code 91587355