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Scot: Troy, I've got a question for you. I'm going to say a word, and I want you to tell me the first thing that comes to mind. Botox.

Troy: Crow's feet.

Scot: Okay. Mitch, Botox.

Mitch: Wrinkles.

Scot: All right. That's the same for me, crow's feet and wrinkles. Today, on "Who Cares About Men's Health," we're going to talk about Botox, not only for a more youthful appearance, but also some other things that it can treat that men might find useful. And also, we're going to answer the question "Is it safe?"

This is "Who Cares About Men's Health," providing information, inspiration, and a different interpretation of men's health. I'm curious if you might have a different opinion about Botox by the end of this episode. We're going to find that out. My name is Scot Singpiel. I bring the BS. The MD to my BS is Dr. Troy Madsen.

Troy: Hey, Scot. I'm excited to learn about Botox for something besides my wrinkles.

Scot: All right. A guy who's working on his health and always has a unique perspective, Mitch Sears is on the show.

Mitch: I'm curious because TikTok keeps telling me in my 30s, I should start preventative Botox, and that worries me. Am I doing something wrong?

Scot: And Dr. Sarah Akkina, director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology at University of Utah Health. Welcome to the show.

Dr. Akkina: Thanks so much for having me. I'm very excited to blow your minds about the other uses of Botox, botulinum toxin.

Troy: This is great.

Scot: I actually looked it up and it was really shocking some of the other things that Botox can do, because at the beginning of the show, as we all said, we tend to think about crow's feet or wrinkles, using it to get a more youthful appearance, right? And a lot of times, guys hear that word, too, and we have that misconception that maybe it's not for us, right?

Mitch, you had a similar experience. Tell us about how you reacted when you heard that you needed Botox for another reason.

Mitch: Oh, frustrating. So I had Bell's palsy, right? We've talked about it. It's another episode. We can direct you towards it. But one of the weird after effects was that I have a thing called crocodile tear syndrome, which means when I eat, my eye will sometimes tear up. Big tears sometimes, whatever, it depends on what I'm eating, etc. It just is a nerve that didn't quite match up right.

And so I went to the ophthalmologist and they looked at it, and the potential treatment was Botox in that area to see if we couldn't numb up the nerve that was misconnected.

And unfortunately, I immediately just said, "Nah, I don't do Botox." I don't even know where that comes from, this idea, "Yeah, I hear what you're saying, but no, that's not for me. I'm a man." How dumb is that?

But then afterwards, I thought about it and whatever, and there were some other things that I wasn't quite super excited about. But yeah, the second that word Botox came out, I shut down very quickly.

Troy: Oh, I think I would do the same thing, Mitch, if I had to tell people, "I'm going in for my Botox injections." Number one, I wouldn't tell people that, but if I had to admit it, I would be embarrassed.

Scot: Yeah. You would rather cry when you eat, huh?

Troy: I'd just rather tear up.

Mitch: Yeah, I would apparently.

Scot: Than tell somebody you were . . . Yeah. Dr. Akkina, is this how guys typically respond when they hear Botox, that word?

Dr. Akkina: Yeah, absolutely. And I think it's funny because in the zeitgeist in our society, it's become so synonymous with cosmetics and appearance, and then people think, "Oh, it's mostly for women." But there are so many different ways that we can use it.

So stepping back, Botox is a brand, first of all. So it's a type of botulinum toxin. If we want to be more cool, if you want, we can say the toxin.

Scot: Yeah, you're getting the toxin.

Dr. Akkina: So you can say you're going in for your toxin treatment.

Troy: I'm getting my toxin.

Mitch: Rad. I love that.

Dr. Akkina: That's right. So, heretofore, we'll say toxin. So your toxin treatments, the best way to think about it is it's this really cool drug that we can use that basically shuts off muscles right at the junction that the nerve is giving them input.

So when you think about it like that, this toxin can be used to basically shut down any muscle that we feel like is not working well. In Mitch's case, one of the kind of muscles that I think you're talking about treating for the crocodile tears, it's basically things around the lacrimal gland. So we can use it to stop that gland from secreting things because you're affecting that muscle function.

And another way that we can do that in a similar case, which probably a lot of people don't know, is you can actually use toxin to treat over sweating. So actually there are especially a lot of men who use it. Actually, we can use it in your armpits or other areas that you feel like you're sweating a ton and it's embarrassing or you're just not into it. We can treat that with Botox, or toxin, as we're saying.

But that does require a little bit of higher doses than we're typically talking about versus things like wrinkles. So that's one option that we can do.

Another really great use of toxin is in your masseter muscles to stop teeth grinding. Do any of you guys teeth grind?

Scot: Yeah.

Dr. Akkina: Fancy word, bruxism So that masseter muscle is often the culprit in what's really causing that grinding.

And fun side note, my husband was very much like you guys and was very anti all sorts of toxin treatment. But when I told him about this and he had been having a lot of struggle with teeth grinding and stress, things like that, he actually let me attempt to treat his masseters and his teeth grinding stopped. It was amazing. And to this day, this is actually two years later, he's still not grinding his teeth. I think because his body just learned to adapt without it a little bit.

Troy: After one injection, one treatment?

Dr. Akkina: Yeah, after one series of treatment.

Important things to just remember for toxin treatment, it does take about a week to bring into effect. And then it only lasts three to four months. So you do have to know that. So typically that effect wears off. Some people are able to use that for teeth grinding, for instance, just to kind of rewire their body a little bit. Other people certainly need treatment still every three to four months.

But it's a great way to, like I said, selectively stop these muscles from over-activating and to help you in whatever that means for you for that muscle.

Troy: And what about things like facial twitches? If someone notices their face gets kind of twitchy when they get anxious or something like that, have you used it for that?

Dr. Akkina: Yeah. So blepharospasm, or that twitching around the eyes that can happen when people are stressed, tired, things like that, super common indication, and actually one of the first indications for using Botox, or toxin.

So toxin initially was actually developed and promoted in the '80s by ophthalmologists who were treating something called strabismus or basically crossed eyes where your eyes are misaligning. And that was one of the first uses in humans. And then quickly after that, they realized they could use it for blepharospasm or the spasms around the eyes. And then that led to saying, "Hey, we don't have crow feet anymore. How exciting."

Scot: That was the side effect, huh?

Dr. Akkina: That's right. So that was a side effect of all the initial use of toxin. So that's how we started to develop in the market.

And all jokes aside, there are some very serious other medical conditions that we can treat with toxin. One of the other things in my field of otolaryngology is for people who have spasms in their larynx. So you can have these spasms that really prevent you from having normal speech and normal talking patterns. And our laryngologists, or throat specialists, are able to basically direct toxin to those specific muscles and help shut that down so people can talk normally.

Another really common indication, probably more than that, is things like migraines, or anything that you can think of that's a muscle chronically or misfiring where we can kind of gently turn that off.

Now, it's a little tough because the dosages are obviously all different for different areas. So, depending on what you want to treat and what the indication is, insurance can cover some.

So, Mitch, if you'd gone forward with your crocodile tears, it's likely that insurance would cover that because that's a medical disease and illness that you're treating with it. Certainly, for cosmetic things like the crow's feet and forehead wrinkles, things like that, that is out of pocket.

Troy: And where would you do an injection for a migraine?

Dr. Akkina: Yeah. So you can inject things like the temporalis muscles and sometimes even behind. Our neurology colleagues do treatments for that typically. But yeah, there are different things that we can work.

For me, I used to get a lot of tension headaches, and when I started getting toxin for my forehead wrinkles, actually my tension headaches went away because I think I wasn't contracting or squeezing my brow angrily all the time.

Troy: Wow.

Dr. Akkina: I don't actually do that, for the record, but . . .

Scot: You don't sound like an angry person, so I can't imagine that.

Dr. Akkina: Well, I can't contract my brow right now.

Scot: Because the toxin shut that muscle down.

Dr. Akkina: Because of the toxin, yes. Very smooth and content all the time now.

Scot: So what is the actual name of it, not the brand name?

Dr. Akkina: So botulinum toxin, that's the actual name.

Scot: I don't know. That doesn't sound too good to me. On one hand, it sounds cool because, "Oh, I'm tough, I'm taking my toxin," but on the other hand, is that safe?

Dr. Akkina: Yeah, there are very little side effects. So a few important things is that whenever that toxin is injected, it can diffuse to other things in the area. And this is a little dependent, of course, on where it's injected, what the concentration it's injected at, things like that.

So you do have to be careful, and that's why I always recommend going to someone who knows what they're doing and is very familiar in the anatomy and structures in whatever area that they're injecting.

But it's relatively safe. The nice thing, again, is that while it takes often five to seven days to act, it goes away in three to four months. So if you don't like whatever the action is, it will wash out eventually.

Very few people do have allergies to toxin. If you have egg allergies, actually the botulinum toxin A in Botox, for instance, is formulated with egg proteins, albumin, so you have to be a little bit careful to just think about that.

And if you have other things like neuromuscular diseases or disorders, yes, you definitely have to be very careful about the effects of it.

Also, certain antibiotics, like aminoglycosides, botulinum toxin can potentiate some of the effects of that.

But outside of those pretty specific circumstances, it's got a really safe profile for use in a lot of different ways.

Scot: I've heard of something else called botulism. Is it related to that?

Dr. Akkina: Yeah, the toxin is the same, believe it or not. So that is how they initially learned about it. And yes, that's a serious disease. That is more if you have canned food, like cans that are crushed or look funny or things like that, those can harbor botulinum toxin. Honey can actually technically have some relation to that too, but not in the ways . . . mostly just serious for babies and infants, things like that.

Scot: Sure. But the way you're using, it's . . .

Dr. Akkina: Yeah, very different.

Scot: It's safe. I'm not getting any of that illness.

Dr. Akkina: Correct. Yes, you're not getting any of that illness from an injection of the toxin.

Troy: My one piece of advice, Scot, would be to avoid botulism. Don't drink pruno. It's a prison wine. We had a big case series we published. A bunch of prisoners who unfortunately drank that, and they had a potato in it, which was the source of the botulism. But it was a big CDC report that we published with multiple prisoners. So yeah, if you want to avoid botulism . . . But this is not botulism. I think that's the point here. You're not putting yourself at risk of botulism.

Dr. Akkina: Yes, correct.

Scot: So it has a lot of really, really cool uses. The sweating thing, I bet you, for some guys could really be a game changer. We talk about the Core Fore, and emotional and mental health is one of them, and if it makes you self-conscious or anything like that . . . Lazy eyes, I think you mentioned that as well. Any sort of spasm disorder. To remove that from your life, I would imagine, can be a great thing.

Do you have any guys that have ever used it for those purposes and how did it change their lives?

Dr. Akkina: Yeah. I think the sweating thing in particular, I remember a patient a few years ago who came in, it was a gift from his mom for his 19th or maybe his 18th birthday, because he was going to be taking prom pictures soon and he didn't want to sweat through his shirt during prom, which is actually a really sweet gift I thought from his mom. So small things like that, I mean, they can make a big difference in people's lives.

Troy: Sweaty palms, people use it for that?

Dr. Akkina: I've not personally done that, but I think in theory you could. When you're treating large areas like that, again, you do have to be a little bit careful because it's probably just going to be a high dose. So it might just be a little bit dose-limited in terms of having to inject all these little areas there. The other tough part there is you wouldn't want to turn off the muscles in your hand.

Troy: Right. That could get awkward.

Dr. Akkina: It's always a balance. You can inject it in glands and things like that, but yeah, if you're injecting around muscles, you have to be prepared that it might diffuse a little bit.

Scot: So it can do a lot of really cool things. And since you're here, let's talk about using it to remove wrinkles. I'm just gathering information. I'm not saying it's for me.

Troy: Asking for a friend.

Dr. Akkina: For a friend, yeah.

Scot: I'm just asking for Troy.

Troy: I was curious. Yeah.

Scot: So, actually, I want to throw that out. Mitch, you had mentioned that it had been recommended that maybe . . . well, on the internet . . . that you start doing some preemptive Botox.

Mitch: Oh, no. I have a friend in my life who has also said it's not that big of a deal and if you start now, you'll never have wrinkles. I don't know if that's true or not, but . . .

Scot: Have you considered ever using Botox for a more youthful appearance?

Mitch: See, I have a pretty youthful appearance anyway, and the rule I've always told me is as long as I could play a high schooler on a CW original, I am okay. But there is a part of me that does wonder . . . I don't know. I don't particularly love the idea of becoming super duper wrinkly. Maybe. I'm open to it, but I'm not super excited about it.

Scot: What would your dad have to say about all this?

Mitch: I don't know. He's probably listening right now. I'm sure I'll get an email.

Scot: Troy, is this anything you've ever considered?

Troy: Botox? I haven't seriously considered it. No. It's probably crossed my mind because I'm at a point in life where I do see more wrinkles appearing, but I can't say I've ever really looked into it beyond thinking, "Huh, maybe."

Dr. Akkina: Well, fair enough. I think a lot of patients, and especially men, are in that boat. But it is nice because from that . . . Mitch, you asked earlier I think about the preventative part. So Botox or toxin can't take away wrinkles that are already formed.

So when I think of wrinkles, there are both static wrinkles and dynamic wrinkles. So when we're young, if I raise my eyebrows, you can see typical areas where my muscle is causing contraction of the skin. That's causing temporary wrinkles. But when I relax, you can't see any of those wrinkles. Versus in another 20 years, unless I keep my toxin up, then those wrinkles are kind of permanently etched in the skin.

So important distinction. Toxin can't take the permanent wrinkles away because that's just part of your skin at that point. But it can always, as we said, inactivate the muscle under it.

So for forehead wrinkles, for instance, that's the frontalis muscle. We can make that muscle calm down, be much less active with the toxin, and then you're not actively working to keep forming those wrinkles. So that's why it can still help even if you have static wrinkles that are there.

Scot: What are other wrinkle locations it could help? So crow's feet, if I already have them, that's not going to help that, right?

Dr. Akkina: It still will make I think the appearance of the deep wrinkles less, right? If you have the crow's feet, yes, they're there, but if you're not activating the muscle all around it, it can still look a little bit softer, a little bit less aged overall.

For other areas . . . So we talked about the forehead. The between-the-eyes area, that brow, that's another super common one. And especially for men, right? It's that kind of furrowed, angry brow look. We call those the 11 lines because it leads to those two often horizontal lines in the very middle of your forehead. Those can respond really well to Botox.

And again, if you have permanent wrinkles there or static wrinkles, it's not going to take them away, but it does soften the overall appearance of your brow. It can help you look a little bit less angry or things like that.

Scot: How many men do you see in your office that actually come in and get treatment? And what are their reasons? Because I had read somewhere that Botox has just exploded among men. I think a 400% increase in treatment since 2000, so a lot more men are getting it nowadays. Why are they doing that?

Dr. Akkina: And most of it is for appearance. Yes, overall, for my patients coming in for toxin treatments, less than maybe . . . It's certainly a minority. I would say probably at this point, maybe 5% to 10%. But among those men, certainly things like the forehead wrinkles, but the masseters is also another really common indication for people who want to try to stop grinding their teeth.

That's another actually great thing that I'm getting more folks coming in for. I'm glad that it's getting out there that's something that we can use toxin for.

Scot: Yeah. I Googled a couple things because I was curious. I was like, "Gosh, is it vain that I want to get rid of my wrinkles?" For me, it's not actually wrinkles. I don't think Botox is the solution to my problem. I have these bags under my eyes. I look like I'm constantly fatigued. Botox isn't going to help that.

Dr. Akkina: No.

Scot: And I never thought I would think about getting any sort of cosmetic anything until we came into this world of Zoom. I'm looking at my face all the freaking time and I just look so run down and so tired, and I'm afraid people in the office are going to think, "Does he ever sleep? He looks sleepy."

So social media was one of the reasons why. And I thought, "Well, again, that's kind of vain." But then it said online dating. Well, okay. We're representing ourselves in a completely different way than we've ever had to, our dads or grandfathers have ever had to, in high resolution. So do you guys come in for those reasons and . . .

Dr. Akkina: Yes, absolutely. I had a patient the other day who was telling me that he's a little bit upper level in his company now, but he feels like some of the other people in the company are much younger than him and seem more youthful. And he gets embarrassed on these Zoom calls where he feels like he's the old person in the group, and he just wanted to feel more youthful.

So talked to him about things like facelifts, blepharoplasty. That's the under-eye or over-eye surgery where we try to help reduce that evidence of the extra skin and the bags, things like that. And he's really excited to get a little bit more of a youthful appearance just so he feels like he can stand up with the younger folks at his company.

Troy: I was going to say what about . . . The big thing I've heard with Botox is kind of the mask face where you get to where you always look like . . . Your expression doesn't change.

Mitch: You're a Barbie?

Troy: Yeah, exactly. Is that common, or are people just overdoing it when that sort of thing happens?

Dr. Akkina: Yeah, I call that a frozen face or freezing someone out. I don't like to do that. And when you have an injector that you're going to, I think talking about what your expectations and what your goals are is super important. And then having your injector listen to you and make sure they're not overdosing things to freeze things out is important.

So when folks come to see me, I talk through exactly what they're interested in getting. We talk through wrinkles often. And then I discuss my normal dosages.

And usually, I like to err on the lower side, right? I never want to free someone out. That's just my preference. So starting on lower ends of dosages, and then always coming to back for touchups, things like that. Super easy to do.

In general, when we go through the process of injecting Botox or Dysport or Xeomin, it's a very tiny needle. It's a couple little sticks. Yes, there is a risk of just a little pinpoint bleeding, things like that, or just a tiny bit of bruising. But overall, it's a pretty short and sweet procedure.

So we can start at low doses. I can have people come back and we can kind of keep augmenting until we find a regimen that they like in terms of its outcome.

Mitch: Now, I've heard about Botox parties. I've heard about going to a "spa." Is there a benefit? I mean, it sounds like this drug is pretty safe. Is there a reason that we should maybe err towards going to a medical person rather than some of these other things?

Dr. Akkina: Yes, absolutely. So we talked a little bit about some of the risks. I just mentioned injection risks certainly are something to always think about. But making sure that whoever is injecting your face is intimately familiar with those muscles and the other things in the area that could get affected by your injection is so important.

So one of the other common things that can happen if you're injecting around the eye, and especially if you're injecting in certain areas, is that toxin can diffuse and affect one of the upper muscles in your eyelid and basically give you a droopy eyelid. So that's something called ptosis.

And especially for cosmetic things, it's a little bit less common, but you want to make sure that your injector is injecting in places where that's a much lower risk. Certainly, we can treat that with eyedrops, and often it only acts for a few weeks even.

But yeah, that's a small example of you want to make sure you're going to someone who knows what they're doing and can provide the treatment in the places that you want it, giving you the effect that you want, and the dosage that you want.

So yeah, Botox injectors come in all sorts of varieties. I've even seen dentist office offering Botox. Have you guys seen that?

Mitch: What? No.

Scot: No.

Dr. Akkina: I mean, I think if you're well trained and have good results, okay, for sure. But yeah, you just never know and I think it's safer to make sure you're going to a place where the person knows the face, knows the muscles, knows what they're doing.

While it's safe in general, you can have unwanted consequences. You can freeze out a face. You can cause droopy eyelids. You can affect things like the smile overall. If you're doing masseter Botox, sometimes that can diffuse in different places. So you just want to make sure someone's really knowledgeable when they're doing it.

Scot: Those are some really good tips on how to look for a professional. And also, I love the fact that you said you should have a conversation and make sure that you feel comfortable with the person . . .

Dr. Akkina: Yes, absolutely.

Scot: . . . that's going to do it for you.

So I'm not going to pass judgment, I guess. I think the Scot of 10 years ago, and certainly the Scot that is the son of a South Dakota Rancher would. But we're in a different world, right? Botox is super useful for a lot of reasons beyond just appearance. If you want to get it for appearance too, and I've considered it, so I would completely understand.

So I want to find out where we are after our conversation. We started out with the association game. Troy, Botox.

Troy: Teeth grinding.

Scot: Okay. Wow. So we did change perception there.

Troy: That was my takeaway. And as we talked about it, I was grinding my teeth and I thought, "Maybe I need this."

Mitch: Oh, my. I've been struggling with this forever. I have a little mouth guard thing that I wear most nights, and I've still got sore muscles. It's like, "No duh, we have something out there that can turn those muscles off for a bit."

Scot: All right. Mitch, Botox.

Mitch: Toxin, my eyes. I don't know. What I'm thinking now is just, "Maybe I . . ." If it's for the most part relatively short term, maybe I could try it and see if it's worthwhile to have those muscles near my eye frozen. I didn't fully realize that it was kind of a temporary thing. So I don't know. I feel very different about it.

Scot: You're more open to it now?

Mitch: Oh, very much so.

Scot: All right. Very good.

Well, thank you very much, Dr. Akkina. We appreciate having you on the show.

And if you're listening, where are you about Botox after this episode? Have you ever used it for other procedures, for your appearance, or any of the conditions we talked about? And how did it work for you? Then finally, is it legit for a man to care about their appearance and want to use Botox?

If you have thoughts on any of those topics, you can email us at hello@thescoperadio.com.

Thank you for listening, and thank you for caring about men's health.
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Interviewer: As patients and loved ones of patients who have suffered from Bell's palsy know, the loss of one's ability to move one's face can be really serious and impact their lives. And if it's lasted for longer than six months or so, a surgical option may be available to give back a loved one's smile and ability to move their face.

We're joined by Dr. Sarah Akkina. She is the Assistant Professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology and Director of the Facial Nerve Center at University of Utah Health.

Now, Dr. Akkina, briefly, what is Bell's palsy and why is facial paralysis so potentially life impacting?
What is Bell's Palsy?

Dr. Akkina: Bell's palsy is a rapid, or less than 72 hours, one-sided facial nerve weakness of unknown cause, meaning we don't have an alternative reason for a patient to have it.

It's really important to know that recovery from Bell's palsy should start two to three weeks after. So that as an entire category really classifies Bell's palsy.

There are other conditions that can cause facial weakness, and that includes stroke, brain tumors, salivary gland tumors, cancers, and infectious diseases, including things like Lyme disease or a tick-borne disease.

Overall, we suspect that Bell's palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear, and taste to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth, a change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye, trouble keeping food and liquid in their mouth, nasal obstruction, and overall difficulty expressing emotions. So they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.
Treatment Options for Bell's Palsy

Interviewer: Wow. And so for patients who are maybe suffering from these different symptoms, whether it be facial paralysis, or inability to tear, or asymmetry, etc., what options are available for patients who are still experiencing those types of symptoms longer than is typically expected for healing, say, six months or so?

Dr. Akkina: For overall treatment of patients who have Bell's palsy with incomplete recovery, meaning they still have some muscle weakness, some asymmetry of their facial movements, or some major functional issues like being able to keep food or liquid in the mouth or nasal obstruction, we have a series of treatments that we can provide for those patients.

We provide treatments that are focused on both moving, or dynamic, and non-moving, or static, facial reanimation. Static procedures are focused on improving the overall symmetry of the face at rest, and that includes procedures focused on the brow, the eyes, the nose, the mouth, and the cheek.

Dynamic procedures can bring back facial movement itself, and that includes surgeries that connect working nerves to non-working nerves, as well as surgeries that transplant nerves or muscles from nearby or separate areas of the body.

For patients that have developed abnormal facial movement after facial paralysis called synkinesis, we offer procedures to reduce that abnormal movement, including chemodenervation, or using botulinum toxin injections, or Botox/Dysport/Xeomin, as well as selective neurectomy. And this is cutting nerves that lead to the abnormal movements. We can also cut selective muscles that are moving abnormally.

So there's a variety of ways that we can really delve into exactly what is abnormal for a patient and help them in these matters.

Interviewer: Wow. So you just described quite a few procedures. These are all under the umbrella of facial reanimation?

Dr. Akkina: Correct. Yeah.
What is Facial Reanimation for Bell's Palsy?

Interviewer: Wow. So what kinds of patients are, say, eligible for these types of procedures? Is there anyone that for one reason or another would not be eligible for something like this.

Dr. Akkina: So by group, I'll say, for things like nerve transfers, it's important to know . . . For Bell's palsy, we don't assume that there are other nerves that are affected. But for patients who may have the facial paralysis because of other skull-based tumors or other pathologies that may then affect other nerves, we have to make sure that the nerve we connect to the non-working nerve is going to work, if that makes sense.

Interviewer: Sure. Okay.

Dr. Akkina: For muscle therapies, a lot of patients will qualify for different work such as cutting muscles that are abnormally moving. But for moving muscles, so sometimes if a patient has permanent, abnormal movement of their smile, we can transplant a muscle from their leg into their face to basically recreate their smile muscle movement.

That, of course, does require that that patient's a good candidate to be able to undergo a long surgery where we transplant that muscle. They have good arteries and veins in their face that we can connect it to and are otherwise healthy from other standpoints too.

So, as you can tell, it is pretty individual-based, and that's why it's so important to be able to see a specialist who can talk you through all these different options.

Interviewer: And the specialist that they're looking for is a facial nerve specialist in surgery?

Dr. Akkina: Correct.

Interviewer: I guess this might be a strange question, but considering how tailored and kind of unique it is per patient, what kind of success rates do you see with your patients?

Dr. Akkina: We can get great success rates, especially with nerve transfers. One critical part is that timing is super important. So we talked about for things like Bell's palsy, if you have abnormal movement after three months, you should get immediately referred to a facial nerve specialist. Because overall, for some of these nerve transfers to work, we only have 12 to 18 months before that facial nerve itself may not work very well even if we connect it to a better nerve that can give it more input.

So overall, for the nerve therapies, we really need to see patients, again, ideally within 12 months so we can start planning for whether they may be a candidate for the nerve surgeries.

That muscle transfer surgery can be done essentially at any time. That one we like to wait a little bit longer to know that they won't recover from the other standpoints and that they may not recover from things like the nerve transfers. But that is a really great option for patients who don't qualify for the nerve transfers themselves.

Interviewer: And for the static procedures, it's mostly for cosmetic, mostly for that kind of situation, or . . .?

Dr. Akkina: Both cosmetic and function. So the static procedures, they can really help with, for instance, for the eye work, again, closing the eye. So being able to maybe not necessarily use as many eye drops or have to tape the eye at night, things like that, our eye procedures can give that function back.

Another really great thing is . . . Outside of the symmetry, the nose can be droopy, so a lot of patients have nasal obstruction. And some of our static procedures, one called a static sling where I take fascia from the leg and reattach it to parts of the face, bring back basically support of the nasal valve and support of the mouth, so it's not drooping so much.

So it helps both the appearance of the face and the function in terms of that droopiness, which is why a lot of patients have difficulties with chewing food or keeping food and liquids in their mouth. So the static procedures can help both of those aspects.

Interviewer: We're just not necessarily replacing muscles or reconnecting nerves.

Dr. Akkina: Exactly.

Interviewer: We're doing structural things. Okay. Interesting. So what are some of the potential complications that come with these types of surgeries?

Dr. Akkina: Yeah, one of the main complications is sometimes for the nerve transfers, the nerves unfortunately don't connect as we like or don't eventually function as we like. But we do like to work with our physical therapists very intimately for those procedures as well, to teach patients how to use those new nerve connections.

One example is that we can connect a nerve that controls one of the muscles of mastication, or one of the muscles that's responsible for us closing the jaw, back to the facial nerve. But that does mean that a patient essentially has to clench their jaw to activate their smile. So there are different physical therapy things to learn about that, to teach a patient how to use their new nerves correctly.

Some of the complications that always exist for surgeries are things like bleeding, infection of the site, sometimes failure of the static sling procedures where we don't get as much of a lift of the face as we want, as well as ultimately relaxing of the face again.

Gravity wins always at the end, so even if we do these procedures when a patient is, say, in their 30s or 40s, over time the face will continue to droop and may need additional procedures in the future.
The Cost of Facial Reanimation for Bell's Palsy

Interviewer: Well, this is kind of really exciting to hear about all the potential ways that we can work on this, but what does this kind of procedure cost and is this something that is covered by insurance?

Dr. Akkina: Great question. So this procedure is typically covered by insurance. That's the number one thing, especially for things related to overall facial paralysis. Typically, insurance will cover any procedure related to that facial nerve motor dysfunction.

There are insurances that won't cover some smaller procedures. Sometimes things like the brow lift on that side of the face, because it is very focused on the symmetry and appearance of the face, has difficulty getting covered by insurance. But for the most part, a lot of these advanced procedures we've discussed will be covered.
How to Choose a Facial Nerve Specialist

Interviewer: So we've got a patient, and they're dealing with this kind of long-term facial paralysis. What should they be looking for in a doctor? If they want to explore some of these potential facial reanimation options, what kind of doctor are they looking for, and are there any particular trainings or certifications or something that they should be searching for?

Dr. Akkina: Absolutely. The first thing I'll note is that taking care of facial nerve disorders is a team sport. So we have, in our facial nerve center, multiple specialists from different aspects that all come together to collaborate and care for our facial nerve patients.

So our team includes experts in facial plastic surgery, neurotology, otolaryngology, head and neck surgery, oncology, ophthalmology, facial nerve rehabilitation. So you can get a sense that there are so many different aspects that we can come together to treat for patients.

And each specialist focuses on their area, but certainly in a facial nerve center setting, we can all basically collaborate on our individual aspects.

Initially, I think it is important to see a specialist who's at least aware of many of the procedures and treatments that we can offer. So, typically, facial plastic surgeons or even some neurosurgeons are focusing their practice on these areas.

This is an exciting field where we do have development of new techniques and new practices that are coming out each year. So being at an academic center can also really help because specialists in these centers are usually up to date on the latest knowledge, if not performing some of these trials and experiments ourselves. So going to folks who are most up to date on what's going on, I think, is also important.

For facial plastics, there are board-certified surgeons who have additional training and are, again, certified on a particular level with that training. So I would recommend always seeking a board-certified surgeon, especially moving forward with the surgical treatments.

Interviewer: So I guess look for a board-certified surgeon maybe at an academic center, or just look for that doctor that will be able to help you get the type of treatment that you need.

Now, as a patient who might be first starting out onto this, first looking into potential options, or a loved one of a patient, what is the message that you have for them in kind of starting this journey towards facial reanimation?

Dr. Akkina: Yeah, my main message is that, one, you're not alone, and two, there are ways that we can help. Even if that's mainly connecting a patient with a therapist to work on facial retraining or discussing some of these more advanced, both surgical and injection options, there is likely a way that we can help. And we want to work with you and evaluate all these aspects that you're going through.

Places like a facial nerve center will have multiple specialists who are all geared towards helping this very special patient population. So we want to help you. Please come find us.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an academic dermatologist at TexasTechUniversityHealthSciencesCenter, in beautiful, sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, everybody. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to talk about topical steroids. Luke, what are topical steroids?

Dr. Johnson: Well, they're a topical medication, and the type of medication they are is a steroid.

Dr. Tarbox: : Ba da bum bum!

Dr. Johnson: I know, right? Topical is something you put on the skin. So sometimes you can think of it as I put it on top of my skin. So it's topical. It's not tropical. That would be palm tree-derived medicine.

So a steroid is a specific type of molecule. And I don't think the exact biochemistry of the molecule is all that important. But what is important is that this molecule goes into your cells and affects the way the cells express their genes. There are some kinds of steroids that the body makes, all the sex hormones, like estrogen and testosterone are steroids. And the body also makes a type of steroid called a corticosteroid, which is sort of an anti-inflammatory stress molecule. And we take advantage of the anti-inflammatory properties to make corticosteroids in our medications. So even though, like, testosterone is a steroid, when dermatologists say "topical steroids," we're not talking about topical testosterone, we're talking about topical corticosteroids.

Dr. Tarbox: And sometimes my patients, when I say the word "steroid," they'll think about, you know, oh, a big muscle man. And I always tell them this is not the kind of bodybuilding. And then I pose because, of course, steroids. We're not going to make your pose sicker. We're just going to make your skin less inflamed.

And you mentioned that that's really the side effect we're taking advantage of, of these medications. So the reason we love to use these, when they're necessary, is because they work against inflammation. And many problems we run into in the skin are inflammatory. And as dermatologists or patients who are treating a skin-related condition, we're all lucky that the organ we're treating is right there under our fingertips. It's literally accessible to us all the time. So it's easy to put medication on the organ that's having the problem. What about their safety Luke?

Dr. Johnson: Well, the good news is they are very safe. The body makes its own steroids. So we're putting on steroids, something that the body can make itself. We can use them in pregnancy. We could use them in breastfeeding and children and babies. I mean, they're not completely without risks, because neither is anything, eating avocados isn't completely without risk, but they are extremely safe.

One of the benefits, as well, is that there are no interactions with other medicines that you could be taking, right? You're putting it on your skin. So it's not like taking a pill that could interfere with some other things. And also unlike taking a pill, they don't have those potential side effects that you might get if you were to take a pill by mouth. So dermatologists love our topical steroids.

Dr. Tarbox: It's definitely not the only medication we use, and there are other topical medications we use as well. But one of the benefits of topical steroids is they tend to be relatively quick, relatively well tolerated. There is a variety of strengths and vehicles. So most people can find a preparation they can use and tolerate. And they range from a gel to a solution, to a lotion, to a cream, all the way down to an ointment, which is very thick, greasy medication with no extra water in it. So that actually often will allow you to spare the use of some preservatives and some patients are allergic to those. So those can be very good choices for that.

And in general, they're relatively inexpensive. One issue I think all physicians run into, when taking care of their patients, is considering the cost of the medication for the patient. Are they going to be able to get that medication? It could be the perfect fit medicine for their condition, but if they can't get it in their hands to use it, it doesn't do them any good. So medications that are reasonably priced for our patients are things that we have to think about.

What are some things we don't like as much about topical steroids, Luke?

Dr. Johnson: Before I talk about that, I want to mention that you said that they come in various strengths and what we call vehicles, which are is it a cream or an ointment or a gel or whatever. So if you wanted to try out a topical steroid on your own for some inflammatory skin condition that you have, like a mosquito bite, for example, you can just go to the grocery store or the drugstore and buy one.

Hydrocortisone is generally the one that's available over-the-counter, at least here in the United States. And it's usually a 1% preparation. It's very weak, but it could be strong enough for, you know, a mild insect bite or something like that. But it's so weak that really I don't think you have to worry too much about the side effects. It's best as an ointment. Ointments tend to have better delivery into the cells. So you want to find a nice gloopy ointment hydrocortisone 1%. It's a really good thing to start with if you're trying to treat something on your skin that is itchy. And remember very weak, you could probably put it on twice a day forever and never have a problem with it.

Dr. Tarbox: So what are some of the things that cause problems with topical steroids?

Dr. Johnson: Well, they can be annoying. They might feel greasy or unpleasant. But you might be able to find a better vehicle if they did feel that way. And if they are kind of greasy, they might get on stuff, like they might get on your clothes or your furniture or your pets, I guess, you know, especially stuff that's an ointment doesn't really rub in very well sometimes even though it works well.

You might have a hard time knowing how much to use. You know, it's not like a pill where there's the dose. So some people might put on a tiny, tiny little bit, and some people might put on a huge glob. In general, you need just an amount to cover the area with a thin film of medicine.

Also, if you have a lot of affected skin, it might just be a pain to try to put it on everywhere. You know, we see patients who have eczema or psoriasis or other conditions, where it affects 40% or 50% of their body. I don't think we can expect them to be slathering medicine on that much of their body twice a day, every day.

Dr. Tarbox: I agree. That's a lot of ground to cover. You know, when you're talking about applying these topical steroids, I think that, you know, some people get very nervous about using these. And one of the things that we try to emphasize as dermatologists is that the way that we use these medicines for limited periods of time on areas that are specifically inflamed is less likely to cause problems. And side effects for topical steroids is actually quite rare. What are things we need to look over for?

Dr. Johnson: The side effects are rare, but they do happen. And I have seen them, and I feel bad when one of my patients gets one of these side effects. Though I assume every doctor feels bad if their patients get side effects from their medicines, whether they're topical steroids or something else.

I do like to emphasize that as long as you're putting it on a rash, you are unlikely to get into trouble. However, if you've been putting it on that rash for two weeks and nothing has happened, then probably it's not working. And just continuing to put it on isn't going to get you any better and might give you side effects. If you've been putting it on for two weeks and it's getting better, well, then you might continue doing it until the rash is gone. Or if it's not gone in two weeks, maybe it's time to talk to your dermatologist and make sure you're using the right medicine.

But side effects that can exist are more likely if they're placed on certain types of skin. So thin skin, like the skin of the face is thinner than the skin of the back, more likely to have side effects. Skin that is often occluded, meaning there's other stuff covering it, like your clothes, for example, like right on the waistline where your waistband will be pressing against that medicine and pushing it into your skin, increased risk of side effects there. Similarly, if there's areas where skin touches skin, like in your armpits, for example, again, pushing that medicine into the skin, increasing the effect of the medicine, which also increases the side effect.

Using them without medical advice. So again, over-the-counter hydrocortisone, very safe, but in this day and age, you can probably find stronger steroids on the internet. You probably shouldn't be using those without medical advice, so look out for those.

And also I find that the vast majority of my patients and their parents underuse the medications because they're worried about side effects rather than overuse them and get side effects, because there seems to be a lot of misinformation about there claiming that the medicines are quite unsafe and scary and, you know, on a baby don't use them for more than three days in a row or something, which is completely made up. So one thing to look out for is don't be scared off by stuff that you read on the internet. Get medical advice from people who know.

Dr. Tarbox: Yes, absolutely. And, you know, the side effects that we can see tend to be skin limited in most cases. So the one we talk about the most is that atrophy of the skin or skin thinning. Where I see this most commonly is where people have misunderstood the instructions and are using the topical steroid as a moisturizer, generally applying it over large areas of skin, instead of focusing it on the areas of the rash. So that's an area of potential danger.

We do talk about steroid rebound, which means that when you take the medicine away, people can have sort of return of the eruption with some vengeance. That's relatively rare with most conditions, but it can occasionally occur. And especially in some areas, like the face or the chest or back, topical steroids may induce some acne or folliculitis or some rosacea-type symptoms. So we always have to balance the risk of that with the topicals that we choose.

So with all these complications with topicals, why don't we just use some oral steroids, Luke?

Dr. Johnson: So there's different ways to deliver steroids to the entire body. Probably the most common is by taking pills, though you can get shots as well that affect the whole body. We call these sorts of medicine systemic medicines. That means they affect the whole body. There's a lot more potential side effects with systemic steroids than with topical steroids. Some people need them, and those side effects are more dangerous the longer you take them. So some people have conditions for which they need to take steroids for months and months or even years and years.

Some of the side effects include things like high blood pressure, high blood sugar, difficulty sleeping. Some people can feel a little crazy on them. And then you can gain weight. And there can be problems with the eyes or the bones.

There's a lot of potential problems with systemic steroids. So a lot of reasons to like topical steroids, especially since we're putting them directly on our organ of interest. It's a good thing I'm not a heart doctor because I'd always be tempted to reach into the patient's chest and put medicine on the heart.

Dr. Tarbox: So in general, we like our patients to understand that these medications can be very helpful when used properly and can also be quite safe. So, of course, you want to use them under the direction of your physician, and you want to ask if you have any questions or concerns.

Dr. Johnson: That is all for today. Thanks for hanging out with us and learning about topical steroids. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. And if you're a super dermatology nerd, like we are, maybe you would like to come hang out with us on our other podcast.

Dr. Tarbox: We have another podcast called "Dermasphere." That is the podcast by dermatologists for dermatologists and for the dermatologically curious. It is available wherever you get your podcasts. We also have social media profiles, and you can check us out on dermaspherepodcast.com.

Dr. Johnson: We'll see you guys next time. Stay healthy.

Interviewer: After a person has experienced major weight loss, either through lifestyle changes or something like a bariatric surgery, you may be left with a bit of excess skin that just won't seem to go away. And there are a few surgical options available to help remove that skin. Dr. Brad Rockwell is a professor of plastic surgery at University of Utah Health.

Now, Dr. Rockwell, when it comes to the excess skin from weight loss, how common is it for someone to have excess skin that just won't seem to go away?

Dr. Rockwell: Oh, virtually 100%. Unfortunately, as we get older, our skin loses some of its collagen, loses some of its elasticity, and the skin will become loose. So, even at certain ages of maturity, even if someone is not overweight, they will still have some lax skin in their abdomen. For everyone that's lost weight, virtually 100% will have some extra skin that could be improved with abdominal surgery.

Interviewer: So the surgery is an abdominoplasty, correct?

Dr. Rockwell: Correct.

Interviewer: And it's my understanding that there's a gradation of how much skin, and that kind of relates to what kind of surgery that you as a plastic surgeon would perform. Why don't you walk me through some of these treatments and kind of walk me through how they work and what a patient could expect?

Dr. Rockwell: There's the standard abdominoplasty. The non-medical term for that is tummy tuck. That's also essentially one of the main components of a Mommy Makeover. But it's just loose skin in the abdomen. In addition to the loose skin, usually the muscles beneath. If it's in a female who's had a pregnancy, the muscles will be a little loose. The skin may have some redundancy.

And the standard abdominoplasty or tummy tuck will remove skin in the lower portion of the abdomen. The skin that is higher on the abdomen is stretched to close where the skin was removed. And in addition, the six-pack muscles or rectus muscles are tightened and that will narrow the waist.

Interviewer: Okay. So it's not just the skin that you're operating on. It's also the muscles underneath?

Dr. Rockwell: Right, by tightening the underlying muscles. No muscle is cut. No muscle is thrown away. The muscle is still fully functional. There's some experimental evidence that actually shows the tone in the muscle is increased and athletic performance may be boosted a little by tightening the muscles. But the muscle is tightened. That will narrow the waist and that actually allows more skin to be removed because the inside becomes a little smaller.

Interviewer: Ah, got you. So what's the next stage of treatment?

Dr. Rockwell: So the standard abdominoplasty that we just talked about will pull the skin from the upper portion of the abdomen down lower and remove skin in the lower abdomen. Some people who have lost more weight will have a vertical skin redundancy and also a transverse skin redundancy. So the skin can be tightened by pulling it down, and the skin could also be tightened by pulling each side towards the middle of the abdomen.

The standard abdominoplasty leaves a longer scar in the lower abdomen. It goes from one hipbone to the other hipbone. The second stage does everything that a standard abdominoplasty would do, but in addition tightens skin from side to side, and that leaves an additional scar along the vertical midline of the abdomen. It goes from the bottom of the breastbone down to the pubic bone.

Interviewer: Okay. And so that's for, say, someone who has additional excess skin on the sides, love handle area, or . . .

Dr. Rockwell: It would be someone who's probably lost 50 pounds or 100 pounds. Standard abdominoplasty, maybe the people haven't lost weight. Maybe they've actually gained a little bit of weight from their younger days.

So this second stage, which is also called a fleur-de-lis, which is a French term, that will tighten side to side. And most of those people have lost probably 50 to 100 pounds.

Interviewer: And so as we go onto the last stage, this is for people who have lost a lot of weight. Tell me a little bit about this Stage 3. And I hear that it was a procedure that was developed by someone from the University of Utah?

Dr. Rockwell: Yeah. So the third stage is called a corset abdominoplasty. Dr. Alex Moya, who was a plastic surgery resident at the University of Utah in the early 2000s, now practices in Pennsylvania, and he developed this surgery.

So it incorporates everything that a standard abdominoplasty would do and everything that a fleur-de-lis abdominoplasty would do. And in addition, he pulls skin from the upper portion of the abdomen up towards the chest. The downside of it is it adds a scar right under the chest, or in women right under the bottom of the breast. But it allows even more skin to be removed compared to the other two options.

Interviewer: When it comes to deciding which surgery to do . . . I've heard you kind of discuss it depends on how much weight has been lost, how much excess skin. How much does the scarring come into that decision-making?

Dr. Rockwell: For most of these people, scarring is a secondary concern. Removing the extra skin is more of a concern. Obviously, if someone is in clothing, the scars are not visible at all.

And the majority of people who have the fleur-de-lis abdominoplasty or the corset abdominoplasty may not be on a beach exposing their abdomen. They may have little more modest clothing to cover it up, and then the scars would not be visible at all. But even if they're in that clothing and had not had surgery, the redundant skin and the rolls of extra skin would show through their clothing.

So, for most of these people, the priority is removing as much skin as possible, and the secondary concern would be the scarring.

Interviewer: So, for patients that are choosing to have this procedure done, is it an outpatient procedure? Are they in the hospital for a few days? And how long does it take to get back to your day-to-day life?

Dr. Rockwell: So just about everyone that has any of the three versions of a tummy tuck that we have discussed, it would be performed as an outpatient. The reasons to stay overnight would usually not be specifically related to the involvement of the surgery, but would depend on pre-existing medical conditions.

So if someone had lung trouble or heart trouble and their lung doctor or heart doctor might say, "You need to be monitored overnight in the hospital after that surgery," that would be the reason to stay. But most of them, it's an outpatient operation.

Interviewer: After they get home, what is the recovery time, and what are the steps of recovery, and how long will they expect to be recovering for?

Dr. Rockwell: So if someone has a desk job, they would probably be able to return to a desk job after two weeks. If they have a job that's a little more physically demanding, maybe three weeks.

In tightening the muscle, there's a six-week recovery period to resume exercise. Where the muscle is tightened, it takes six weeks for the muscle to heal where someone could attempt to do a sit up. So the long point of recovery would be six weeks to resume exercise or six weeks to lift more than 10 to 15 pounds.

Interviewer: So, for patients that might be interested in a procedure like this, what should they be looking for when it comes to choosing a good surgeon who will be able to give them the best results possible?

Dr. Rockwell: So none of these options of an abdominoplasty are small operations. They usually require between three and maybe six or seven hours in the operating room. So you want to make sure you have a qualified surgeon.

The best level of qualification that the public could find out about a surgeon is to make sure the surgeon is board certified. And for this type of surgery, make sure they're board certified by the American Board of Plastic Surgery. There are non-plastic surgeons who offer this surgery, but their background training would not be as rigorous as a board-certified plastic surgeon.

Interviewer: And I guess the last question is what are some of the positive results that people see? Are most people happy with the procedure? What can a patient expect after they're all healed up and back to their lives?

Dr. Rockwell: Yes, I think universally the patients are happy. The extra skin is gone. The satisfaction is largely patient-derived where the abdomen is closed. There's not a lot of positive reinforcement from other people because other people aren't seeing it.

But the patient himself or herself just feels much better. Their confidence increases. They find clothing will fit differently. They can buy clothing more easily because they're more a standard size. And if exercise is an option, that extra skin, extra fat is not there, and just normal everyday moving around is easier and exercise is easier.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Dr. Michelle Tarbox. I'm an Associate Professor of Dermatology and Dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, everybody. This is Dr. Luke Johnson. I'm with the University of Utah, where I am a Pediatric Dermatologist and a General Dermatologist as well. And we hope that you guys like us, warts and all.

Dr. Tarbox: Beautiful segue, Luke. So today we're going to talk about warts. So Luke, what are warts?

Dr. Johnson: Warts are annoying little bumps on your skin. They are caused by a virus. They are specifically caused by the human papillomavirus, or HPV. Now, if that sounds scary, it's because there are occasional types of HPV that can be associated with certain types of cancer, specifically types of genital cancer like cervical cancer. But even your random common wart that you might get on your foot from walking around on the pool deck this summer is caused by a strain of this HPV virus. There's a whole bunch of different strains, like dozens, if not hundreds.

Dr. Tarbox: And warts really are defined by being a small, hard, benign growth on the skin that is caused by a virus, and that viral cause is very important to the behavior as well as their transmission. If I was going to biologically engineer a way to transmit warts, Luke, do you know what I would design?

Dr. Johnson: A pool deck.

Dr. Tarbox: A pool deck. A pool deck has a rough surface that is often wet, and so it can abrade the skin where the wart exists, and then it can create a new abrasion on non-infected moist skin and cause a new infection.

The easiest way to transmit wart virus is to and from wet skin, so pool deck is sort of the perfect storm. And this is why I'm a strong advocate for water shoes for anyone using a public pool facility of any type.

Dr. Johnson: I don't fight with my kids about water shoes, but I do rub hand sanitizer on their feet afterward. I call it foot sanitizer.

Dr. Tarbox: Awesome. So as you were saying, there are lots of different strains of the virus that cause warts. What kind of warts are there, Luke?

Dr. Johnson: Warts are kind of defined by where they tend to show up on the body. So there's just the common wart, which is some random wart you might get on your hand or elsewhere. The bottom of the foot in medicine is called the plantar surface. That's the plantar foot. So if you get a wart there, it is by definition a plantar wart.

Dr. Tarbox: So not Planters nuts, but plantar warts.

Dr. Johnson: Right. So it's not really plantar's warts. It's a plantar wart because it shows up . . . Just like if you got a wart on your palm, it would be a palmar wart. So you get a plantar wart. And they do tend to be caused by different strains of HPV than common warts. We mentioned genital warts and then there's a particular type of wart that's flatter and smaller than other warts. It's just called a flat wart. Again, caused by a different strain.

Dr. Tarbox: And that one likes to affect the face and the back of the hands in women and children most of the time. It can also be very difficult when you get flat warts on the legs, especially for people who shave their legs, because if you shave over a flat wart, you just keep re-inoculating more flat warts everywhere that that little blade scrapes the skin. And remember that you're usually shaving with wet skin, which, again, wet skin is one of the better ways to transmit the wart virus. Of course, the virus has to be there.

So that is one way that that can get spread. What other ways do you get the wart, Luke, in general?

Dr. Johnson: As you mentioned, the little wart viral particles have to get down into the base layer of the skin. So the skin has a lot of different layers. And if you're a dermatology nerd like we are, then the wart has to get down to what we call the basal layer of the keratinocytes, which are the skin cells, in order to create infection. The wart virus can only create an actual wart if there's a little bit of damage to the skin, because the wart virus has to get down into there.

Sometimes it's damage we don't even know exists. Microabrasions we call them, which you might get from walking around barefoot on a pool deck, for example. But people can spread them around by shaving. It is a pretty common way to spread them to other parts of yourself. Or if you're scratching at a wart and get some wart virus on your fingernail, and then scratch another part of your body and cause a little bit of damage, that's a way to get them too.

Anywhere where there's wart virus, if you've got a little tiny open part of skin and those two come in contact with each other, you can develop a wart. So you might get them from somebody else with warts. You might get them from just, again, floors and things, showers, if you're walking around barefoot. You can get them from doorknobs, just anywhere where other people with warts have been and have left viral particles lying around.

Dr. Tarbox: And you can even give them from yourself from one part of your body to another part of your body. We call that autoinoculation when that happens, and one of the more common places that I see that occurring on is when patients, often younger patients, have warts on their fingers. They'll tend to bite them, and that biting of the wart can actually transmit the wart virus from the finger to the lips. So then you have a lip wart and a finger wart, which is not an ideal circumstance.

Dr. Johnson: So what if you have a little bump on your skin? How can you tell it's a wart? Well, you could bring it to a dermatologist. But then how do they tell it's a wart? Well, there are a couple of different things we look for.

Dr. Tarbox: Usually, what we're looking for is a disruption of skin lines. So on the parts of our body where we commonly get warts, the fingers and the toes, we have the lines that make our fingerprints. We call those dermatoglyphics. And our dermatoglyphics actually get disrupted when a wart is present. That's one of the ways that dermatologists can interpret that they're there.

Another change you might see are these thrombosed capillaries. This is one of the reasons some people refer to warts as a seed wart, because they can actually see these little black dots in the wart.

And some people interpret those as seeds, but what they actually are, are little blood vessels that the wart virus has actually told to give the wart itself more blood supply so it can grow faster. And so those little blood vessels get thrombosed. They make little tiny clots, not dangerous ones at all, but you can see them on the surface of the wart. And it can give it little black speckles, which is why some people call them seed warts. There aren't seeds that spread them, though. They're actually dead skin cells that carry the virus that are then picked up by another person.

Dr. Johnson: And even parts of your body that aren't the fingerprint-y parts, they're not your bottoms of your hand or the bottoms of your feet, you can still see little tiny skin lines there, especially if you look closely with a magnifying glass or something. So if you do have a little bump there, then you look real close and it interrupts those skin lines and it has some little black dots in it, good chance it's a wart. But there are a lot of things that kind of look like warts that aren't.

Dr. Tarbox: Yeah, absolutely. One of the most common things is actually the most common tumor, benign or malignant, that human beings make both by number and by weight. Somebody actually did those calculations. But these are things called the seborrheic keratosis.

Many people will refer to seborrheic keratoses as warts. Some people will call them liver spots. Some people will call them barnacles. These are the crusty, kind of waxy, stuck-on-looking growths that a lot of people will have in their adulthood and then more prominent as you go along in life. So your oldest relative might have the most of these in your family, but all adults usually get at least some.

Seborrheic keratoses are not contagious at all. They're not transmissible from one person to another. Trust me, we've checked a lot. So dermatologists and our ilk have been researching the cause of seborrheic keratosis for very long time, and what actually causes them is a typo. So when your skin cells are repairing themselves, sometimes they make a little mistake, just like when we're typing and we type T-E-H when we mean to type the T-H-E.

But it's a benign mistake, right? T-H-E and T-E-H aren't that different. People can figure out what you mean. It's not like you typed "murder" and you meant to type "mother." So it's a benign mutation that causes the seborrheic keratosis.

What are other growths that can look like a wart, Luke?

Dr. Johnson: Actinic keratoses are also very common, especially in adulthood. They're caused by the sun. So because of that, they usually show up on areas that are exposed to the sun, like the face or the bald scalp. They're small, rough, scaly, kind of gritty feeling papules. Papules is the medical term for a bump, by the way.

And they have a really tiny chance of transforming into a very mild type of skin cancer. So if you think you have some, don't worry. It's probably fine. But these are the things dermatologists like to freeze. So if you've ever been to a dermatologist and they have frozen spots on your face, it's probably these little actinic keratoses. They're not warts, but they could kind of look like warts.

Dr. Tarbox: Also, sometimes skin cancer can look like a wart or act in a warty way, which is the reason why it would be important to get a dermatologist to look at these spots on your skin.

Skin cancers are more likely to be solitary, so you're usually going to have multiple same-looking skin cancer in a localized area. Although with severe sun damage, that is possible.

Skin cancer often is a little bit more tender. It often is a little bit larger than a typical wart. It might be more red because the immune system is like, "There's something wrong with this thing. I'm going to make some inflammation about it." And it might even become ulcerated. So if you have a growth that's behaving in any of those worrisome ways, you definitely want to see a physician.

Dr. Johnson: And the skin cancers usually have more substance to them as well. You can kind of feel like there's more oomph there, especially under the skin.

And then there are a few other more uncommon things that can look like warts, but are not. So if you're wondering if something is a wart or not, it might be worth bringing it to a dermatologist, especially if you've tried to do something about it and it hasn't gotten better.

Dr. Tarbox: So do we have to treat warts?

Dr. Johnson: No. They're not dangerous. They don't threaten people's medical health, generally. I mentioned earlier that there are some rare high-risk types that can be associated with cancer, but sort of a random spot on the back of the hand . . . For example, I've had plenty of patients who have been like, "This wart has been there for 15 years," and I'm like, "It can be there for 15 more. It doesn't really matter."

If you're a kid, though, good news for you. Your warts will eventually go away in all likelihood, but it takes a long time. After five years, 80% of the warts in a child are gone, which means that one in five warts are still there after five years. But still, warts in kids eventually go away on their own. Not so much in adults.

And then these high-risk types should be treated. Not all genital warts are caused by the high-risk types, but the high-risk types tend to show up in that area, the genital area, the anal area, and sometimes elsewhere, and especially in people whose immune systems aren't working right.

So there are people out there in the world who have particular diseases that impact their immune system, or they have to take medications that impact their immune system for various reasons. And because the immune system is not working right, it can't fight off the warts as much, and so then they get worse warts that can do worse things.

Dr. Tarbox: There are also some areas of the body that can get infected by what we call the carcinogenic types or the oncogenic types of the human papillomavirus, the ones that we have a vaccine for. Some of those areas of the skin that can also get infected with those genital types of the human papillomavirus are the areas actually right underneath and around the nail itself. So sometimes those are a higher-risk type of the human papillomavirus.

But the great news is that there is a very effective and safe vaccine against these high-risk types of human papillomavirus, which also participate in the generation of head and neck squamous cell carcinoma. And those vaccines, of course, are the Gardasil vaccine, which is available and had broadened recently its age restriction. So this is something that's generally available to the public, and it's been found to be very safe and effective.

Dr. Johnson: Yes, the HPV vaccine, and the brand name is Gardasil, in the U.S. is approved for people aged 9 to 45 of both genders. If you want it, and you haven't had it yet, good news, you can just go up to the pharmacy and get it. You don't need to get it from a doctor. You don't need a prescription. This is what I did. I just walked up to the pharmacy at the hospital and said, "I would like the HPV vaccine."

And it's intended to prevent genital warts and cervical cancer. And how awesome is it that we have a vaccine that can prevent cancer? Very awesome. But there's some data that says it can help prevent just common warts as well. So I think just about everybody should get it. And the reason I got it, even though I was 40 and monogamous, is because I deal with a lot of warts in clinic and I don't want to get more warts.

Dr. Tarbox: I have also had the vaccine because I am a dermatologist, and in my daily work, I encounter many, many patients that might have human papillomavirus. And we also, in our work, sometimes do surgery that involves a tool called cautery. Cautery makes a little smoke plume. And there's some evidence there might be some viral particles in there, so they recommend we, as surgeons, protect ourselves against that.

In general, when I want to look for what I should do in a certain circumstance, I look at what the experts in that field do for themselves. So when I want to pick a great shampoo, I asked my hairstylist, "What shampoo do you use?" When I want to get the right kind of toothpaste so that I can re-mineralize my beautiful dental enamel, I asked my dentist, "What toothpaste do you use?" So if you want to listen to the dermatologist, most of us have the Gardasil vaccine on board because of the prevalence of the human papillomavirus and its ability to cause skin cancer.

So we generally recommend that for most patients, and we do find it to be highly safe and effective.

Of course, we have no conflict of interest with that. This is something we have used our normal healthcare access for.

So how else do we make warts go away? Prevention is always best, but how do we get rid of them if we've already got them?

Dr. Johnson: Oh, warts are super annoying. There are lots of ways to treat them, and none of them is considered the best. Though, in general, warts take multiple treatments before they eventually go away. So I usually say whatever we do to a wart, we have to do it over and over and over again for three to five months before the wart finally goes away. So that's the kind of path you're looking at. They tend to be successful, but it's a long road.

Certainly, there's stuff you can do that's over the counter. So most of the over-the-counter products contain salicylic acid. It generally comes from 17% to 40%. Higher is generally better, in my opinion.

But some of the stronger ones like the 40% salicylic acids have a warning on them about diabetes. They say if you're diabetic, you shouldn't use this one. And I think the reason is because if you put them on the feet, people with diabetes sometimes have problems with sensations on their feet and they can end up getting wounds on their feet, which can then become infected.

So if you happen to be one of those people, I would watch out for the 40% on the feet, but otherwise, I do like the 40%, in general.

Some of the specific brands . . . And again, we have no conflict of interest. Compound W makes various different strengths. Mediplast and WartStick are also some pretty decent options. WartStick is kind of fun. It looks like a stick of Chapstick. Do not accidentally use it for Chapstick, you will not be happy, but put it on your warts.

Dr. Tarbox: I think that these kind of destructive ways are very helpful. Other things that you can use, duct tape sometimes helps by causing a little bit of irritation. I tell my patients that our immune system sort of generally ignores the human papillomavirus, because if it's dangerous to you, it takes a long time to get there. So, in general, the humor papillomavirus acts so slowly that our immune system sort of ignores it.

And sometimes we have to get our immune system's attention to help get rid of the wart. So sometimes these irritational methods like the tape stripping or the sal acid are both destructive, but also bring the immune system to play in terms of getting rid of the wart.

Other things we do are things like counter-irritant therapy, where we put an irritating chemical on the wart. Sometimes we even use sort of the mugshot of a yeast organism our immune system really doesn't like as an injection under a wart to help the immune system target and destroy that virus.

Dr. Johnson: Those are things that dermatologists or potentially doctors or other healthcare providers could do for you in the office. I just want to talk a little bit more about the over-the-counter stuff in case anyone is at home and it's like, "Wait, how do I use this?"

So specifically, what I recommend is that at night, you put a little bit of Vaseline on the normal skin around the wart, because you don't need to damage the normal skin. You're just trying to get the wart. Then put the medicine on the wart, and then cover the whole thing with a big piece of duct tape or medical tape, just something to keep that medicine in place, and just do that every night.

And you can take the tape off in the morning if you want or you can just leave it on for 24 hours, but replace it every night. Do that over and over for three to five months, and the wart will be gone, if it's like most warts. The wart will get pretty gross, and white, and grody, and moist-looking. We call that being macerated. That means that it's working.

Dr. Tarbox: And if you need to, you can take some of the dead skin off with the disposable, and that is key, emery board. So those things that are basically cardboard and sand glued to it, you can file down the wart and then throw away that disposable emery board so you don't re-inoculate yourself with the wart virus. But that can help you to keep them thin.

Dr. Johnson: Of course, dermatologists love freezing things, so we like to freeze warts. The stuff we use is so cold that it kind of burns, so sometimes we say we burn them off. We're freezing them off.

There are over-the-counter freezing options too. They're wimpier than what we have in the office. Sometimes people get success with them, especially if the wart is kind of small or really thin. They can still be effective. We like to do that, but we have to do it over and over again, usually every month for three to five months, before the wart goes away.

You mentioned this yeast treatment. I like that treatment. It's called Candida antigen. And I think it's important that you mentioned that it's kind of like a mugshot. So we're not actually injecting yeast. It's a protein that kind of looks like the yeast that the immune system doesn't like.

There are other things we can do in the office. We can apply this stuff called Cantharidin, which causes a blistering reaction. Sometimes we're stuck using that on little kids who won't put up with a shot or won't put up with us freezing them. This medicine doesn't hurt when we put it on, but it causes the area to blister, and then we hope when the blister peels off it kind of takes the wart away with it.

We talked about the over-the-counter salicylic acids and stuff too. There are also prescription creams. I haven't seen any medical data that says the prescription creams work better than the over-the-counter creams, but they're more expensive. So I usually start with the over-the-counter stuff. And if that doesn't work, sometimes warts just need something else. So there's various prescription things we can try as well.

Dr. Tarbox: And really, the biggest thing about the wart virus is it's kind of everywhere. It's in the environment. It's easy to encounter it. Most of the time, our immune system deals with it well. If you have anything that's not behaving normally, it's a very large wart, it hurts, it bleeds on its own, it has other unusual symptoms, it's always best to get it checked out by a healthcare professional.

Dr. Johnson: And I know we talked about a few scary things today like cancer and immunosuppression, people whose immune systems aren't working right, but I'd like to emphasize in the vast majority of people, warts are not dangerous, especially in kids who are otherwise healthy. So you don't need to knock yourself out. But there are effective treatments, even if they're annoying and inconvenient to use.

Dr. Tarbox: Well, thank you so much for listening today to our lovely podcast, "Skincast." We have another podcast, Luke. Why don't you tell our listeners about it?

Dr. Johnson: Yeah, if you're a dermatology nerd like we are, then you might want to check out our other podcast, "Dermasphere." It's really intended for other dermatology providers, but we would love to have you there, whether or not you're a dermatology provider. We talk about some of the latest research in dermatology.

And of course, we want to say thank you to the University of Utah for supporting this podcast, and thanks to Texas Tech for lending us Michelle. We'll see you guys next time.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. I'm Dr. Michelle Tarbox, a dermatologist and dermatopathologist at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, everybody. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah in Salt Lake City.

Dr. Tarbox: So today we're going to talk about something you hopefully don't run into personally, poison ivy.

Dr. Johnson: That's right. Poison Ivy is the alter ego taken by Dr. Pamela Lillian Isley, an eco terrorist and prominent enemy of Batman who first appeared in Batman #181. Just kidding. This is a dermatology podcast, so we're going to talk about the plant.

Dr. Tarbox: But great nerd culture. I'm proud of you.

Dr. Johnson: Thanks. So the rash that you get from poison ivy is technically allergic contact dermatitis, or ACD. You can get allergic contact dermatitis to all kinds of stuff. Think of something, you can get allergic contact dermatitis to that thing. But today, we're just going to talk about the plant types of allergic contact dermatitis: poison ivy, poison oak, and poison sumac.

Dr. Tarbox: So the poison plants all have the ability to produce a significant rash in humans upon contact. The first one we're talking about, of course, is poison ivy, because it's sort of the leader of the pack, if you will, of the itchy gang.

So Toxicodendron is its actual name. It's such a nasty plant it has toxic right there in the title. This plant is found everywhere in the United States, except for Alaska and Hawaii. Even in places where it was less common, it's starting to have territory expansions.

And it can really be just about anywhere, because it sometimes gets accidentally shipped with nursery plants around the base of a tree or shrub that's taken from one part of the country to be grown in another part of the country. So you can actually run into it pretty well in most places. Do they have it in Utah, Luke?

Dr. Johnson: They do. It shows up just about everywhere in Utah. How about in Texas?

Dr. Tarbox: Not as much in the part where I live because it's very dry and that plant likes a lot of moisture. But when we have our wet years, we end up with some expansions of the growth of those things out from around the bases of the nursery plants. And it's out in the countryside most places in the country.

Dr. Johnson: "Leaves of three, let it be." That's the saying, because this plant has what they call compound leaves with three leaflets. So a little plant stem will actually have three little leaves coming out of it, and the middle leaf is kind of longer than the others.

When I was learning dermatology, I remember complaining that, "Man, I'm already a doctor, and now they want me to be a botanist? And I'm also supposed to learn about bugs and be an entomologist and all that stuff?"

There are pictures of these plants. We can talk about what they look like. The edges of the leaves can be smooth or toothed. The surface can be glossy or dull. But I discovered that there are now apps that can identify plants. So instead of trying to memorize pictures or torturing our dermatology residents, we should probably just use these apps.

So some that I found are PlantSnap, Leafsnap, and Planta. So if you're going to go out hiking or camping, especially if it's somewhere kind of new for you, you might want to download one of those apps first and make sure that your children aren't tromping around at a big poison ivy patch.

Dr. Tarbox: I like that plan. One of the things that we kind of can unify with these plants is that they all have an oil that they make that is the problem child, the thing that causes the rash. And so that makes the rashes look a little kind of shiny or glossy, a lot of the time but not all of the time.

Dr. Johnson: They only produce this stuff at certain times of the year, certain seasons, or when the plants are doing whatever plant things they do. But sometimes these little black dots show up and that's the urushiol.

Poison oak and poison sumac also exist and are kind of similar. Poison oak is found in western North America and the Southeastern US. It's not a tree, despite the fact that oak is in the name. That was surprising to me. It's more like a shrub or a vine. And it kind of similarly to poison ivy has the three leaflets, and in the spring it has white flowers. So if you find something in the spring that has red flowers, you're probably good.

Dr. Tarbox: Yeah, white flowers, that could be a problem. Could you imagine if somebody made a bouquet out of those and then just . . .? Their poor little hands.

Poison sumac is also a thing. Less common. It is a shrub or a small tree up to about 30 feet and it tends to grow in wooded swampy areas like Florida in the southeastern portion of the United States. It's also present in wet, wooded areas in the Northern United States. So you and I probably don't have a lot of sumac in our areas, Luke.

Dr. Johnson: I don't think so. So they're easy to avoid, which is what you should do for all of these if you can. Just don't come into contact with them. Stay in your house, play video games, everybody will be fine. Well, probably not. Actually, there are some dermatologic conditions that can be associated with excessive video game playing.

So if you do come into contact with a plant, well, you want to wash the affected area. Not necessarily with just normal soap either. You want to use laundry soap, dish detergent, rubbing alcohol, and rinse. You want to get that plant juices out of anywhere that it could have gone, so rinse onto your nails. And remember, it could have gotten on your clothes, so carefully remove your clothes, perhaps with gloves or something, and put them in the wash.

Dr. Tarbox: And you want to wash your whole body surface because we may touch parts of our body with our hands that made contact with oil and transfer it. So one almost emergency situation that more commonly affects men is when they have contact with the plant and then maybe they go to the bathroom. And you can imagine that the severe allergic contact dermatitis on that part of your body might be significantly uncomfortable.

There are products that are made specifically to help you to remove the oil that causes the rash. One of the most common ones you can find is called Ivy Block. Again, we have no relationship with any commercial product. We just like people to be able to find the product in the stores.

So the active ingredient in Ivy Block is something called bentoquatam, and it tends to protect the skin like a shield against the poison ivy, poison sumac, poison oak by kind of blocking skin contact with their resin. They also make a soap that can help you to rinse off the oil very well.

Any of these preventative products, of course, you wouldn't want to get in your eyes. You obviously don't want to get poison ivy residue in your eyes either.

And one very important thing is to not try to go all vengeance on the plant and burn it. I've had several patients who actually, after they determined what had caused their rash was poison ivy, then sort of in retribution ripped the plant out of the ground and burned it. The problem is if you burn it, then you aerosolize the oil and you can actually give yourself a chemical pneumonitis. You can give yourself poison ivy in your lungs if you burn this stuff, so you should never burn it.

If you think you've been exposed to airborne, poison ivy resin from burning that kind of thing, you may need to seek medical care. So do not burn anything you think is poison ivy.

Dr. Johnson: "Leaves of three, let it be." Do not incinerate.

Dr. Tarbox: Now what about the rash, Luke? Does everyone who touches poison ivy get a rash?

Dr. Johnson: Interestingly, no. Maybe only about half of people seem to actually get this allergic contact dermatitis to poison ivy. And like other allergies, if you've already been exposed in the past, that means your immune system is extra ticked off if it sees it again. So if you've had a poison ivy rash in the past, and you get exposed to poison ivy again, you'll probably get a rash within a few hours of touching the plant.

However, if you've never seen poison ivy before . . . well, if you have not ever touched poison ivy before, and you end up touching it, then the rash might take a couple of weeks to show up. So remember how you were hiking in the woods two weeks ago? Do you have a rash now? Maybe it was poison ivy.

And it occurs where the leaves brush against the skin. So sometimes dermatologists refer to something looking like an "outside job." So if we're having an immune reaction within our body against something that's going on in our body, not a reaction to something outside our body, it usually doesn't show up as nice lines or swirls or curves and things like that. So if it looks like someplace where a leaf may have brushed and left a rash there, well, it could have been something like this.

Dr. Tarbox: So what do you say we should do if patients get this? How do we take care of it?

Dr. Johnson: Well, if it's not too bad, you can just treat it with over-the-counter stuff like soothing lotions and things and mild steroid creams and steroid ointments like hydrocortisone. A dermatologist or another doctor can prescribe you stronger medicines if necessary.

For really bad poison ivy, especially these people who burn poison ivy, we can sometimes even do steroids by mouth to help get over the reaction because it can be really, really horrible and it can last two or three weeks.

Dr. Tarbox: It can be quite awful. So the really best thing to do is just avoid it. If you, of course, know what the plant looks like, that helps. I encourage people to kind of refresh their memory about what these plants look like before they go on a hiking or camping trip.

You can also wear clothing that will protect the skin from both the sun and from the brush of those leaves. So a lot of sun-protective clothing with long sleeves or long pant legs can be preventative in terms of preventing skin contact. And then you can wear the Ivy Block when you're out and about in areas where the plant might live.

Dr. Johnson: The rash can blister, by the way. So if you see that you've got a blistering rash, it still could be poison ivy.

That's most of the poison ivy/oak/sumac stuff I wanted to talk about. I want to talk about Mr. Freeze next.

Dr. Tarbox: Okay.

Dr. Johnson: Thanks. Was waiting for that.

You can get allergic contact dermatitis to other types of plants as well. Compositae is a super common type of plant that causes allergic contact dermatitis. It doesn't cause it in nearly as many people as poison ivy does, which I guess is why it's not called poison sunflowers. They're just called sunflowers. But there are all kinds of plants in this family, sunflowers and things that kind of look like sunflowers with that kind of circle/radiate/Starburst appearance. It's a common thing we see in dermatology. Tulips can do it too.

Dr. Tarbox: Alstroemeria.

Dr. Johnson: What's that?

Dr. Tarbox: Alstroemeria. So there's a kind of Peruvian Lily that is used very frequently in floral bouquets because it's a hardy plant, and it lasts for a long time and has really beautiful blooms. So the Peruvian Lily or Alstroemeria can also cause contact dermatitis.

Dr. Johnson: So we like plants, but they might not always be your friends. In addition to allergic contact dermatitis, there's also irritant contact dermatitis. So the difference is that to have allergic contact dermatitis, your particular immune system has to be angry for some reason, whereas in irritant contact dermatitis you're coming into contact with something that is just irritating to human skin. A chemical burn is a good example of an irritant contact dermatitis.

And some plants can do it too, including plants that we eat, like garlic. So sometimes especially people who prepare a lot of food with these plants can start to get irritation of their fingertips, for example.

And also, there's this funny condition that some plants can cause called phytophotodermatitis. It's one of my favorites. There are particular plants that have a chemical in their juices and when the juice gets on the skin and then sunlight shines on the juice, you get this big reaction and it can kind of look almost similar to poison ivy. And its significant forms can be this itchy blistery rash. That calms down pretty quickly, but then you're left with this pink-brown discoloration that can last for like two years.

So common plants that can do that are citrus plants like limes. So some people refer to margarita hands. If you were on vacation in Mexico smashing limes for margaritas, you were probably hanging out in the sun too and bam, margarita hands.

There are also different weeds and things, like hogweed, that can do it. So sometimes we'll see this in people who are doing yard work or something.

Dr. Tarbox: And there are also plants that cross-react with a person's allergy to poison ivy. So for some people, it'll be mango peel. If you have a significant poison ivy response, then making significant contact with the peel of a mango fruit can potentially cause you allergic contact dermatitis.

So if you're one of those people who likes to get every last bit of mango out of the mango slice, and your skin is coming in contact with that mango peel, if you've had a reaction to poison ivy in the past, you may get a rash from that. So it's probably safer to just cut the peel off.

Patients can also react to ginkgo leaves or potentially cashew plants if they've reacted previously to poison ivy.

Dr. Johnson: That's all for today. Thanks for hanging out with us, guys. And thanks to our institutions. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle.

If you like to nerd out about dermatology, you might be interested in our other podcast as well. It's called "Dermasphere." We say it is the podcast by dermatologists for dermatologists and for the dermatologically curious. We talk about dermatosis you can get from video game playing, for example. And I think we've even talked about Super Villains at one point, like they're depicted as having less hair than heroes. So we talk about some fun stuff. You can find that in Apple Podcasts or wherever you get your podcasts.

"Skincast" episodes you can also find on Apple Podcasts or wherever you get your podcasts, and, in two weeks, right in your earbuds. We'll see you then.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in.

I'm Dr. Michelle Tarbox, a dermatologist and dermatopathologist at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey Hello, everybody. This is Dr. Luke Johnson. I am a pediatric dermatologist and general dermatologist with the University of Utah in Salt Lake City.

Dr. Tarbox: So what are we going to talk about today, Luke?

Dr. Johnson: Hey Today, we're going to talk about alopecia areata. This is a condition that affects 1% to 3% of the population, so it's fairly common. So again, that means if you just grabbed 100 random people off the surface of the earth, 1 to 3 of them would have alopecia areata.

And alopecia areata shows up as bald spots. Usually they're little circles. Usually they're on the scalp, though people with alopecia areata can also lose hair elsewhere on their body.

Dr. Tarbox: And there are some celebrities that have it, right, Luke?

Dr. Johnson: Hey Yes. As you might guess, since 1% to 3% of people have it, there are some celebrities who have it. One of them recently brought the condition into public viewing, front and center, Jada Pinkett Smith. I don't pay too much attention to this stuff, but I was told that there was slapping of movie stars at the Oscars and it was a big deal. I've heard the term Slapgate, I think.

But apparently, Jada Pinkett Smith has the condition. So do Tyra Banks, Selma Blair, Christopher Reeve, and an actor named Matt Lucas. I'm a big nerd, so I know that Matt Lucas was in "Doctor Who," and I also saw him in "The Great British Baking Show" when I was walking past my wife while she was watching "The Great British Baking Show."

Dr. Tarbox: Yeah. And I think that Slapgate somewhat, as some people are calling it, emphasizes the emotional nature of hair loss. So hair loss can be a condition that has a significant psychological impact on the patient, and something, especially for female patients but also for male patients, that sometimes causes quite a lot of anxiety or potentially depression, sometimes avoiding social interaction because they don't want to have to explain.

Dr. Johnson: Hey Alopecia, by the way, is just the medical term for hair loss, and alopecia areata is this particular type of hair loss. There are lots of other reasons for people to lose their hair. Androgenetic alopecia, for example, is the medical term for just male-pattern hair loss or female-pattern hair loss.

But all hair loss is pretty crummy. People like their hair. I like my hair. I hope it doesn't fall out. But if you notice that you or your child have started to get circular bald spots, there's a pretty good chance it's alopecia areata because there's not a lot of other stuff that looks exactly like that.

Dr. Tarbox: And that last name of the condition, the areata part of alopecia areata, comes from a Latin term meaning area and referring to the vacantness of it, so an empty space. And so while other kinds of alopecia lead to generalized thinning sometimes, a completely hairless patch is less common, disregarding the kind of large central patch that might happen in advanced androgenetic alopecia. So a completely hairless patch anywhere on the scalp might be this condition.

Dr. Johnson: Hey It's an autoimmune disease. It's caused by the immune system attacking the hair follicles. Why does somebody's immune system decide to attack their hair follicles but somebody else's doesn't? We don't really know. Kind of like some other conditions we've discussed like vitiligo. We assume there's a genetic predisposition, so something about somebody's genes puts them at risk for it. And then something kind of triggers to make those genes become active, and then the immune system is off to the races.

Dr. Tarbox: And those triggers can be variable. The most common one that patients express is stress-related. Often, you'll see this condition arise maybe in a child whose family is moving or whose parents are going through a divorce. You may see it in young patients who are going through college entrance exams, but it can also just occur all by itself.

Dr. Johnson: Hey And whenever we talk about stress making things worse, I like to emphasize that it's not your fault that you're so stressed, and because you're not dealing with your stress appropriately, that's why your hair is falling out, because that's nonsense. Everybody has got stress and sometimes these genes just play tricks on us.

Good news is that there are treatments for it, if you want to treat it. Like we talked about with vitiligo, there are some people who could be really, really bothered by the appearance of their hair not being there. And then there are some people who just don't care and live their life kind of ignoring it. And there are some people who kind of like the way that it looks and wear it loud and proud.

So that's one reason I think it's kind of helpful to talk about these celebrities because some of them, like Matt Lucas, seem to wear it loud and proud and serve as advocates for patients who have the condition.

Dr. Tarbox: Yeah. But there are lots of treatments for it. So some of the things that we usually start with are topical steroids. These medications are relatively easy to use, relatively simple to obtain most of the time, and are relatively predictable in how they're going to behave on the skin.

Often, we'll either use a liquid solution or a gel. The scalp has got hair on it, so putting a cream on that ends up with kind of a lot of crusty cream mess on your hair and people tend not to like that.

In patients who have a more coiled hair structure, sometimes we'll use an ointment base because the moisturizing nature of that might help prevent hair breakage that an alcohol-based solution might exacerbate.

Dr. Johnson: Hey Good news is that whether we treat it or not, the odds are that the hair will recover. Unlike some other conditions that we've discussed, this one usually kind of just gets better on its own in the majority of cases. Probably at least two-thirds of cases, if we do nothing, in a year the hair will all be back to where it was before the condition began.

So this is what I tell patients and their parents. I say, "We do have some medicines that we can use that can probably help the hair come back faster, but if you're like most people with the condition, it's going to come back whether we do anything or not."

Of course, if you look up the condition on the internet, you'll find the dramatic situations where that was not the case, but in most people, it comes back on its own. So that's another reason why treatment might not be necessary.

Dr. Tarbox: But if you do have a condition that is getting worse or not improving, there are a lot of options. So we start with the topicals. If those are not working and the patient is amenable and capable of tolerating it, we sometimes will do intralesional-injected steroids, meaning we take a syringe that has the medicine inside it and we actually inject the medicine directly into the patch of hair loss. This is sterile medicine that's intended for injection, so this should only be done in a physician's office who has experience with the treatment, but it can be very effective.

Dr. Johnson: Hey If you've listened to other episodes of "Skincast," you probably have heard us talking about immunosuppressant medications. So these are fancy medicines that you take by mouth or even that you get injected, which turn down the immune system overall. They have names like methotrexate and cyclosporine and mycophenolate and azathioprine.

We can use them in dermatology when the immune system is rudely being overactive in particular parts of the skin. But as we have mentioned before, they have significant side effects, as you might guess, since they have such an effect on the entire body, so we prefer not to use them. That said, most people who take them don't really have any significant side effects and it can be really helpful to help stop hair loss in this condition.

Dr. Tarbox: Other things that can potentially be useful? There are some specialized treatments that are also used in physician offices, including platelet-rich plasma where blood is actually taken from the patient, centrifuged, and then the platelet-rich fraction of that is re-injected into the area of hair loss.

Red light therapy has also been beneficial for some patients. Not every red light device is equal. You actually do want something that has near-infrared wavelengths. So the most effective ones that are available over-the-counter to the lay populace is the Theradome, the Hairmax laser comb, and some versions of the iRestore. So those are different red-light-emitting devices that can be helpful for hair loss of all kinds and also for alopecia areata.

Counter-irritants is another thing that might be done in a physician's office where they may apply a little sensitizing agent to part of the skin and then use a lower concentration of that to elicit a very low-level contact dermatitis, which sort of switches the type of inflammation that's happening in that skin away from the kind that's attacking the hair follicles to the kind that makes a dermatitis. And so you sort of trade one problem that's a more problematic issue for a slightly less troublesome problem that's easier to treat.

And then there's a special kind of laser-like device that's called a laser but it's not really a laser. It's called the excimer laser. And it has a UV wavelength that can be used with the targeted hand piece to help treat patients who have these patches of hair loss.

What are some other medications that are coming up, Luke?

Dr. Johnson: Hey There are some new medications in therapeutic trials for this condition. There is a type of medicine called a JAK inhibitor, which shows a lot of promise even for people who've had alopecia for a long time.

So kind of like we discussed with vitiligo, the longer the hair loss is present, the harder it is to regrow the hair. But some patients who have had hair loss for even 10 years or more, again this particular type of hair loss, alopecia areata, have regrown their hair with these medicines. And they look pretty safe. So they're not FDA approved yet, but my guess is that they will be in the next one to two years.

Of course, some people who have more extensive hair loss, as you might guess, prefer to disguise or camouflage the areas of hair loss with hairpieces and extensions and things like that.

Dr. Tarbox: And most of the time with the camouflaging agents, those are going to be something that you clip into the hair or put on top of the hair. There are camouflage powders such as XFusion or Viviscal fibers or something called Toppik. Those work well for most types of alopecia.

If you have a completely hairless patch, though, they won't work because the way they work is to attach themselves through an electrostatic charge to hair shafts. And if you don't have any hair shafts in that area, there's nothing for that kind of sprinkle powder to attach to. So it might have to be more of a scalp applied dye or a hairpiece.

Dr. Johnson: Hey But look at all the medications that are available. So if you or somebody you know has alopecia areata, and you want to treat it, then you should probably see a doctor, perhaps a dermatologist, because there are lots of treatments we can use.

Dr. Tarbox: Is there anything else that people who have alopecia areata need to worry about, Luke?

Dr. Johnson: Hey Well, like with other autoimmune diseases, if you've got one, then there's a chance you might have another. Most people who have alopecia areata do not have other immune diseases. But if they do, the most common one is thyroid. So perhaps your doctor would want to check a little bit of lab work, especially if you have other symptoms of thyroid disease.

And like other autoimmune diseases, we can't change your genes yet. I guess CRISPR-Cas9 might be coming. But for now, if your hair does come back, which again is the norm, it might come out again. So a common story is little 6-year-old kid develops alopecia areata during a move, hair comes back just fine, and then that same kid becomes a college student and again loses patches of hair while studying for finals. It might happen.

Dr. Tarbox: One thing I want to emphasize is that sudden patchy hair loss is pretty much never normal. So it should probably be seen by a physician, because there are also other conditions that may cause patches of hair loss on the scalp.

There's something called alopecia neoplastica, which is actually a condition where some kind of cancer actually metastasizes to the skin of the scalp because of the specialized structure of some of the veins in that part of our body. And you can end up with a lumpy patch of alopecia. If you have a patch of hair loss that's got lumps underneath it, you need to see a doctor quickly because that could be something called alopecia neoplastica.

There are also certain infectious conditions that can cause patchy hair loss, including tinea capitis, which is basically ringworm on the scalp. So a fungal infection on the scalp can cause hair loss and should be treated with medical attention.

And then hopefully not too commonly, but syphilis can also cause some patchy hair loss on the scalp and is a condition you would definitely want to see a physician for if you had concern that might be something you had.

Dr. Johnson: Hey And I mentioned that most patients with alopecia areata, the hair just recovers on its own. Sadly, that is not the case for everybody. So perhaps a third or a bit less of patients will progress. So these are the patients you're likely to see if you Google alopecia areata image search. And there are individuals who then lose all the hair on their scalp, or even all the hair on their head including eyelashes and eyebrows, or even all of the hair on their body as well.

And when it's that extensive, it gets special names. So alopecia totalis is the name if you lose all the hair on your head and alopecia universalis if you lose all your body hair.

Again, some people are not bothered by it. It's not a medically dangerous condition. Some people choose to just go on "Great British Baking Show" as a host. But if you do notice that your hair or your child's hair is progressing to that degree and you want to do something about it, you want to see a doctor sooner rather than later so we can implement some of these therapies.

Dr. Tarbox: Well, I hope everybody has gotten to learn a whole lot about alopecia areata today. If you're really interested in alopecia areata, and you want to dive deeper, you might want to listen to our other podcast.

Dr. Johnson: Hey We talk about all kinds of stuff on this other podcast, including alopecia areata and a lot of different dermatologic diseases and treatments and things. It's called "Dermasphere." We say it is the podcast by dermatologists for dermatologists and for the dermatologically curious. So if you are a dermatology nerd, like we are, then you can come hang out with us there on Apple Podcasts or wherever you get your podcasts.

Dr. Tarbox: And of course, we also want to give our special thanks to our institutions.

Dr. Johnson: Hey Yes, thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us Michelle. You can find our "Skincast" archives on Apple Podcasts or wherever you are finding your podcasts. And you can find the next episode of "Skincast" hopefully in two weeks. We'll see you then.

Dr. Tarbox: Hello, and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox, and I'm an associate professor of dermatology and dermatopathology in beautiful, sunny Lubbock, Texas at Texas Tech University Health Sciences Center. And joining me is . . .

Dr. Johnson: Hey, this is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah in Salt Lake City.

Dr. Tarbox: Today, we're going to talk about a topic that can affect a certain number of patients. We're going to speak about vitiligo.

Dr. Johnson: Yes. We thought it might be a good idea to have a few episodes on some fairly common dermatologic diseases though most people still don't get these. But vitiligo affects about 1% of people, which means that if you pulled 100 random people and looked at them all, one of them would have this condition.

Dr. Tarbox: So it's actually relatively common in the general population. And if you personally don't have it, and there's nobody in your family that's experienced vitiligo, you probably know somebody in your friend circle that does. So it's something that is relatively common, and we have a lot of good information about it.

Dr. Johnson: So vitiligo is white spots showing up on the skin. And we'll talk a little bit more about it. Some people call it the Michael Jackson disease. Michael Jackson did indeed have this condition. There are other celebrities who have it as well, including Jon Hamm, the actor who played Don Draper in "Mad Men" and also does some funny stuff on "30 Rock" and so on, Rasheed Wallace, an NBA player, and Winnie Harlow, a model.

I like to talk about the celebrities who have some of these conditions because I think it just makes it a little bit more fun, and it shows that people who have these conditions can obviously still achieve great things. And also the celebrities have done a good job of bringing attention to the condition and have sometimes been good spokespeople for it.

Dr. Tarbox: Yeah. Winnie Harlow, especially, has been a great spokesperson and has embraced the unique beauty of her unique skin. I think recently there was also a Barbie doll released that had vitiligo. So I think that there's more general acceptance of the skin condition. But a lot of people want to know more about it and how to treat it if they would like.

Dr. Johnson: So in your skin, you have a bunch of different kinds of cells, like a surprising number of different kinds of cells. But the majority of them are probably keratinocytes, which are the cells that make up most of the skin that we can see from the outside. And then there are melanocytes in there, and the melanocytes are the pigment-producing cells. So they make little tiny balls of pigment called melanosomes, which they share with a bunch of different keratinocytes. And sort of the number and size and darkness of those melanosomes determines how dark your particular skin is. And also if you have a whole clump of those melanocytes together, you have a mole. And in vitiligo, your immune system attacks those melanocytes and gets rid of them, which is why you then get a pale white spot, which just has no pigment at all.

Dr. Tarbox: Now, a lot of patients want to know why this happens. And that's a great question. We don't 100% know the answer to that. We know that there are some genetics that can predispose patients to developing vitiligo. We know sometimes vitiligo will happen after intense sunburn or after a period of severe stress, but often it just comes up on its own. What do you find in your practice, Luke?

Dr. Johnson: Well, a lot of autoimmune diseases are like this, and we do consider vitiligo an autoimmune disease. So there's a certain amount that medical science understands. It's your immune system attacking a part of your body that it's not supposed to. But we don't understand why it happens. And the way I describe it to my patients is often, well, we think there's something about your genes that puts you at risk for it, and then something triggers those genes to become active. And we don't really know what that trigger is in any particular case. We like to blame viruses a lot, just like a normal viral cold or infection, potentially significant psychosocial stress or significant physical stress, like some other underlying medical condition or going through a surgery or something like that, potentially. All of those, we think can potentially trigger it.

And I think it's also important to know that even though there's a genetic component, it's common for only one person in a family to be affected. So sometimes, you know, I'll explain this, and patients will say, "Well, nobody in my family has this." And well, that's actually pretty common because it's probably, you know, 20 different genes plus some kind of triggering event that all create the perfect storm for vitiligo in a particular individual.

Dr. Tarbox: Very occasionally, certain specialized medicines can also cause vitiligo to arise. Those are typically medications that are prescribed by a physician to treat either a type of cancer or a different autoimmune condition, things like a topical medicine called imiquimod or some of the medicines that are newer injectable agents that people use for psoriasis, for example.

Dr. Johnson: And, Michelle, you mentioned that a sunburn could potentially trigger it. And we know that vitiligo expresses this phenomenon where it shows up at sites of injury. There's a special word for that in medical world. It's called koebnerization I think because Dr. Koebner must have described it well, probably back in the 1800s or something. So if people with vitiligo get, like, a big scratch on their leg or something, they might discover that that line becomes vitiliginous, as we say, it turns white. And so if you have vitiligo or know somebody who has it, then you want to watch out for injury if you can.

And also, you mentioned sunburn. So those areas of pale skin that have no pigment at all, as you might guess, they're extra susceptible to sunburn. And if they get sunburned, well, the surrounding area can then koebnerize and make the whole thing worse. So be careful about the sun to at least some degree.

Dr. Tarbox: And apparently, it was Heinrich Koebner who named up the Koebner phenomenon, if anyone was just dying to find that out.

Dr. Johnson: Not his brother Reginald Koebner.

Dr. Tarbox: Yes. Not Reginald Koebner, but Heinrich Koebner. In the 19th century, he named the phenomenon. And then I think that, you know, that koebnerization, that homing of this condition to sites of trauma explains to us why it likes to happen in some of the places where it likes to happen, like the tips of the fingers or on the knees, the skin in the groin where the clothing might rub, and then areas around the face that are touched a lot or move a lot, like the eyelids and the mouth.

Dr. Johnson: So one question might be how to treat it. I think it's important to know that this is not a medically dangerous condition. So there are some people who are very, very bothered by the appearance. And there are medical studies that can say it can significantly affect somebody's quality of life, and it should certainly be treated in those cases. There are other people who just don't care about it. And then there are other people who kind of like the way it looks, like perhaps Winnie Harlow, and they wear it loud and proud.

So treatment might not be necessary from a medical standpoint, depending on the individual's preference and that of their family, especially if they're a child. But the longer vitiligo sticks around untreated, the more likely it is to not respond to treatments in the future. So I find that I run into this with my, like, 5 and 6-year-old patients who just really don't care at all, and their family doesn't really care either because it doesn't bother the patient. But, if when that child is 14 or 15, they wish they had pigment, then everybody kind of wishes they had treated it 10 years prior. So I find that families often like to treat it for that reason.

Dr. Tarbox: Yeah. And this is a more complex thing to navigate. Now, I've actually run into this recently where I was taking care of a new patient that was a young teenager who had vitiligo, and she actually liked how unique it made her. And when we talked about it, we discussed the fact that, you know, treatment is a good idea. It's not often 100% successful. So she would likely still have some of her special, unique skin, but treating it so that most of her skin was still protected from the sun, especially here in beautiful, sunny Lubbock, Texas, was a good intermediate compromise we came to, and she felt comfortable with that. And we felt better about the fact that, you know, there was less likelihood of it hardening and becoming impossible to treat.

Dr. Johnson: For some reason, I find that a lot of people think that there is no effective treatment for vitiligo, even people in the medical community. And I'm not sure why that is. There are definitely effective treatments. One of the downsides, though, is that they take forever.

So I like to explain that treating vitiligo is a marathon, not a sprint. So if I start a patient on treatment for vitiligo, I have them come back in six months because that's about how long it takes to start noticing a difference. Hopefully, we can stop the disease process a lot faster than that, but to see repigmentation, it takes about that long.

And I think if you think about how the treatment works, that makes some sense. Most of our treatments for vitiligo work by telling the immune system to chill out, right? The immune system is overactive here. It's beating up the melanocytes. So if we use medicines that get the immune system to calm down, then around your hair follicles, you have these little stem cells and they could then stick their little heads up and look around. And if the coast is clear, they can turn into melanocytes and slowly crawl along the skin and then slowly grow a bunch of little tentacles and slowly then spread their new melanosomes to the keratinocytes and you can get repigmentation. But you can imagine how it takes them so long. I mean, their heads are so small, probably their legs are so small, they just have to crawl along. It takes forever.

Dr. Tarbox: Well, and the way that our skin repigments the location of those special stem cells is typically our hair follicles. So the areas of our body that have that greatest density of hair follicles, like our face, are more likely to repigment than areas that have fewer hair follicles or no hair follicles, like fingertips. So that's also something we discuss when we're treating patients.

Dr. Johnson: It also is something to think about for prognosis. So if somebody is hair is white in an area, it's harder to get the pigment to come back because, you know, even those hair pigment cells have been affected.

But specifically about treatment, a lot of times we'll use creams and ointments and things that you rub on the skin, like topical steroids, and, of course, dermatologists and other doctors are very familiar with these medicines and know how to use them safely. There are other topical medications as well that can work, again often by telling the immune system to calm down in a particular area, but not necessarily.

There's also a treatment called phototherapy. So I think we mentioned this before, when we've talked about some other conditions, but there is a particular wavelength of light that tells the immune system to calm down in the skin, and dermatologists have machines that produce that wavelength of light. So sort of the official way to do it is to go to a dermatologist's office and have this light shined on your skin. If you have just a small patch of vitiligo, you can use, you know, just a tiny little lamp to do it. But it's onerous. It's inconvenient. It takes about three times a week for at least, well, three to six months to see if you're getting better. Sunlight has that wavelength in it as well. But beware sunlight has a lot of other wavelengths that we are worried about, especially in vitiligo because it could sunburn the skin. So natural sunlight for 10 to 15 minutes a day is probably all right, but longer than that, you want to make sure you're careful.

Dr. Tarbox: And paying good attention to how the skin feels is a good idea. Most people who've experienced a sunburn know that you can kind of feel it when that's starting to happen. So if that's something that's occurring for you, it's a good idea to check in with your skin and protect it accordingly.

Dr. Johnson: In addition to putting medicine on your skin that tells your immune system to calm down in that area, a dermatologist or other doctor might treat vitiligo by giving you medicines by mouth, or through an injection even, that tell your immune system to just calm down everywhere on the body. As you might guess, those have a lot more potential side effects, but they're also more powerful. So we might have to use them for people with pretty extensive or rapidly progressing vitiligo.

Dr. Tarbox: And then there's other things that are kind of natural things to help support the repigmentation of the skin. One of my favorites in this category is a medicine based off of the plant, whose scientific name is polypodium leucotomos. It's fun. It sounds like a spell from Harry Potter, "Polypodium leucotomos, you are now protected from the sun." So this is actually a tropical fern that lives on the equator and has been used as a folk medicine by people who natively live in those areas for centuries to protect against sun-related illness. It's a very safe medication. It's actually so safe it's put into gummy drops for children to use. There are different manufacturers, call them Sundots or Sundailies. There's also a broadly available commercial product over-the-counter called Heliocare. We have no relationship with this company. We are not sponsored in any way. It's a good product, it's easy to find, and it doesn't have any meaningful drug interactions, and no side effects have been reported with this medication.

Dr. Johnson: There also is some medical data behind vitamin A, vitamin E, and alpha-lipoic acid for vitiligo. I think that, you know, adding the vitamins and the polypodium leucotomos, Harry Potter spell, are good things to do if you're also doing something else to treat your vitiligo. I think probably just the vitamins by themselves are not good enough to treat most people's vitiligo. So if you or somebody you know has it, your doctor might recommend those as well as some other kind of medication.

Dr. Tarbox: I totally agree. They're good supporting cast, but they're not the main characters.

Dr. Johnson: You might also want to camouflage your vitiligo, or somebody with vitiligo might want to just camouflage it, for example with makeup or something like it that is the color of their natural skin. There are a number of brands out there. Again, we're not sponsored. We just like to say names of things so you guys know what to look for. So there's one called Zanderm, for example, Z-A-N-D-E-R-M, which is basically this little marker that you just rub on your skin in the area. And unlike the markers that my children use in their coloring books, this one lasts for a longer time, probably a week or so, before washing off.

Dr. Tarbox: That's a great product. And I have a funny little anecdotal story. A different kid who had vitiligo, youngest teenager, similar age, got the Zanderm markers and figured out she could make patterns on her vitiligo. And it was kind of cool looking because she's not allowed to have a tattoo yet, she's only 12. So it's really cute that she kind of was coloring in her vitiligo with her Zanderm marker.

Dr. Johnson: That's fun. Her own canvas?

Dr. Tarbox: Mm-hmm.

Dr. Johnson: There are also some new medications coming out or that are currently in therapeutic trials that look very promising. So if you or somebody you know has vitiligo and especially if it's extensive and you've tried some stuff that hasn't worked and if you're starting to feel a little discouraged, these new medicines look pretty good. So they're not FDA approved right now, but I bet they will be in the next year or two. So there is hope.

Dr. Tarbox: So what else do people who have vitiligo have to worry about, Luke?

Dr. Johnson: Well, usually nothing, but if your immune system has decided to attack your melanocytes, it's possible that it might want to attack some other part of your body too. So rarely people with vitiligo have some other autoimmune diseases, most commonly thyroid. I want to emphasize that most people don't, but your doctor might want to check some lab work, especially if you have some other symptoms as well.

Dr. Tarbox: And then what other kinds of things do people have to worry about? Does this disease ever go away and then come back?

Dr. Johnson: Well, yes. So we talked about how your genes probably put you at risk, and you're going to keep your genes even if your treatment successfully repigments all your skin. So people who develop vitiligo unfortunately are kind of always at risk for developing it again or developing new spots. So be on the lookout. For my patients who, you know, we've pretty much repigmented them, I say, you know, "If you develop a new spot, please start treating it with the same medicines and let me know what's going on."

Dr. Tarbox: So I think that, you know, if you have any questions about vitiligo, if you're worried that you have a spot that's vitiligo, it's a good idea to seek the opinion of your physician. There are conditions that kind of mimic it and that are much more common. The most common one is a condition physicians will call pityriasis alba. But it's actually light colored spots on the skin that come from some other inflammatory condition, most commonly mild eczema, and that is not vitiligo. So sometimes people will see those lighter splotches, especially on the cheeks of young children that have sensitive skin. And that's a different condition that's much more treatable and a lot less likely to have any kind of permanence.

Dr. Johnson: Yes, that's a good point. Most pale spots on the skin are not vitiligo. And one way dermatologists tell them apart is because vitiligo is just like super pale, it's a bright white, and then other sorts of pale spots on the skin are usually not completely bereft of pigment. So they're not as bright, striking white as vitiligo is.

Dr. Tarbox: There's another condition called tinea versicolor that can also make little round, light colored spots on the skin. And that again is a treatable condition, that I believe we talked about in a different episode of this podcast, where you have a mild yeast overgrows on the skin that lightly depigments it, and that's very treatable and doesn't have any significant long-term impact.

Dr. Johnson: Well, that's vitiligo in about 15 minutes. Thanks for hanging out with us today, guys. And thanks, of course, to University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle.

If you like listening to us, I can hardly blame you, you can find our entire archive on Apple Podcasts in the Skincast website. You can also listen to us more talk about a lot more nerdy dermatology stuff on our other podcast called "Dermasphere." We say it is the podcast by dermatologists for dermatologists. And for the dermatologically curious, you can find that one on Apple Podcasts as well or wherever you get your podcasts. And we'll see you guys next time.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox, and I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful, sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, hey. This is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to talk about virtual visits and how to make the most of them. So what are the different types of virtual visits, Luke?

Dr. Johnson: Virtual visits are when you use some kind of technology to communicate with your health care provider, instead of seeing them face to face in person like in an exam room. So even something like a phone call or an electronic message could count as a virtual visit. But normally, when we talk about virtual visits these days, we break them into two main categories. There's the live video version where you're talking to somebody like Skype, or Zoom, or FaceTime, or whatever. You're talking to your doctor that way. And there's the what we call the store and forward type, which basically means you send us information. In dermatology, that information usually includes photographs because we like to see stuff on the skin. And of course, as we all know, since the pandemic has been chugging along for a couple of years now, especially at the beginning, a lot of doctor visits that could move to virtual did and some of them have sort of hung around. So there's a lot more virtual visits happening now than they were five years ago, for example.

Dr. Tarbox: And the types of visits can also be modified by whether or not they're self-operated. So sometimes a virtual visit has a facilitator, a person at the remote site that helps with the videography as well as with communication and documentation. The other type of virtual visit that is a live interaction would just be patient-directed. So this is the Zoom phone call or FaceTime with your healthcare provider that you facilitate the technology of. Similarly, store and forward can be self-facilitated or can have a facilitator where somebody might take the photographs maybe even using a special kind of camera, or a special kind of tool like a dermatoscope to send forward for analysis versus a picture you might take with your own phone and send to the physician to review.

Dr. Johnson: Some of this might be happening behind the scenes. So, for example, your primary doctor might take a picture of your mole or your rash and then send it to a dermatologist to get a consult about what to do.

Dr. Tarbox: And sometimes it might be something that's arranged ahead of time when you're having the facilitator of communication as well. Sometimes there's also backend communication that happens with the facilitator. So what are the ways to optimize these visits, Luke?

Dr. Johnson: So out of all of those things that can happen, I think by far the most common thing that actually does happen is a live video. I was going to say chat, but it's more than just a chat. It's an experience between you and your healthcare provider from wherever you happen to be. And the doctor is usually in their office, though, not all the time. So I certainly do plenty of video visits like this, and there's a lot of things that you can do to make it the best possible experience for your overall health. So, for example, the first thing to do is make sure you are in a spot that is conducive to you having this virtual visit. So your house would be a pretty good example, but I have had video visits with patients doing all kinds of things. They are actively commuting, driving in a car, they're parked in a car, they're in a parking garage, they're at another doctor's appointment. So . . .

Dr. Tarbox: I had some . . . I actually had a couple in a drive-thru, it was really funny.

Dr. Johnson: A drive-thru?

Dr. Tarbox: We had to compete with the person at the window.

Dr. Johnson: And people have been on break from work like in a break room and stuff. And of course, if you can make it happen in a safe way and this is just what you have to do because of your schedule, then they normally work out okay, but a calm environment like your house would be a pretty good idea.

Dr. Tarbox: Yeah. I tell my patients to try to make the space that they're in as much like the space I usually see them in in my office as possible. So, of course, in my office, each patient is in their own room with perfect privacy so that there's not somebody else listening to their conversation or seeing them, especially if there's any state of undress. But the most important part is making sure that you can see the patient. So we talk about the importance of lighting and how they sort of brighter broad-spectrum light like a fluorescent light or if you have accessible sunlight can be beneficial for the interpretation, although not direct sunlight because sometimes that wipes out the whole camera lens.

Dr. Johnson: Right. You don't want to be backlit either. And we should be able to see your skin. So, for example, you might want to wear clothes that are easy to move out of the way to show the appropriate area. I have a number of teenagers who wear skinny jeans, for example, and they just can't pull up their pant leg for me to look at the rash on their leg. And then it's like weird for them to actually take their pants off, especially if their mom is also there or something. So maybe they should have just worn shorts.

Dr. Tarbox: Yeah. I think that that pre-planning is really important in terms of the visit as well. Sometimes people get a little bit of stage fright. This is a weird thing to have to do. Here, I'm going to talk to my doctor, we're in a separate space, I may be in some state of undress. Sometimes people get a little anxious or nervous and actually forget what they wanted to ask.

Dr. Johnson: Yes. So I think this is true if you're coming in person to the doctor too. It helps to write down any questions that you might have in advance. But it's more important in a virtual visit, I think because after you hang up, it's not like you can turn around and go back into the office and say, "Oh, yeah. I forgot to ask the doctor something."

Dr. Tarbox: That's right. And I do have a percentage of my patients that will think of something that they'd forgotten to ask while I was in the room after their visit has concluded. Of course, we always try to answer those questions for the patients before they leave. But you're absolutely right. Once you're out of a virtual encounter, it's really hard to get back into one. You might have to schedule another appointment. So definitely writing those questions ahead of time is a good idea. I know myself, personally, I'm not my own best camerawoman. How about you, Luke?

Dr. Johnson: I am my best camerawoman.

Dr. Tarbox: So if you are excellent at taking videos or photos of yourself, you might not need this help. Or if you don't have it accessible, you do the best you can. But if somebody can assist you with holding the camera, making sure that you can be seen through the video interface, that might create a little bit more of a conducive environment to a good exam.

Dr. Johnson: If you've got a virtual appointment coming up, answer your phone. Usually, our staff will give you guys a call ahead of time to say, "Hey, I see you're scheduled for a virtual appointment with Dr. Johnson. Can we go ahead and get that started? Here are the technical details of how you would get into the platform." So I know there's so much spam these days in terms of phone calls. But if you've got a virtual visit like the next half hour, answer your phone, even if it's a phone number you don't recognize.

Dr. Tarbox: Another thing people might not think about is that things in their environment may also react to the virtual visit. One thing that I saw happen a lot was people would have a pet in the room with them. And as soon as a new voice came on to the interface, the pets got excited about that and made a bit of a distraction that made it hard to communicate with the patient.

Dr. Johnson: I do think it's kind of fun to see people's pets. But if they're going to be a significant distraction, then you might want to put them in another room or go in another room yourself. I've also seen televisions just running in the background, which makes it difficult to have a conversation. Children, you got to do what you got to do. But children running around and being loud and tapping on the screen, not conducive. So just do what you can.

Dr. Tarbox: Many people are using the same device they would use to take pictures to do the virtual visit. So it might be a good idea to take some good photos with good lighting and good focus ahead of the appointment so that if the doctor asks for a picture to be emailed to a secure and compliant email address, you can do that without taking a lot of bandwidth away from your phone. For some people's phones, that actually turns off the video while they're doing anything else in the phone's operating system. So having those in advance might save you some time and also help make sure that you have as much information for the doctor as possible.

Dr. Johnson: Because of technology, usually, the video images that we see are much less crisp than a photograph that might be taken. So, especially in dermatology, it's nice if we just see an actual photograph sometimes rather than seeing it all on video. So, as you say, if you take a picture or two of the concerning rash or whatever it is, or this is what my acne looks like today and send it to us ahead of time, that's great. A lot of academic and other institutions have what we refer to as patient portals, which are ways for you to interact with your healthcare staff virtually. So it's basically just sending us a glorified email. So, for example, here at the University of Utah, we use a medical record system called Epic and it supports this patient portal that's called MyChart. And so people can log into their MyChart, they can see their lab results in their visit notes and things, and then you can also send us a message. And just like with an email, you can attach a photograph to that. So if you wanted to do that ahead of time, it can help us out.

Dr. Tarbox: Absolutely. Now, some people don't have a very good internet connection at home or have no internet connection at all. So there have been some people who have proposed that there might be special spaces set up for telehealth in public spaces like libraries that would have virtual access.

Dr. Johnson: That would be nice if such a thing exists. In terms of technology, you do want to be in a place where you've got a good, stable internet connection. So this is one of the problems with like commuting or doing it in a parking lot or something. You want to have a piece of technology with a good camera. And the technology is not super complicated but not 100% simple either. So if you're not feeling particularly comfortable with technology, it might be helpful if your helper could be there to help you out in terms of getting on the platform. And you could even consider just trying it. If you're like, "Okay. I really want to get the most out of this virtual visit that's in two hours. I'll set things up now and let me just try ahead of time to make sure the video looks good and the lighting is good and all that." Like a rehearsal.

Dr. Tarbox: Exactly. I love that. Now, certain conditions are more conducive to being well treated by telehealth than others. What are some things you think are easy to treat by telehealth?

Dr. Johnson: So, in dermatology, I think it's a little different than some other medical fields. But the best candidates for a virtual visit are patients who have a known condition. So we already know that you have eczema or acne or psoriasis, or something like that, and we've already met you at least once and we've put you on a treatment plan and now you're following up. Hemangioma is a common birthmark. That's another good example. So I don't need to make my patients who have tiny babies drive three hours to see me basically, just to make sure things are going okay and adjust their dosing. I can do that via virtual visit. So those conditions, we can usually get a pretty good handle on seeing them in the video, especially if a photograph or two is sent ahead of time. And we can adjust treatment as necessary that way. It's a lot harder to look at all of somebody's skin over a virtual visit to make sure none of their moles are concerning.

Dr. Tarbox: I totally agree. I think that if you have an unknown condition, it's really better to see the physician in person. There are some entities that can look very, very similar in photographs without being able to examine the patient completely, and also even touch the skin, we call that palpating the skin. Sometimes the feel of the skin gives us some information, sometimes the overall distribution of a rash gives us some information. And while people are generally comfortable showing an arm or maybe a leg or something on a webcam, presenting yourself in a greater state of undress, potentially close to not wearing any clothes at all, might be much more uncomfortable for some patients. And so our determination of the volume, the distribution actually of the condition might be harder. There's conditions that look very similar like eczema can overlap clinically with cutaneous T-cell lymphoma and can overlap with psoriasis, all of which can have different treatment protocols.

Dr. Johnson: Speaking of being uncomfortable with getting undressed on the camera, some people have a concern that doing this in this sort of technology can allow hackers or some malicious people to somehow get in there and either see your information or actually see the video stream itself. And I won't say that's impossible because I don't know enough about the technology, but the platforms that we use are considered to be safe and secure. So they are HIPAA compliant. And that's why we generally can't just do it on FaceTime or whatever, you have to use a special platform like through this MyChart thing, or if there's one we use called doxy.me as well that are secure in that sense.

Dr. Tarbox: The most important thing is that you're able to get the care that you need in a way that you're comfortable getting it. So I think that telehealth can be a great option for certain conditions. And hopefully, it will help us expand our services to the patients who need to see us.

Dr. Johnson: And if you just can't get to our office physically because you live seven hours away or there's a ton of snow and you can't make it or you're worried about the pandemic and coming out of your house or whatever, a virtual visit is better than nothing, which I know is not a high bar. But even if you have a wart or you have a funny rash and we look at it and we say, "Well, we can't treat your wart physically because you're not here," we can at least give you some advice about warts." And even if we say, "Well, it would be really nice if you were here in person so we can look at the rash more closely and maybe even take a biopsy or something," we can at least give it our best shot. So I know mejor que nada, as you say. Nothing is not, again, not a high bar, but we are better than nothing. So keep that in mind if you just can't make it out.

Dr. Tarbox: Yeah. Especially if you have a suspicious lesion, getting it looked at and triaged is very important. And while we might not be able to make a concrete specific diagnosis through telemedicine for a changing or new spot, we can at least help to determine how concerned we are about it being a dangerous spot for you. And if we do find that it's a high concern, we'll work our backsides off to get you in as quickly as possible.

Dr. Johnson: Thanks to our institutions. Thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us Michelle. If you would like to hear more of us talk, you can listen to our other podcast.

Dr. Tarbox: Our other podcast is called "Dermasphere." It's a little bit longer than this podcast. Each episode is about an hour, and it's actually directed at people who take care of skin problems and other patients. So this is the podcast by dermatologists for dermatologists and the dermatologically curious. And we welcome anyone to come and learn more about the skin.

Dr. Johnson: Thanks again for hanging out with us today and we'll see you virtually or otherwise next time.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox and I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, everybody. My name is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to talk about urticaria sometimes also referred to as hives or welts. Luke, what's urticaria?

Dr. Johnson: Well, urticaria is hives. Medical term for hives is urticaria. I have also heard people refer to them as welts or welps sometimes, but I think most people call them hives. And there's a type of white blood cell called a mast cell that is responsible for these things showing up on your skin.

Mast cells are all full of histamine and stuff like histamine, and various things can cause them to basically explode and release their innards all over and those innards contain histamine and some other stuff. And that causes the blood vessels to get swollen, which causes the skin to get swollen in that area, which is why hives are pink and sort of raised up.

Dr. Tarbox: And what kind of things can cause hives, Luke?

Dr. Johnson: Many things can. In children, the most common cause is just a viral infection. Usually, something mild like a cold. So if you have a child and they get a bunch of hives, you don't need to get too excited. The most likely explanation is that they have a viral infection, especially if they have some kind of other symptom like if they have a runny nose or a cough or something like that, it's probably what's going on.

Sometimes the hives can be the only thing that the kids have, even if they also have a virus. They're just otherwise healthy but have some hives, it's related to their immune system, getting extra excited about what's going on not necessarily to the virus specifically, and just tends to go away on its own.

Another common cause of hives is medications. Again, the immune system sometimes gets excited about things that it doesn't necessarily need to get excited about, and medications are the most common cause of hives in adults probably because they take more medications and their immune systems are a little bit more mature and a little bit more used to the viruses that can cause the hives in kids, but kids can also get hives from medications and adults can also get hives from viruses though it's a lot less common.

Dr. Tarbox: Some of the most common medications that can cause hives include penicillin, aspirin, ibuprofen, naproxen, and blood pressure medications.

Dr. Johnson: There's also a large category of hives that end up being idiopathic.

Dr. Tarbox: Wah wah.

Dr. Johnson: And idiopathic is the medical term for, we don't know why. And we made up a term idiopathic so that we didn't sound by saying, well, we don't know why.

Dr. Tarbox: We say we say idiopathic, so we don't sound like idiots.

Dr. Johnson: Right. But the good news is that even though we can't always figure out what's causing the hives, we can usually treat them safely and effectively. We can talk about that later.

Dr. Tarbox: There's also some other small categories of hives. Some people will get them related to hormonal changes. Women will sometimes get them in pregnancy, things that kind of perturb the immune system in one way or another can create hives. Some people even get at hives from sunlight.

Dr. Johnson: It's true, very rare. And of course, allergies can cause hives. I'm sure there are people out there who've gotten hives after they've been exposed to a dog or a cat or rolling around in the grass or something.

And then there's what we call physical urticaria. So there are various what we refer to as physical stimuli, things that happen to your skin that can cause it to develop a hive. So there are these very rare patients who can get highs from sunlight, some people get hives from vibration on their skin, some people get hives when their skin gets cold or when it gets wet. The most common of these physical urticarias is dermographism.

Dermographism literally means skin writing, and that's because when you scratch the skin, you create a hive and the exact line where you scratched. So if you were so inclined, you could scratch your name onto the back of somebody who has dermographism, and then your name would show up in hives.

Dr. Tarbox: Yeah. About 2% to 5% of the population has dermatographism, so if you don't personally have this unique human trick, you probably know somebody who does, who can really make a little billboard out of their back.

Dr. Johnson: And usually people aren't really bothered by it though sometimes they can be. And then sometimes people can get dermatographic even if they normally aren't if they have like a viral infection, for example. So the same things that can just caught as hives can also just make your mast cells extra twitchy and make you dermatographic.

There are other pretty rare causes of hives. Like there are some things that you can come into contact with, then you get a hive. That's pretty uncommon. We call that a contact urticaria. And then the ones that are kind of scary is that every so often, hives can mean that there's something a little bit more going on in your body. So sometimes people who have an autoimmune disease can get hives and sometimes certain infectious diseases can cause hives, but don't let your brain go there right away. If you've got hives or your kid has hives, it's most commonly a virus or a drug or it's idiopathic.

Dr. Tarbox: About 10% of the population will experience hives at some point in their life so it's relatively common. The good news is most of the time it goes away. About, you know, a small percentage of patients will have hives that last a little bit longer. When they last more than six weeks, we call that chronic urticaria and then we start getting more serious about trying to figure out exactly what's causing the problem. But what can people do about their hives, Luke?

Dr. Johnson: Well, hives are mostly caused by histamine, and the good news is we have medicines that are antihistamines. There's a lot of them and they're over the counter. There are some that are sedating, means they tend to make people sleepy. And then there are some that are not sedating, meaning they don't tend to make you sleepy. So generally, we recommend that you take a non-sedating antihistamine in the morning and a sedating one at night. Do you have some favorites, Michelle?

Dr. Tarbox: I do. My actual favorite one for hives is Allegra or fexofenadine. It comes in the 180-milligram dose over the counter. It's important that you don't need the decongestants. So you don't need an Allegra-D, Just plain Allegra is the medicine that I prefer the most for urticaria for the non-sedating antihistamines. For the sedating antihistamines, we have a couple of options that we can use.

Dr. Johnson: Benadryl's the most common example of a sedating antihistamine. The generic name is diphenhydramine. It's a fine choice for the evening, as long as it doesn't make you groggy in the morning. There's also a prescription version of Benadryl called hydroxyzine that you make have seen occasionally. Other non-sedating antihistamine, there's a lot of them. The brand names are things like Xyzal and Zyrtec. The generics are levocetirizine, and cetirizine, they're also all good choices.

Dr. Tarbox: Some patients can get a little bit sleepy with cetirizine and levocetirizine, more cetirizine which is Zyrtec. About 25% of the time, it actually crosses the blood-brain barrier and can cause some fatigue. So if you're one of those patients, you would choose a different non-sedating antihistamine to help aid things. So we talked about Benadryl as a sedating antihistamine being helpful for itch. What about topical Benadryl, Luke?

Dr. Johnson: Well, before we move on to topicals, Michelle, I want to just talk about what to do. If you're itchy, you take an Allegra or something in the morning, a Benadryl or something in the evening, and you still got these hives, well, you can increase the dose.

So we know that taking up to four times the normal daily doses of these antihistamines is safe and is usually what we do if people don't get better with kind of the normal dosing. So for example, you could take three Allegra fexofenadine throughout the day, and then a Benadryl diphenhydramine at night. And if that's still not controlling your hives and you're miserable, well, that would be a good time to reach out to us. Though as you say, there are topical options as well.

Dr. Tarbox: Yeah. So when we were talking about topical products and we talked about oral Benadryl for as a sedating antihistamine, we were going to say, what do you think about that topical Benadryl?

Dr. Johnson: I hate topical Benadryl.

Dr. Tarbox: Why do you hate it?

Dr. Johnson: Well, Benadryl's a brand, and so if it's topical diphenhydramine, which is the oral antihistamine. It doesn't work if you put it on your skin and strangely it can actually make you allergic to it. So don't use diphenhydramine cream. I think it's possible that the brand Benadryl also makes a hydrocortisone cream just to confuse things, and a hydrocortisone would be a good thing to put on your hives. It can help the inflammation calm down.

Dr. Tarbox: Yeah, I think that that would actually potentially be beneficial. So topical steroids like topical hydrocortisone or prescription topical steroids can sometimes be beneficial for itching. So do we need to get super excited about figuring out what's causing this?

Dr. Johnson: Usually not. And I know it's frustrating to not know what's causing the hives, but if they get better with antihistamine and then they just go away and don't come back, I am comfortable living in ignorance.

So if you've got hives for just a short period of time, like less than six weeks, that's what we consider short. And especially if the antihistamines control them and they go away, I don't think you need to knock yourself out trying to figure out what's going on.

But situations where you might want to try to figure out what's going on as the hives have been going on for a long time, like more than six weeks, especially if antihistamines are not sufficient to control them.

If you think it's obviously related to some kind of trigger, especially like a food, especially in like a little kid. So if somebody eats peanut butter and they get hives five minutes later, don't eat any more peanuts and you got to make sure you know exactly what's going on there because you can have these dangerous anaphylactic reactions to stuff like that.

But if you just have some hives and it's not obviously related to a food, most likely it's not the food that you ate last night or for breakfast or whatever.

If you have some other funny symptoms that are unexplained, like you've just been getting fevers for no reason, you feel crappy, you also have hives, we should figure that out. And if the hives are just miserable, you know, you've tried antihistamines, they're not better, you're itchy as heck, you're hating life, we should help.

Dr. Tarbox: I like it. So in terms of what doctor people should see to help them when they do get to that state where they're just miserable and they need some help, I actually feel particularly qualified to talk about this because both myself and my husband's specialties treat urticaria. So I am a dermatologist, my husband is the allergist, and both of us are capable of taking care of patients with urticaria.

We have a relatively similar toolkit, although we sometimes use it a little bit differently. If there's a suspicion that there is an inciting element like a pet or food, it might be more helpful to go see an allergist because they can do something called prick testing.

Prick testing allows us to test for the kind of allergy that can cause hives as well as the kind that causes sneezing. If you're having other symptoms that involve the skin, a dermatologist may be more able to help you. But the real answer is when you get urticaria, usually you get it quickly and usually you're pretty uncomfortable. So really whoever you can get in with first is probably the one that you would choose so that they can get you on the road to recovery.

Dr. Johnson: Our first step is usually these antihistamines plus maybe some topical steroids, but if those aren't controlling your hives, know that there are powerful prescription medications out there that can help.

And I think that's all we've got time for. So thanks for hanging out with us today, guys. Thanks to our institutions. Thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us, Michelle. If you would like to hear more of Michelle and I talking, you can listen to our other podcast.

Dr. Tarbox: Our other podcast is called "Dermasphere." That podcast's a bit longer. It's about an hour-long and it's actually aimed at people who take care of the skin. So we call it the dermatology podcast by dermatologists for dermatologists and the dermatologically curious. We invite anyone to come listen though. If you want to learn more about the science behind skin, it's a place that you can take a deep dive.

Dr. Johnson: Thanks for hanging out and feeling hiver with us today. We'll see you guys next time.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox and I'm an associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey. This is Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about ways to take care of the meaningful sensation of itch. It is such a troublesome problem for patients and people really can suffer with it. So we've previously discussed what can cause itching and why it's so uncomfortable. Now let's talk about what we can do about it.

Dr. Johnson: And we discussed that just discussing itch makes me itchy, so hopefully discussing how to treat it will make me not so itchy.

So there are lots of different ways to treat itch, and as we discussed in our last episode, there are lots of different reasons why people can be itchy. So to start out, we start with the safest things that are effective for at least a lot of different types of itch, and we start off with just being gentle with your skin. I think we've talked about gentle skin care before.

What exactly dermatologists mean by gentle skin care is perhaps a little bit up in the air, but in general you want to avoid things like harsh soaps and harsh cleansers and irritating cosmetics, and just use gentle things on your skin instead.

Dr. Tarbox: I like to tell people to kind of think about how they would take care of a baby's skin. When we think about our skin, it's actually kind of like a living, breathing fabric. Its job is to protect us from the outside world, and it's designed to be able to do that by itself. We interfere with that function a lot by what we put on the skin. So we use a lot of things that can be potentially irritating, like harsh detergents. We also add things that might cause irritation, such as fragrance and other topical products with harsh preservatives.

So when you have itchy skin, really babying that skin is key. Very gentle cleansers that don't remove too many of the essential oils from the skin, that don't strip that natural oil that's there to protect it, and then things that aren't heavily fragranced to be irritating, using good gentle moisturizers that replenish the moisturization of the skin.

Dr. Johnson: We've talked about some specific products in other episodes, but white Dove bar soap tends to be a good choice if you're just looking for a soap to use in the shower, for example. By the way, we're not getting paid by any manufacturers of these products.

Dr. Tarbox: Not sponsored.

Dr. Johnson: Then for your face, just a gentle facial cleanser. There are lots of brand out there that make good ones, like CeraVe and Cetaphil and Aveeno and a bunch of others. So those are good choices for the face.

And then beyond that stuff, moisturize your skin. Dry skin can be super itchy, so if you want to go after your itch, you can moisturize your skin. I've had a number of patients, and not to stereotype them, but many of them were adolescents. They're kind of itchy, but they just don't want to be bothered to put moisturizer on their skin. So if you rather would be a little bit itchy than put moisturizer on your skin, that's your choice. But if you would like to moisturize your skin, and I think we've talked about this before as well, the thicker and greasier they are, the more effective they are at moisturizing your skin.

So I didn't realize this until I became a dermatologist, but moisturizers do not work by adding moisture to your skin. They work by preventing your own moisture from evaporating away from your skin. That's why the thick, greasy ones that prevent your own moisture from evaporating away tend to be the most effective.

I like plain old Vaseline or petroleum jelly. It's cheap, does a good job, but it's messy, so it's not for everybody. I also like shea butter and coconut oil. And then anything that's got to be scooped out of a jar or squeezed out of a tube is going to be more effective than things that pump out of bottles. Though if you're just a little dry or a little itchy, then the things that pump out of bottles might be fine and are more convenient.

Dr. Tarbox: If you've gotten past the moisturization stage, you're doing your gentle skin care, and you're still itchy, there are some things that are available over the counter that can help with itch. One of my favorite ones is an ingredient called pramoxine, which is actually a topical anesthetic that's very good at treating itch and it's very gentle to the skin. So you can get topical products with pramoxine over-the-counter such as Sarna Sensitive, which is a cream that's made for treating itch, as well as the CeraVe anti-itch cream or lotion, which also contains pramoxine, which is very helpful for itching.

What else can you use topically?

Dr. Johnson: Some people will use topical Benadryl, but Benadryl is not great topically. No offense, Benadryl. The generic name for Benadryl is diphenhydramine, and if it's in a cream, it doesn't really do anything. But you can take antihistamines like Benadryl or others by mouth and that can help with itch if your itch is related to histamine. They are antihistamines after all. The main itch that's related to histamine are hives. So if you get hives, then think about an antihistamine. There are a lot of them out. There are generic names. There are brand names. You want to use a non-sedating when you don't want to be sleepy. Xyzal or levocetirizine, that's two names for the same thing, is one of the least sedating ones. And then Benadryl or diphenhydramine is one of the more sedating ones that you might want to use in the evening.

Dr. Tarbox: And do remember that antihistamines can make you sleepy. They may also interact with other medications, so if you take a lot of other medications, you may want to discuss with your doctor which antihistamines would be safe for you to use.

Dr. Johnson: Dermatologists love topical steroids, and there's a reason we love topical steroids. They are effective and safe. So the over-the-counter topical steroid that is available is hydrocortisone 1%. It's totally safe to use. You could use it on your face every day forever and you would probably be fine. You can put it on babies. It's pretty wimpy. It's so wimpy the dermatologists sometimes look at it and say, "Is that doing anything beyond just being a moisturizer?" It probably is. There's a little bit of hydrocortisone in there. We have access to much stronger ones if you want to use prescriptions, but you might not need it.

So if you're a little bit itchy, especially if the skin looks a little bit pink plus is itchy, that could mean there's some inflammation there, and steroids are really good at calming down inflammation. So you can start with a hydrocortisone product. The ointment tends to work better than the cream. So if you can find hydrocortisone 1% ointment, that's the strongest topical steroid you can get over the counter and is still very, very safe.

Dr. Tarbox: If the itch is still uncontrollable past those different control mechanisms, sometimes dermatologists will turn to something called light therapy where we actually use some of the properties of natural light to help control itching. How do you use it, Luke?

Dr. Johnson: Light therapy is also called phototherapy, so if you've seen that or heard us talk about it, that's the idea. And the way I like to explain it is that there is a particular wavelength of light that helps calm down the immune system in the skin. The immune system is often involved in itch, so this tends to be effective for lots of different kinds of itch.

It's very safe, can be quite effective depending on the person. The main problem is that it is inconvenient. Not all dermatologists, but a lot of dermatologists have machines that produce this wavelength of light, and the machines often look like little closets, little rooms, or sarcophagi. You go stand in one and then this special light shines all over your skin.

The problem is you have to do it three times a week for at least three months to really see if it's helpful, which is not convenient because you have to drive to the dermatologist's office three times a week for three months probably during normal work hours or school hours. You're not really in the machine for very long, usually just one to three minutes, but it's the commute and everything that's really a hamper. But if you can make it work for your schedule, it can be a good idea.

Dr. Tarbox: And we sometimes also use outdoor sunlight for patients who are itchy when they can't get into the doctor's office. That does have to be done with some thought because, of course, sunlight can also cause sunburns, and in high doses over long periods of time can cause skin cancer.

So if you do have a chronic itching problem that's not under control, you may need some guidance on how to use some of these mediators to help improve the itching.

What about other medications, Luke? Is there anything else available to treat itch?

Dr. Johnson: Oh, yes. Itch fortunately, over the past five years or so, has been the subject of more research than in the rest of human history. We're finally believing Dante, that it is miserable to be itchy.

So if you've tried a bunch of this stuff and you're still itchy, then a dermatologist or another doctor might prescribe you various types of medicines to help you out. The first part of our job is to figure out if we can identify what exactly is making you itch. So dermatologists or other doctors might do some lab work, for example, to see if there's a problem with your thyroid, for example. Or we might do a skin biopsy where we take a little piece of your skin so we can look at it under the microscope to see if that might shed some light on why you might be itchy.

So depending on what's going on will help us decide what kind of medicine that we should use. For example, if you have thyroid disease, then you can take thyroid medicine. That should help your itch.

Otherwise, sometimes we're stuck using other therapies that are useful for various types of itch. So for example, we can use the type of medicine we call systemic immunosuppressants. They have several different names like Methotrexate and Azathioprine, and they're pills that you take by mouth that just calm down your immune system overall. So as you might guess, they have some potential significant side effects. That said, most people who take them do fine and they can lead to a lot of relief.

Dr. Tarbox: When we face chronic itch, sometimes patients will also have distress in the form of sleep loss. Some patients experience anxiety. Others experience depression. And of course, these are very important things to treat.

We've also found that addressing the patient's internal environment through means such as cognitive behavioral therapy can improve the sensation of itch as well as the suffering that comes from it.

So some patients improve from understanding and having a sort of presence mindset when they're dealing with itching, sort of an acceptance, "Yes, I'm itching right now. It doesn't mean anything bad is going on. This is what I can do to help make this feel better." A little bit of a wellness approach to dealing with chronic itch when there's not a whole lot else we can do, but that can also be beneficial. And treating that internal environment can sometimes lead to some resolution of the skin symptoms.

Dr. Johnson: On a personal note, when the pandemic started, I began a meditation practice, mindfulness meditation, and I think it has helped me out. Not that I was necessarily having a problem with itch, but this business of mindfulness and just being present and feeling the body's sensation and not getting wrapped up in the sensation but just noticing it and acknowledging it, I can understand why that would help somebody who is itchy get over it. Not the way the mindfulness people would describe it, but . . .

Dr. Tarbox: Cope with it. They can cope with it.

Dr. Johnson: Adjust your perspective on it.

Dr. Tarbox: Yeah. I think that's great. And even for some patients, hypnosis has been helpful for treating itch. So there are lots of different ways to go after chronic itching. It is one of those final frontiers in dermatology that we've got a lot of interest in, and there are new medications coming out to help treat it. But now that we understand how we can help prevent the itching, how we can treat our skin when we do itch, and ways we can cope with it when we can't get rid of the sensation, hopefully we can make everybody just a little bit more comfortable.

Dr. Johnson: Before we say goodbye today, I just want to talk about a couple more prescription medicines that are available just because I think they're cool and maybe you'll think they're cool too.

So if your doctor thinks that there's something going on with your nerves, your nerves are extra twitchy or firing and that's what's making you itchy, then they might prescribe a medicine called Gabapentin, or there's a similar medicine called Pregabalin. Those can help as well. They're quite safe, though again they can make you a little bit drowsy, kind of like antihistamines, if they're given in high enough doses. But they can be pretty effective.

Cells in your body talk to each other with little tiny chemicals and some of those chemicals have a special name. They're called interleukins, and I'm not just saying that because my name is Luke…

Dr. Tarbox: They're not “interMICHELLEns”? Come on, man.

Dr. Johnson: No “interMICHELLEns” out there. There's a whole bunch of them and they all have numbers, and in medicine we abbreviate interleukin as IL. So there's IL-4 and IL-13 and all kinds of ILs. But it's been discovered that IL-31 is strongly associated with itch, and so there's a new medicine that's in development nemolizumab. It has shown to be very effective for people who are itchy if they have particular itchy dermatologic conditions like eczema or even just itch and we're not really sure why. So if you are really itchy and you've tried a bunch of stuff and nothing has helped, there is hope on the horizon.

Dr. Tarbox: Well, thank you guys so much for joining us today. We've really enjoyed having you here to learn how to take better care of the skin you're in. Luke, you and I have another podcast.

Dr. Johnson: We sure do sure do. It's called "Dermasphere." It's intended for dermatologists and for the dermatologically curious. So if you're like us and kind of nerd out on a lot of the science aspects of dermatology, then you might want to check it out.

Thanks, of course, to our institutions. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle. And thanks, of course, to you, listeners, for hanging out with us today. We will see you next time.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in. My name is Michelle Tarbox. I'm an academic dermatologist and dermatopathologist at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, everybody. My name is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah. And I'm itching to talk about some interesting subjects today.

Dr. Tarbox: Ba-dah-bum-bum. I love that. So, Luke, we're going to talk about itch today. Basically, we're going to talk about why we itch and maybe how to do something about that.

So why do we itch? Our skin is really a giant sense organ, and its biggest job, really, is to protect us from external threats. And really, any sensation in our body that's uncomfortable for us, anything we want to avoid in medicine, we call these nociceptive things, like pain or itch, are really there to protect us from potential harm. It is actually transmitted by a subclass of the same nerves that transmit pain.

So it's, like pain, a protective response and it's there to help us notice if, for example, there's a bug feeding on us, or if a parasite is attached to us, or maybe if we've got a skin infection, or we've come in contact with something like poison ivy or irritating plants that need to be removed from the skin.

So it can be helpful in the acute setting when we can maybe do something about it, like swat that mosquito, pull off that tick, or wash off the area skin that's infected and maybe treat it with something. It's also there to help us know when our skin barrier, that final frontier between us and the rest of the world, has a breach or is damaged.

Dr. Johnson: Why do I feel itchy just because you're talking about itch, Michelle? That doesn't seem right.

Dr. Tarbox: That's a great question. So the sensation of itch actually can be triggered by many things, one of which is our own imagination. So, if you think hard enough about being itchy, or if somebody around you says, "Oh, my dog has fleas" . . . As a dermatologist, we run into this when we treat patients who have the human itch mite scabies. We start to itch almost immediately after we recognize the other patient might have scabies because psychologically we connect that exposure to the risk of itching.

Dr. Johnson: That's something my assistants always say whenever we see a patient with scabies. We go back into our workroom and say, "Oh, I just feel so itchy right now."

Dr. Tarbox: Exactly.

Dr. Johnson: Does it work in reverse, though? Can I think myself out of being itchy?

Dr. Tarbox: Hello, and welcome to "Skincast," the podcast for people who want to take the very best care of the skin they're in. My name is Michelle Tarbox, and I'm an Associate Professor of Dermatology and Dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me today is . . .

Dr. Johnson: Hey, this is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: Today, we're going to talk about scars. Luke, what's a scar?

Dr. Johnson: A scar is a part of your skin that you don't like that was probably caused by some kind of process. That's pretty generic. Not everybody dislikes the scars. Maybe you like your scars. Scars are cool.

They're basically some extra collagen fibers that the body has used to try to repair what it perceives as an injury. And my guess is that everybody listening to this probably has at least one scar on their body from something or other.

There are different reasons you can get scars. For example, I'm looking at my hand right now, and I can very faintly make out the scar that I got in high school when one of our friends pushed me into a chain link fence. That would be a traumatic scar.

Dr. Tarbox: Traumatic scars are probably the most common and almost everyone has some experience with traumatic scarring, whether it be from a skinned knee, an unfortunate incident with a chain link fence, or some other kind of skin assault.

Our skin is kind of miraculous, really. It's this miraculous living fabric that can repair itself. And it has a really important job, which is protecting what's inside of us from what's outside of us. So that outside whole integrity is such an important piece that our body has got a very sophisticated wound healing response that can occur in response to multiple different stimuli, one of which being a traumatic wound.

Another kind of scarring that we sometimes see is inflammatory scarring. I think the hallmark of this would be acne scars. So most people also have some experience with acne. When acne gets very inflamed, it can create scarring on the skin that can result in either indented scars or scars that stick out.

Dr. Johnson: Doctors and other such people also like to make scars on people. So if you have something cut out from your skin, for example, like a mole that a dermatologist was worried about, then you're left with a scar afterward.

Dr. Tarbox: And surgical scars can have a sort of special set of circumstances that can optimize their wound healing after the surgical course. So your physician should give you wound care instructions, and you want to follow them carefully to help improve scar cosmesis.

Another cause of scarring is burns. So burns can take the place of thermal burns, such as heat from a fire or potentially a heating pad or blanket that gets turned on and left on too long. They can also take the place of radiation, such as solar radiation. A sunburn, when it's severe, can cause scarring, as can radiation, which is sometimes used therapeutically to treat cancer or other types of problems.

Dr. Johnson: There is a difference between scarring and what dermatologists call post-inflammatory change. So any time the skin is inflamed, whether it's from a dermatologic condition like eczema, for example, or for any other reason, then it can be discolored afterward. It can be a lighter color than the normal skin, or it can be darker. It can also just be pink. So even if it's pink, it doesn't necessarily mean it's currently inflamed. It could have been inflamed, but now it's just pink, which is fading away.

I think most of us have seen this, especially with acne again. So sometimes I'll see patients with acne and I'll look closely and say, "Oh, actually their acne just looks worse than it is because they have all this post-inflammatory change."

The good news about post-inflammatory change is that, unlike scars, it goes away. It can take a long time. It can take months or even a year or two sometimes before it goes away. But the good news is that it will get better.

Dr. Tarbox: I like to tell my patients that the life of the scar starts at the time of injury and its destiny is determined by what you do after that injury.

So how do we minimize scarring? The first thing is, of course, after the time of injury, you want to make sure that the area of wounding is clean and you want to prevent infection. Infection will almost always result in more severe scarring than healthy skin that heals without an infection. So you want to keep the wound clean and you want to make sure that any kind of debris or anything like that if it's a traumatic wound is removed.

Then you want to keep the wound microenvironment moist. The way I like to think about this is if you've ever tried to regrow a grass lawn, you think about how you treated that lawn. So whenever you're trying to regrow a bald patch in a lawn, you're trying to heal the lawn, if you will, then you want to keep that part of the lawn nice and moist so that new grass can sprout up.

And you also don't want to put big blocks of concrete down on that growing grass, like a scab. A scab is actually going to get in the way of your wound healing well, and it will cause a more significant scar. Scabs are not your friends. So a lot of people kind of want to leave the wound open to air and get it to make a nice thick scab. Scabs can be protective in a way that they kind of reinforce the skin barrier. But if you can protect the skin through some other means, such as a bandage and some kind of moisturizing dressing, the wound will heal with less of a significant scar.

Dr. Johnson: One of our favorite moisturizers to put on a wound is plain old Vaseline or petroleum jelly. You've heard it before on this show. You'll hear it again. Aquaphor is okay too. I consider Aquaphor like expensive Vaseline. No offense, Aquaphor. But whatever you like.

So usually for surgical wounds, for example, if we are cutting something out of people's skin, we'll put some Vaseline and a bandage on it after we're done. And then 24 to 48 hours later, we suggest that every day you would take the bandage off, wash the area gently with soap and water and then reapply Vaseline and a Band-Aid.

And you can do the same thing if you are injured or have a scar or a wound for any other reason. Wash gently every day with soap and water, Vaseline, bandage, and that will give you the best chance of having the best-looking scar afterward.

Dr. Tarbox: If the wound is not infected, you really don't need a topical antibiotic ointment. A lot of the benefit from topical antibiotic ointments comes from the fact that they are basically Vaseline plus medicine.

If you do have a superficial skin infection, a topical antibiotic can be beneficial. However, some people are allergic to certain over-the-counter topical antibiotics. I'm one of those people. I'm allergic to Neosporin. If you're allergic to Neosporin, it's also quite likely you're allergic to Polysporin or Bacitracin. Those have a lot of cross-reactive allergies.

And if you have that allergic response, you get itchier and more uncomfortable after you put on that topical product, it might be better just to go back to plain Vaseline.

With Aquaphor, it does have lanolin in it, which is kind of . . . Actually, it's sheep sebum. It's kind of a weird thing that we put that on skin, but our skin has our sebum on it. It's oil secretions from our oil-making glands. What we put in Aquaphor to make it Aquaphor is sheep sebum. So we have sheep sebum plus Vaseline, which is Aquaphor.

Some people really like vitamin E oil. How do you feel about it, Luke?

Dr. Johnson: I am unconvinced that it does anything beyond just moisturize the way Vaseline would.

Dr. Tarbox: And vitamin E oil is one of the other things people can develop an allergy to. A true allergy to Vaseline is almost nonexistent.

Some people will also use silicon sheets. Silicon sheets are very unlikely to cause any kind of allergy and can definitely improve scar cosmesis. They can be purchased over the counter or can be prescribed. And there are also silicon gels that can be used. What about . . .

Dr. Johnson: I also haven't seen convincing data about the silicone sheets, I'll say. We have a different podcast, Michelle, and we discussed a dermatology research article about silicone sheets in women with C-section scars and the women who had a tendency to overgrow scars. So if you have a tendency to develop something called a hypertrophic scar, or a keloid, then the silicone sheets did help. But I don't think they improved the appearance of just sort of average run-of-the-mill scars. So I'm not convinced about those ones either.

Dr. Tarbox: There's a product called Mederma that is sold over the counter as a scar gel to help improve the appearance of scars. It actually is based on an onion extract, Luke. There was a trial that actually compared head-to-head just plain Vaseline versus the Mederma as a topical treatment for scar and hypertrophic scar prevention.

And they did a very sophisticated type of study where they did something called a randomized double-blinded split scar study. So it was a very rigorous study where they put the onion extract gel, which is the Mederma, on one part of the scar and the Vaseline on the other part of the scar. Same patient, same scar, just different treatment for different parts of it. And the onion extract gel did not improve scar cosmesis over the petrolatum, the Vaseline. The result was the same. So you can kind of save your money with that one.

Also, Mederma can cause some skin allergies. I'm actually also a person who happens to be allergic to Mederma.

What other topicals do people use?

Dr. Johnson: People use lots of different things, but I am a believer in Vaseline if that wasn't clear by now. So I don't think that there's a lot of good medical data . . . I'm not saying it definitely doesn't work. I'm just saying that there's not good medical data that says things like essential oils can help, or I've seen people use oregano oils. They smell good and they're moisturizing, so that part can help, but I feel that simpler is better and you want to stick with something pretty plain.

Dr. Tarbox: Yeah. And extra fragrance, extra herbal things can also trigger allergic responses, which can complicate the healing process and actually worsen the scar.

Once the scar is mature, how can people improve the appearance of their scar?

Dr. Johnson: Well, it depends on what you mean by a mature scar, I suppose. I like to tell patients that a scar takes a complete year to fully remodel, and it's at its wimpiest in the first few weeks. It never, ever gets to full strength, but it eventually gets to like 80% of normal skin strength. So I think a month or two after you've been injured, perhaps with a surgery, perhaps with a chain link fence.

You can massage the scar. So there's some medical data that says massaging the scar can help. Do you have recommendations to your patients about that, Michelle?

Dr. Tarbox: I do think scar massage can help in a couple of different ways. One of the ways it can help is just improving circulation to that tissue. Our scar tissue doesn't have as much vascularity to it, actually. It can appear extra red when it's in the acute healing period, but when you look at it under the microscope, the actual density of blood vessels in a mature scar is decreased.

You can also help improve adherence to underlying tissue. So if the wound is deep, you might have more of an indented scar because it gets kind of stuck to the tissue underneath it. And scar massage can help alleviate that.

The way I recommend to do scar massage . . . I like a couple of different things. You can use just plain Vaseline. Some people like castor oil. There's an over-the-counter product called Bio-Oil that I like for scar massage. But I like for patients to take the scar between their fingers and kind of roll the scar and pull it up away from the underlying tissue to help give better movement and decrease any kind bound-down appearance.

Dr. Johnson: When do you have them start using the massage, and for how long, and how many times a day, and for how many weeks, and all that kind of stuff?

Dr. Tarbox: So once the scar is kind of done with the acute healing process, about four to six weeks in, I have people start to do scar massage. I don't want them to do it too early after the initial wound is placed because I don't want the wound to get opened back up. We call that dehiscence of a wound, and that gives a more complicated healing process to the skin. So about six weeks out, I'd have them start to do the scar massage.

I like for them to do it for about five minutes at a time, and at least two to three times daily, if possible. And this can be continued up to, I think, three to six months, depending on the patient's preference.

There's no evidence that scar massage after the acute wound healing period causes any damage to a scar. So it's not possible, I don't think, to hurt yourself with scar massage.

If you have a really bound-down scar, you can actually use those little silicon suction cups to help kind of improve the movement of the tissue and kind of pull it up away from the tissues it might be bound down to.

What other kinds of things impact scars, Luke? What other kinds of habits might impact?

Dr. Johnson: Having sunlight shine on it and smoking. So dermatologists are pretty suspicious of the sun across all aspects of the human body. And it can sort of pigment the scar, especially if your scar is already a little bit pigmented. The sunlight can kind of fix that pigment in place. So especially while your skin is healing, you want to protect it from the sun.

And then smoking is bad for all kinds of reasons, but it reduces blood flow, especially to the smallest blood vessels in the body, which are responsible for delivering nutrients to some of the cells that are working on repairing that scar. And if those cells aren't healthy and working just as well as they could, then the scar is also not going to look so good.

Dr. Tarbox: And what else can be done after all of these processes to help with the appearance of a scar? Let's say they've done all the right things. They didn't smoke, they protected it from the sun, they moisturized the wound, they did their scar massage, but they're still not entirely happy with it. What can we do?

Dr. Johnson: Right. So what if you had a chain-link-fence-related injury in high school and you hate the scar?

Dr. Tarbox: Hypothetically.

Dr. Johnson: What can a dermatologist or somebody else do for you? So one thing we can do is cut the scar out and replace it with a different scar. But this new scar will be done in a more controlled fashion, so perhaps it will be better.

Dermatologists can also use laser treatments on the scars. There are different types of lasers. Some of them are good for the pink color that some scars get. Some of them are good for the texture to kind of help the scar blend in with the surrounding skin.

Unfortunately, there's nothing we can do to just make the scar kind of go away and look like normal skin, but they can still be improved significantly. And acne scars in particular, there's some medical data that says that different types of lasers and then a technique called micro-needling can lead to significant improvement.

Dr. Tarbox: We can also, if we have a very thick scar, potentially inject some steroids into it to help flatten the scar down. Especially if you're dealing with a hypertrophic scar or a keloid, that might be a mechanism that we use to improve the scar's appearance.

If it's more that the edges are very visible, we might do something called dermabrasion, which is kind of like sanding the skin in a technical way. And that's to try to give the skin sort of a chance to re-heal itself.

What about topical things we do?

Dr. Johnson: Well, I think most topical things, unfortunately, don't work once a scar is mature unless, and I don't know why this is true, they're acne scars. So there's a type of medicine called retinoids. We've talked about them before. The prescription versions are tretinoin and tazarotene. They're also available over the counter as products that contain retinol or retinoic acid. And then there's a product called adapalene. The brand name is Differin.

And for some reason, acne scars seem to respond to those, but other types of scars don't. Maybe someday somebody will figure out why, or they'll find that they do work for other types of scars under some particular circumstance. But if it's acne scars that are bothering you, I think you should be using a retinoid unless you're pregnant or breastfeeding.

Dr. Tarbox: Good point. If you've got a scar that you really just don't like the appearance of, and these modalities have been tried, with a physician you may decide to go through what's called scar revision surgery, where the original unsatisfactory scar is removed and another wound is placed in its stead to try to give a second chance to a better opportunity for wound healing. When that happens, it needs to be done carefully by somebody who's an expert at scar revision so that you end up better off rather than worse off.

Dr. Johnson: Well, that's all we've got on scars. I hope you're all "scarry"-eyed after this discussion. Thanks for hanging out with us. Thanks to our institutions. Thanks to the University of Utah for supporting the podcast, and thanks to Texas Tech for lending us Michelle.

If you like hearing us talk, you might want to listen to that other podcast that we make, because I like hearing us talk. Michelle, you want to tell them about "Dermasphere"?

Dr. Tarbox: Our other podcast is called "Dermasphere." It is the podcast for the dermatologists. It's actually the podcast by dermatologists for dermatologists and for the dermatologically curious. It's a longer podcast. Each episode is about an hour, and we review scientific articles that discuss the treatment of dermatologic diseases.

Dr. Johnson: Check it out if you are so inclined, and thanks so much for hanging out with us today. We'll see you next time.