Search for tag: "cosmetic dermatology"

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.

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.

Dr. Tarbox: Hello and welcome to "Skincast," another episode of 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 associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hello, hello. This is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah. This is Part 3 out of three to four episodes in our series on cosmetics. We had Dr. Adam Tinklepaugh, one of our faculty at the University of Utah, here a few episodes ago. We've got Michelle back here, and we're going to spend today talking about procedures.

So, in a couple of our last episodes, we talked about sort of things you could buy over the counter, maybe stuff that you can have your doctor prescribe. And here is stuff that you can basically pay to have people do to you. And since 70% of my patients are kids, I'm going to lean on Michelle's expertise to talk about a lot of these things.

Dr. Tarbox: Well, there are a lot of different kinds of things that can be done in the office or in a procedural specialty to help improve skin health and appearance. And it starts off relatively straightforwardly and simple with an office procedure called a chemical peel.

Now, chemical peels have been around for a very long time. In fact, the idea of a chemical peel has been around for a very, very long time. There are some writings about how Cleopatra used to bathe in soured milk because it would make her skin softer and more clear-appearing. And what we know now was happening is that some of the acid degradation products of the milk were helping exfoliate the skin, some of the lactic acid and things like that that were in that preparation.

They were used medically for the first time in the 1800s by an Austrian dermatologist named Ferdinand Ritter von Hebra, who actually helped us understand the virus herpes and a lot of things about it.

But chemical peels are one of the first ways that we start to improve cosmesis in the office. A chemical peel involves the application of some kind of chemical substance, usually an acid that's a weak to mild acid that's placed on the skin, and then utilizes what we call the skin's “wound healing response”. And that plays a role in a lot of our regenerative therapies that we can do in the office.

Any time we engage the skin's wound healing response, we can improve cell turnover, we can improve collagen building, we can improve the appearance of fine lines and wrinkles, and also just pigmentation.

But it has to be done carefully because all of us have had wounding to the skin and have had it turn out in not as cosmetically-elegant a way probably as we'd like if we scraped our knee or we fell down and ground our elbow into the concrete. Many of us wear scars to remind us of that. So this kind of procedure does have to be done with care.

But when we do a chemical peel, we evenly apply typically a chemical substance over the surface of the skin we're trying to treat. That causes some level of damage or wounding to the epidermis, and then the skin's natural self-healing mechanisms are triggered, and you get replacement of some of the damaged tissue as well as new collagen synthesis and improved appearance.

Dr. Johnson: Isn't the human body amazing? And especially the skin, of course. It's always pretty awesome when we can use the body's natural procedures in order to achieve results that we're hoping for.

There are a lot of different kinds of chemical peels out there. Some of them are available over the counter, the mild ones, as you might expect. And they can be used for different things. So some of them are used for dark spots, some of them are used for fine lines and wrinkles, and then some of the more intense ones can be used for deeper lines and wrinkles.

Dr. Tarbox: And they're very useful. They have to be used by somebody who knows what they're doing, and the person has to be literate with many different skin types so that they know how oily versus dry or sensitive skin might respond to the peel, as well as different skin tones.

So certain darker skin tones might have a greater risk for hyperpigmentation, where the skin becomes darkened, or hypopigmentation, where the skin looks lighter after the chemical peel if it's done inappropriately in a patient of different skin color. So you have to be careful about selection of therapy for each patient, and each patient should be treated as an individual.

After our chemical peels, we can do something called a Photofacial. You might have heard of Photofacial. That's usually referring to an intense pulsed light treatment. Intense pulsed light is a laser-like device that creates different wavelengths of light for therapeutic targets that can range from pigment, so dark spots on the skin, to vascular, so red areas of the skin, to hair. It can actually help remove unwanted hair with the intense pulsed light.

So those are things that can be done relatively quickly in the office and don't require a huge amount of downtime for light peels. Medium peels will take a little more downtime.

Dr. Johnson: And some of these are fairly inexpensive. I know for some of these cosmetic procedures the price tag can shoot up pretty quickly. But in my experience, the chemical peels and the intense pulsed light aren't too bad.

Dr. Tarbox: And really, when it comes to medical procedures, there are a few things that play into the cost of those procedures. One of those things is the equipment it takes to do that procedure, whether that be an expensive laser, whether that be a consumable product that can only be used once per patient. That has to get factored into the cost.

So, with a peel, the cost is the peeling agent and then the supplies you use to apply the peel. And then we also have price modulation for different services based off of the complexity of the service and the requirement for aftercare.

So things that are what we call the lunchtime facial, the intense pulsed light, or something where the risk is pretty low and the follow-up care is pretty gentle, that tends not to be as expensive as something that takes more product cost, or is more complex to do in the office, or creates greater risk.

As we get to the higher percentages of chemical peels, the more aggressive chemical peels, those might go up a little bit in price. You also have to have more downtime for those more aggressive chemical peels.

Dr. Johnson: You talked about the intense pulsed light devices, a laser-like device. Let's talk about actual lasers. There's a number of them out there, and they tend to be used for different purposes.

A lot of them remove color on the skin, and there are different lasers that target different colors. So, if you've got dark brown spots, there's a laser for that. If you've got pink or red spots, there's a laser for that. And then there are also lasers that just sort of destroy the skin. But again, we can do that in a controlled way to take advantage of the skin's own rejuvenating powers in order to rejuvenate the skin.

Dr. Tarbox: And there are all kinds of lasers. There are what we call ablative lasers and non-ablative lasers. An ablative laser, if you see a picture where somebody's skin is red and it has maybe little white dots on it or it looks very irritated after a laser procedure, that's probably an ablative laser. We call them ablative because they in some way or the other go through the epidermis. So those are laser procedures that are going to require some downtime.

Our ablative lasers can include a CO2 laser. You may have heard of CO2 lasering, like Fraxel. You may have heard of Erbium YAG or Nd:YAG. Those can be ablative as well.

So these are different laser treatments that can wound through the epidermis, which can help engender that wound healing response and improve texture and appearance, but that does require some downtime. And it's a little bit more of a moment, as I like to say, as the patient experiences that laser. So it's a little more intense, but those are really good lasers that can be used to improve skin texture and appearance. The resurfacing lasers, or the ablative lasers, can be helpful in improving skin appearance in a relatively aggressive manner.

Then those ablative lasers can be used either fractionated or fully ablative where they're completely taking out every bit of the surface that they're treating on, or they can be using it in a fractionated way where it's little individual dots across the treatment area, which is going to give quicker healing time and less severe change after the laser. So that's another option.

Dr. Johnson: Poking a bunch of little holes in the skin is how I like to describe it to patients. And it's good for wrinkles. It's good for acne scars. And there's another type of device called a microneedling device that is sort of similar in concept in that it also pokes a bunch of little holes in the skin. But instead of using lasers, it uses little needles.

Dr. Tarbox: So a lot of what we do is controlled wounding of the skin where we're actually using a tool of some kind of, be that a laser, be that a microneedling device, to in a controlled way use the wound healing capacity of the skin to improve its health and appearance. So those are other ways you can handle that.

Microneedling can be used to improve acne scars. It's very good for that. It's also used to improve texture of skin on the face with fine lines and wrinkles. It improves discoloration. It also improves some of the scarring that can be left behind after an inflammatory process.

And microneedling can be used to introduce different medications to the skin. It can also be used with platelet-rich plasma or used to help improve hair growth at home. So there are lots of options with microneedling.

It can also be used with radiofrequency, where the microneedles themselves actually have radiofrequency energy that goes through them and bulk heat the tissue in another way to wound it to help improve the appearance, and texture, and turgor of the skin, meaning it gets tighter.

Dr. Johnson: Some of these microneedling devices are available over the counter. If you were to want to purchase one of those and use it, just make sure you follow the instructions, because if you don't know what you're doing, you could perhaps end up in trouble.

I think it's useful to know that in a lot of these procedures, microneedling and laser and stuff, you often need multiple treatments before you get the full results that you're hoping for. So, for example, in microneedling, it probably takes four to six total treatments to get the results that you're hoping for. So, if you're planning to do something like this, go into it with that in mind. The procedures are usually something like four to six weeks apart.

So what if it's not my face that's the problem? What if I've got spider veins or varicose veins in my legs? Can dermatology help?

Dr. Tarbox: So, for spider veins in the legs, there are lots of different ways that dermatologists can be beneficial. One of the ways that's more straightforward is our sclerotherapy treatment. So sclerotherapy actually involves the use of a medicine that is injected into the tiny vein that is broken. So we're actually injecting into the lumen of the vessel.

It's kind of like a fun skill game for dermatologists. I don't know about you, Luke, but when I'm doing sclerotherapy, I think that I understand people who play video games compulsively because of the sense of reward I feel when I actually get one of those little blood vessels cannulated. And then I see that whole mat of those broken blood vessels just blanch out as the medicine goes through them.

And what the medicine does inside the vessels is it makes the walls of those teeny tiny blood vessels that we don't use for anything . . . They're just there because we have usually a broken valve in a vein or something. Those little tiny vessel walls get sticky to themselves, so they kind of close down on themselves. And they don't have blood circulating through them anymore, so you don't see them on the surface of the skin.

And because these are basically dead-end, useless tributaries that we don't need for anything else, there's no damage to the patient by treating these. It just improves the appearance, and sometimes if there's pain associated, it improves the pain.

Dr. Johnson: Dermatologists could treat some of the little to medium type veins, I would say. If you've got a big old varicose vein, then it might need a vein specialist.

Dr. Tarbox: Yeah, vascular surgeons might be the right place for those big veins. Some dermatologists do the endovenous laser ablation. Some don't.

Dr. Johnson: What about body contouring?

Dr. Tarbox: So liposuction was actually developed by dermatologists. The person who invented liposuction was trying to find a way to treat lipomas, which are those little fatty tumors that some patients get. And so he sort of conceived of a device that was like a suction needle you could put into the lipoma and remove it that way.

We don't really use liposuction to remove lipomas, but it is used for a lot of body contouring and shaping. And it does fall within the purview of dermatology. A lot of dermatologists do liposuction. I was trained to do it when I was a resident, and it can be very useful.

Dermatologists can also use liposuction to obtain fat for fat grafting, which is a procedure that can be done to help improve areas of volume loss on the face or help improve a scar cosmesis following reconstruction.

Dr. Johnson: In recent years, there have been other devices that have been developed that have taken advantage of other technologies and other aspects of physics in order to perform this body contouring. They have names like CoolSculpting, and then there are also radiation ultrasound-type devices that can potentially perform some of these actions.

I'm not super familiar with them since I don't do a lot of cosmetics. How do you feel about these, Michelle?

Dr. Tarbox: So they don't not work. The gold standard is liposuction, where a cannula of some variety is inserted under the skin and is passed through the fat layer either mechanically through the arm motion of the operator, or ultrasonically through a sonic oscillation of the cannula itself that can withdraw the fat cells from the patient's body.

There are other things that are also using the fat's vulnerability areas. So our fat is more vulnerable to cold than other parts of our body. There's a kind of condition that often will happen with toddlers, where they get a popsicle and they just sort of let it sit on the face while they're enjoying it, called popsicle panniculitis where the fat actually dies because of the exposure to sustained cold.

And that's the premise for CoolSculpting, which I have tried to see what it was like. It is a doable procedure. It's not completely uncomfortable, but it is not pain-free. So you need to be aware going in that it's going to require a little bit of mental toughness to go through.

But CoolSculpting is based off of that popsicle panniculitis or that cold panniculitis property of fat where fat does not tolerate very low temperatures for prolonged periods of time.

When they do CoolSculpting, they apply a little gel matrix pad to the skin that is to protect the epidermis from the freezing so you don't also get frostbite of the skin. And then they use a sort of suction probe to suction part of the area of adiposity they want to treat into the treatment handle, which can then cool down and basically freeze that part of the fat that is being subjected.

And then once they remove the suction device, the fat is still frozen. When they do it on the abdomen, it makes something called a butter stick. So it's about that size. It's just frozen solid fat. Then the esthetician or the person doing the therapy for you has to massage all of that out to kind of break it apart, which does two things. It sort of mechanically agitates some of the fat cells that are already frozen, and that can break them up, which kills them. It also helps prevent there being any kind of focuses of increased damage because of temperature irregularity. So that's CoolSculpting.

Dr. Johnson: There are a number of other products out there that exist for specific purposes that have reasonable medical data to support them. So, for example, what dermatologists call submental fullness, or sort of a fatty under-chin or double chin, there's a product that you can inject that'll dissolve the fat and help it tighten up. The brand name is Kybella.

Dr. Tarbox: It's bile acid. It's just bile acid going into the skin. That also hurts. That also is a painful procedure.

Dr. Johnson: But it seems to work all right.

Dr. Tarbox: But it works. It does work.

Dr. Johnson: If you have cellulite, especially on the butt, there's a new product out there that has collagenase, which is a protein that will dissolve collagen, that has some efficacy behind it. I believe the brand name is QWO.

And then plastic surgery is, of course, its own surgical specialty and they can do all kinds of stuff to your face. Some dermatologists do some plastic surgery.

And then we didn't really talk about Botox, or more generically botulinum toxin injections, or fillers. I think we've hit those in some of our previous podcasts. I think the short answer is that Botox . . . both Michelle and I are big fans of these botulinum toxin injections, and I think you'd heard Adam Tinklepaugh talk about them too. I like them. They tend to over-perform. They're good for wrinkles, especially rather small, rather shallow ones.

And then fillers add bulk to areas where you don't have bulk. So some people prefer to have more luscious-looking lips, for example. And then other people, perhaps because of the normal aging process, have just lost some of the subcutaneous fat in certain areas of their face, and filler can replace those.

That's my quick and dirty thoughts about those, Michelle. Do you have any thoughts that are slower and cleaner?

Dr. Tarbox: I really think Botox is a great treatment for facial wrinkles. Dysport and Xeomin are other types of neurotoxins that are similar to Botox. And they also help improve the appearance of the skin as well as decreasing unwanted facial movements.

There are studies that show us that we've reviewed on our other podcast, the more scientifically-based longer podcast that we do called "Dermasphere" . . . We've discussed the fact that long-term use of Botox actually improves brow position. So it helps improve the way the face ages over time. And it helps improve also some aspects of skin texture, so you have finer poor appearance often in areas that have been treated with Botox.

The fillers, there are a lot of different fillers. There's the Restylane product line. There's the Juvederm in product line. There are HA fillers. All of these definitely are usable in a different way to fill volume deficits, to improve tissue building, and to deal with lines and expression changes that happen over the face.

They should be used by somebody who knows what they're doing, because they are not without risk if they're done incorrectly or if there is just a day of really bad luck. People can have the filler get into a blood vessel accidentally, and that can either cause some part of the tissue that's supplied by that blood vessel to die. That's called necrosis, not something that you would want to have happen to you. Or in extreme cases, it can cause blindness. So they do need to be used by somebody who knows what they're doing and has been trained to select the right location and the right filler to use. And of course, they should only be done by medical professionals in a safe and clean environment.

Dr. Johnson: And that wraps up this three- to four-part series of cosmetics, but we might talk about cosmetics more later. Who knows? There seems to be a lot to talk about.

Thanks for hanging out with us today. Thanks also to the University of Utah for supporting the podcast and to Texas Tech for lending us Michelle.

And as Michelle alluded to, we have another podcast that's scientifically nerdy. It's called "Dermasphere." It's intended for other dermatologists and the dermatologically curious. And if you consider yourself dermatologically curious, come check that out. Otherwise, stay healthy, beautiful, and handsome, and 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 Dr. Michelle Tarbox. I am a professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center and beautiful sunny Lubbock, Texas. And joining me is . . .

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

Dr. Tarbox: So today, we're going to continue our discussion on cosmetic issues and what can be done about them. And we're going to start off things focusing on a complaint that's become more of the kind of focus of the beauty industry over the past couple of years, and that is dark spots or pigment issues.

Dr. Johnson: There are a lot of different reasons why you can have a dark spot on your skin. One of the most common reasons is there was something kind of inflamed on your skin, like an acne bump, for example, and it leaves a super aggravating mark after it goes away, which is sometimes even more annoying than the acne lesion itself.

There are some other reasons that you can have dark spots on your skin. For example, just hanging out in the sun for some decades can leave you with dark spots on your skin. Those are sometimes called solar lentigines.

And then again, as we age, or as I like to say, as we accumulate wisdom, there are other sorts of dark but benign spots that can commonly appear on the skin. And people generally are concerned about them on the face and people are generally . . . they understand that they're not dangerous for the most part, but the appearance can be really irksome.

Dr. Tarbox: Yeah, it's one of the complaints that I think I hear a lot of in my practice. So here, where I practice in West Texas, we have a whole lot of sun exposure. We basically have 270-something days of sunshine every year.

Our population is a little bit more heterogeneous. So just under half of our population is comprised of patients with skin of color of one or the other skin tone. And so we do get a fair bit of complaint about skin pigmentary disorders and dyspigmentation.

Another big category is something called melasma, which can happen predominantly to women following some kind of hormonal exposure. That might be birth control pills. That might be a pregnancy. But it's a very difficult-to-treat condition where hyperpigmentation occurs on the face.

Dr. Johnson: The good news is that there are things that we can do about it. The bad news is it is kind of hard to treat. But with diligence and the right products, we can help make those dark spots fade, and perhaps even fade away completely.

Dr. Tarbox: So there is hope. There are products that can be used over-the-counter at home, and they're available to treat different irritating situations that you have with pigmentation.

One of the things we've talked about a little bit previously that's helpful for dyspigmentation of the skin are retinoids. Retinoids are topical versions of vitamin A. And they can actually affect gene expression within the skin cells and help them to withstand damage, to repair damage, or to improve cell turnover. And so retinoids are a powerful class of medications.

There are a couple of myths that go around about retinoids, so I always like to address that when I'm discussing a treatment regimen with patients. Retinoids are a medicine that are active at the level of the skin and activate gene expression in the keratinocytes. They help the skin cells to act more robustly and also to replace themselves more frequently.

Now, retinoids do not thin the skin. Some people will think that, because the skin can peel when you first start to use a retinoid. That's just a sign that the gene expression is changing in those cells because of the topically applied vitamin A product, and that it's actually helping those cells turn over more quickly, which causes the skin to peel. But the skin is not thinning.

You do have to be careful about sun exposure when you use a retinoid, and you should be careful when you're treating pigment issues in general because retinoids do thin the very outside dead layer of the skin.

So we have a layer sort of dead skin cells on the outside of our skin that helps keep us waterproof and helps improve our skin barrier. And that layer, because the turnover is happening more quickly with vitamin A products used topically, is going to be a little bit thinner and you will have less natural sun protection. It equates to about a decrease in UPF or UV protective factor of about two to three.

Dr. Johnson: We've talked about this product before. They are prescription versions of them, like tretinoin, and there are also over-the-counter versions, like Adapalene. And it looks like you've got a couple that you've listed that you like, Michelle.

Dr. Tarbox: There are a couple that I do like over-the-counter that are easy to get. So over-the-counter, you can get the Neutrogena Rapid Wrinkle Repair. That is a retinol pro 0.5% serum. It's not terribly expensive, it's well put together, easy to find.

There's another one called Paula's Choice 1% retinol ointment that is purchasable over-the-counter.

We will prescribe some often as well. There are also easy-to-find ones in the RoC line, which has a topical retinaldehyde that is helpful.

Dr. Johnson: We should probably remind our listeners, as always, that we are not sponsored or paid by anybody. So the products that we recommend, they're just ones that we like. And I know we've hit retinoids before, so let's talk about something else. Michelle, does baby got Bakuchiol?

Dr. Tarbox: So if you want to talk about Bakuchiol, Bakuchiol has everything. Just kidding. But it is a natural version of retinol. So this is from a plant called the Babchi plant, and it is a nicely active sort of natural product. It does have to be prepared properly for it to be safe for the skin. There can be some photosensitizing things in it if it is not prepared properly.

But the ones that are available over-the-counter include the Herbivore Bakuchiol serum. It's a very pretty container. The serum is easy to apply. Patients seem to like it. The active ingredient in that is Bakuchiol.

ISDIN Melantonik Recovery Night Serum is another one that has Bakuchiol, vitamin C, and melatonin in it. And then Burt's Bees Renewal Intensive Firming Serum with Bakuchiol is another alternative to retinol if you wanted to try Bakuchiol.

You should also be careful when you're using Bakuchiol or retinols because they can thin that dead layer of skin on the outside of the skin. The dead layer of skin cells, that it is our stratum corneum. So you always want to be careful with the sun.

Dr. Johnson: You mentioned that Bakuchiol is kind of like a version of a retinoid. Does that mean you don't think people should use both a retinoid and Bakuchiol?

Dr. Tarbox: That's a great question. I think you'd probably want to pick one or the other and just stick with that. Alternating those products potentially could be done properly in a well-selected patient, but it might be too irritating for everybody. So I would probably pick one and stick with it.

Dr. Johnson: Perhaps the most important thing you can do to make your dark spots go away is keep those dark spots away from further sun exposure. Sunlight really likes to fix pigment in place. So sometimes I tell patients, "All right, we're going to do these things to help make your dark spots go away, but if you go outside for one day in the sun without sunscreen, then you lose a month of the treatments that we tried." So you really have to be extra good about sun protection.

We've talked about sunscreen a lot in this podcast, so I don't think we need to hammer it too much, but if you really want to go after your dark spots, you'll put sunscreen on your face every morning regardless of what you're going to do that day, even if you're not really planning on going outside at all. And then I often recommend that people put it on over the lunch hour or something too.

So SPF 30, at least. Higher is better. And again, we've talked about this before, so I don't think we need to hit it anymore. We can move on to something called hydroquinone.

Dr. Tarbox: Yes. So hydroquinone is a product that sometimes gets a little bit of shade thrown at it, I would say, in the media. But it is actually a very helpful ingredient for dyspigmentation, and it's usually relatively easy to get in one way or another.

It helps by actually interfering with melanin production by the melanocytes, the cells in our skin that make pigment. So it actually helps to inhibit that by inhibiting an enzyme, which is kind of fun. So it's inhibiting the conversion of a precursor to melanin, our skin's pigment, into a closer end product. So it's a very useful medication.

It is safe in the concentrations that it's sold over-the-counter in the United States. It can be sold outside of the United States at a very high concentration. When it's used at that high concentration that is not approved by the FDA, it is likely in some patients to cause some dyspigmentation that can be more permanent. So you don't want to use high percentage hydroquinone that's purchased outside of the country.

Dr. Johnson: Weirdly, that can give you dark spots, even though the medicine itself is supposed to lighten dark spots. So pretty strange. When something like that happens, we say it's paradoxical. Very high potency hydroquinone that you can get across the border, for example, not really a good idea because it can leave you with dark spots, and that's exactly what you don't want.

Dr. Tarbox: Exactly. And unfortunately, the dark spots that can come from those high concentration creams that are generally not sold in the United States, those areas of dyspigmentation won't improve with anything, not lasers, not anything. So it's a sad situation when that happens, and we definitely want to avoid that for our patients.

So there are a couple of places you can get the hydroquinone-containing creams over-the-counter. One of the ones that's a nice one that a lot of patients really like is Paula's Choice Resist Triple Action Dark Spot Eraser. So that has a 7% alpha hydroxy acid along with glycolic acid and hydroquinone. So this is a product that helps to improve dyspigmentation and patients can do pretty well with it.

Another product that has been around for a long time and is not terribly expensive and is available over-the-counter is called Ambi Fade Cream. Now this kind of goes in and out sometimes of supply issues, but when it is available, it's a 2% hydroquinone along with the sunscreen.

So these are what the hydroquinone products do. There are other products that can help lighten the skin, including niacinamide. Do you use a lot of niacinamide in your practice, Luke?

Dr. Johnson: I do not, but perhaps I should.

Dr. Tarbox: I use it for a lot of things. Niacinamide is sort of a version of a B vitamin called niacin. Niacin is a very powerful B vitamin. When you take straight niacin by mouth, you can actually have quite an impressive flushing reaction. So niacinamide actually helps to protect against that, but you still get the benefits of the niacin in the treatment.

It can be used topically to help improve dyspigmentation. There are a couple of different product lines that make niacinamide-based topicals. One of the ones we've talked about a lot is the CeraVe AM and PM Lotions that have niacinamide in them. Their AM Lotion has a sunscreen. Their PM is more emollient with ceramides in it, but that's a good product for dyspigmentation.

There's also something called NIA24 that is also available over the counter and is a broad product line that has good concentration of niacinamide in it.

I use niacinamide in my practice as well for patients who make lots of skin cancer. It's a very safe B vitamin and can be taken twice daily at about 500 milligrams to help improve your skin health, decrease the risk of skin cancer that's not the melanoma type of skin cancer, and also it's good for your heart and your brain. So it's a nice thing to be around. It basically is helpful for both inflammation and dyspigmentation.

And then, of course, we like vitamin C. There are many different vitamin C products available over the counter. You do want to make sure it's made by a company that has processed it properly so that the vitamin C is actually active. Vitamin C, especially in certain forms, is more vulnerable to the light, making it deteriorate. So a lot of vitamin C serums, especially, will be in a dark bottle, either brown or blue glass. If it's in a clear container, you're probably dealing with something a little bit less active.

So Estee Lauder makes one. There's a Perfectionist Pro Rapid Brightening Serum with Ferment2 and Vitamin C that Estee Lauder makes. The Estee Lauder Perfectionist is that one.

Ferulic acid is available as a SkinCeuticals product called C E Ferulic Skin Serum. There's also something called Cellex-C Advanced-C Serum and BioBare Serum that has vitamin C in it, and those range at different price points.

But vitamin C can be very beneficial as a brightening agent to the skin, overall pigment evening. It's a very safe ingredient. You can actually use vitamin C products during the daytime and the vitamin A products at nighttime to maximize your benefit to those, or you can use the vitamin C twice a day.

Dr. Johnson: You mentioned ferulic acid for just a second. Ferulic acid helps to stabilize the vitamin C. So it's in a lot of these products too just to make sure they're working right.

Dr. Tarbox: Yeah, it's a good product add-on. It helps to make sure that that vitamin C is active and able to work.

Glutathione is another product that can be used to help improve skin pigmentation. There is a product by JJ Labs that is their Glutathione Super Skin Serum with Hyaluronic Acid in it.

So glutathione can help with the skin in a couple different ways. It's an Antioxidant, so it can neutralize and eliminate free radicals that can damage the skin and cause aging, can cause pigment changes. It is actually a very powerful antioxidant, and sometimes we even use it for medical reasons. It helps improve cell turnover, and it's just a generally healthy skin ingredient. So I do like that product. I like glutathione.

Dr. Johnson: Glycolic acid also works, and one of the ways it's used is in chemical peels. A lot of chemical peels you have to get from a doctor's office or an esthetician, but there are some that are available over the counter as well.

I give my mom glycolic acid peels, for example, that I just purchase on Amazon because they're helpful for dark spots. And if you do them over and over again, then they can cause some permanent changes.

And then they're also available in not so much chemical peels, but just sort of individual spot treatments. You've got a couple listed here, and I lean on your expertise as the more cosmetically inclined of the two of us. Glytone Dark Spot Corrector and Glytone Mild Cleanser with Glycolic Acid.

Dr. Tarbox: I do like that product. I think it's a great glycolic-acid-based moisturizer. There's also a glycolic acid product from Avene. It's a French brand. Many different companies will make an alpha-hydroxy-acid-based product for exfoliating the skin and increasing cell turnover.

Kojic acid is another option for dyspigmentation. Kojic acid works sort of similarly to hydroquinone that we discussed earlier. It sort of blocks tyrosine from forming, which is a building block that's used to make melanin. So when patients use the kojic acid, they have sort of a brightening effect on the skin. It works fairly quickly, in about two weeks, and it doesn't have that risk of the paradoxical skin darkening like the hydroquinone can.

So kojic acid can be found in the SkinCeuticals Discoloration Defense, which is a great product. La Roche-Posay has something called Mela-D Pigment Control Serum, and Neutrogena Rapid Tone Repair Dark Spot Corrector is also a great product with kojic acid.

Do you do a lot of cooking with . . . Oh, sorry. Go ahead, Luke.

Dr. Johnson: You were going to ask me if I cooked with turmeric.

Dr. Tarbox: I was going to ask you if you cook with turmeric.

Dr. Johnson: I don't, really. Maybe I should cook with more turmeric.

Dr. Tarbox: I mean, maybe you should, because it might help you have more even beautiful skin on your hands. Who knows?

So a couple different products have turmeric in it. Turmeric is a spice, but it also has anti-inflammatory properties through curcuminoids that are part of that spice. So Allpa Botanicals makes a turmeric face oil. Andalou Naturals also makes a turmeric serum that can be beneficial for skin dyspigmentation.

Some of the products made with turmeric may have an orange hue to them, and it's possible that they might cause some staining. So you want to select those products carefully.

Dr. Johnson: Does taking turmeric by mouth, like heavy turmeric-containing foods, help my dark spots?

Dr. Tarbox: It helps, in general, with total body inflammation. So it could theoretically decrease the severity of acne and might decrease the spots based off of decreasing how much acne that you have. We know that it helps with psoriasis, so . . .

Dr. Johnson: Mostly, we're talking about getting some kind of product that contains turmeric and putting it on in your skin.

Dr. Tarbox: Yeah. That is generally what we're discussing here.

Dr. Johnson: And then you've got one more product listed on our list of things that can help with dark spots, tranexamic acid.

Dr. Tarbox: I know.

Dr. Johnson: That's something that doctors can prescribe as a pill. It's not FDA-approved for the treatment of dark spots here, and it does increase the risk of blood clots a little bit. But the medical data, I think, is pretty decent for it, that it's actually pretty safe and can help.

Dr. Tarbox: Yeah. So there are products that put the tranexamic acid together with it, over-the-counter topical preparation. As Luke was saying, orally, we sometimes use this as well. We do have to be a little bit careful when we use it by mouth because there's some risk for blood clots.

But topically, there's a great product that is made by SkinCeuticals. It's called Discoloration Defense. And so it has the tranexamic acid that can decrease the occurrence of discoloration. It also has kojic acid, which is produced by a fungus. Did you know that, Luke?

Dr. Johnson: I once did, but I had forgotten. So thanks for the reminder.

Dr. Tarbox: And then also niacinamide as well as some other anti-inflammatory products. So I think that that can be very helpful for dyspigmentation. We have a whole armamentarium of things that we can do to improve discoloration. Maybe next time we can talk about what we might do in the office for that, Luke.

Dr. Johnson: I hope so. We mentioned melasma. That's sometimes referred to as the mask of pregnancy. And one of the most important things you can do if you have melasma is to stop any medicines that you take that have hormones in them. So if you take birth control pills, for example, or hormone replacement therapy, that can definitely make that stuff worse.

So I'll admit, Michelle, that your list of stuff that can help with dark spots is way longer than I thought it was going to be, though it all has some medical data behind it. I primarily see children, so that's perhaps why I'm not super familiar with a lot of these.

But with all this stuff available, give us just a sample regimen. Say we've got a listener who just has some sunspots on their skin that they don't like, and they say, "I don't really want to go to a doctor and get prescribed stuff." What would you recommend?

Dr. Tarbox: Well, of course, I would recommend at baseline all of the things that we talk to people about for a healthy skincare regimen. So getting plenty of sleep, drinking plenty of fluids, eating a nutritious diet with a rainbow of colors and lots of naturally occurring antioxidants and anti-inflammatories in those foods.

On top of that, I would make sure they add an excellent skincare regimen. Washing the skin carefully once or twice daily, at least, with a skin cleanser that agrees with their skin type. And in my personal opinion, I have a religion around sun protection almost, but I think that good regular sun protection is very, very important.

I would probably, for a normal person just kind of starting off with this, maybe have them use a vitamin C product in the morning with a sunscreen or a hydroquinone product that has sunscreen in the morning. I would make sure that they're using gentle products throughout the day to decrease any kind of blemish formation.

But I also would probably recommend Heliocare, which is that sun protection vitamin we've talked about before, that has the extract of that tropical fern in it and helps people deal with sun damage. So I like to use Heliocare as an oral supplement for patients who have dyspigmentation.

And then in their nighttime regimen, I would give them probably an alternating pattern of vitamin A medicine, either a retinol, like we discussed, by prescription or one of the over-the-counter products that I like, like the Neutrogena product. That's a very well-put-together vitamin A. Or if they wanted to try something more natural, they could use one of the Bakuchiol products like that Burt's Bees product.

I do like the alpha-hydroxy-acid-based cleansers if a patient's skin tolerates them well because they're good exfoliating agents.

And then I also would recommend that the patients have a mulberry silk pillow. The right kind of pillowcase can decrease skin breakouts and help improve skin health.

Dr. Johnson: I did not think I was going to hear about mulberries today.

Well, that's what we've got time for. Thanks for hanging out with us today, guys. Thanks, of course, to the University of Utah and to Texas Tech.

And if you really like hearing Michelle and I talk, we've got another podcast. It's called "Dermasphere." It's intended for other dermatologists and people who are like dermatologists, and we get super nerdy about dermatology. So if you consider yourself a super dermatology nerd like us, go check that out. Otherwise, we will see you next time.

Dr. Johnson: Hello, and welcome to "Skincast," the podcast for anyone with skin, especially if they want to learn how to take care of it. I am one of your hosts. My name is Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

And normally, my co-host is Michelle Tarbox, but as you can hear, I am not Michelle Tarbox. She is super busy. January is a really busy time for academic dermatology programs because that's when we interview resident candidates. We thought we'd give her a break and brought in one of our own cool faculty from the University of Utah to join us today. This is Dr. Adam Tinklepaugh.

Dr. Tinklepaugh, thanks so much for joining us. Do you want to start by introducing yourself?

Dr. Tinklepaugh: Thank you for having me. It's an honor to be here. My name is Adam Tinklepaugh. I'm faculty at the University of Utah Department of Dermatology. I'm one of the faculty Mohs surgeons and cosmetic dermatologists.

Dr. Johnson: So I think we're going to spend most of the time talking about cosmetics because we promised our listeners in our last episode that we were embarking on a cosmetics series. We promised a series in three parts. This doesn't really count as one of those parts. So it's like Part 1.5. You're welcome, bonus part.

But I don't know if a lot of our listeners might know what Mohs surgery is. So do you want to just mention what that is before we move into cosmetics?

Dr. Tinklepaugh: Sure. Mohs surgery is a type of surgery specific for skin cancers, mostly basal cell carcinomas and squamous cell carcinomas. Those are the two most common types of skin cancer. It's something that we do at the University of Utah, but it's done throughout the country and really throughout the world at this point. And it's a special type of surgery because it results in the smallest amount of skin removed and the best cosmetic outcome.

Dr. Johnson: And the best cure rate, if I remember my literature correctly.

Dr. Tinklepaugh: Absolutely.

Dr. Johnson: So if you've got a skin cancer in a particularly sensitive area, like the face or if it's especially a big one, then Mohs surgery is the way to go.

Dr. Tinklepaugh: That's correct.

Dr. Johnson: So let's talk cosmetics, Dr. Tinklepaugh. You said you specialize in cosmetics, as well as Mohs surgery.

Dr. Tinklepaugh: I do.

Dr. Johnson: We've talked about cosmetics on this podcast a bit, but it's nice to hear new perspectives. So do you have sort of general advice, or how do you approach patients who come in and say, "I want cosmetics"?

Dr. Tinklepaugh: I think I really leave it up to the patient. So there are many different ways that patients find out about cosmetic procedures, whether it's the internet, magazines, word of mouth. And when they come in, they may never have had any experience in cosmetics before and they might ask, "What can you do for me?" I kind of flip that around and actually use a mirror to do this, and I ask them what can I do for them?

That's the way I approach cosmetics. I want to help people correct the things that they want corrected. I don't want to sell them something. And I think that's a very effective way to practice cosmetic dermatology and patients seem to really like it versus being sold something.

Dr. Johnson: What are some of the most common things that you find that people want corrected?

Dr. Tinklepaugh: By far, dark spots and wrinkles, far and away, more than anything else. And wrinkles, that can move into skin that's a little bit looser than it was when we were much younger. But far and away, dark spots and wrinkles are the first two things people ask about.

Dr. Johnson: Sometimes I look at myself in the mirror and I feel that I might have some dark spots or wrinkles.

Dr. Tinklepaugh: It's very possible.

Dr. Johnson: We've talked about sunscreens being super important and we've talked about retinoids, things like tretinoin, which you can get prescribed by a dermatologist. What else do you suggest for people who have things like dark spots and wrinkles?

Dr. Tinklepaugh: So all of those things are excellent and they're the foundation to good skin care and also cosmetic benefits from them as well. Beyond that, you start thinking about basic entry-level cosmetic procedures, things like Botox. Now, Botox is a brand. Like Dr. Johnson has said, we are not sponsored by any companies. Botox is actually Botulinum toxin, which is a naturally occurring toxin, but it is safe when it's administered medically. By the way, it's formulated.

So Botox, other brands are Dysport or Xeomin. Those are the three most common. And those are really the medications that we use to correct wrinkles. And they work by actually paralyzing or immobilizing the muscles that cause wrinkles underneath the skin.

Dr. Johnson: I have had my fair share of Botox. One of the benefits of becoming a dermatologist is that when you're in residency, the pharmaceutical companies give you a bunch of stuff you can practice on. And as you mentioned, we are not sponsored, so the stuff that we recommend, nobody is paying us to. But I find that Botox over-performs. It's a little bit pricey compared to buying some tretinoin cream, but I usually find that I get more bang than I expected for my buck.

Dr. Tinklepaugh: That's true. We find that almost down the line with people. Retinoids, they're very good at correcting fine lines and wrinkles over time, but really they're better as a preventative therapy, whereas Botox can really turn the clock back, specifically in areas like the forehead or what's commonly referred to as the elevens, the lines between our eyebrows, and then even the lines on the outside of our eyes called the crow's feet.

Almost immediately within five, seven days, you start to see an effect. And over time, as you do more and more Botox, you actually need less and less as those muscles get weaker and those lines are less pronounced.

Dr. Johnson: So you do need it again. Botox lasts for maybe three months. That's what I remember learning in residency. I don't really do a lot of cosmetics now.

Dr. Tinklepaugh: Initially, it'll last for about three months, but as you do it over time, you might get five months and then six months. And some people who do it consistently, they might only need Botox once a year.

Everyone is different. Everybody metabolizes the medication differently. Everyone has different strengths of their muscles. So some people might need a little bit more and a little more frequently. Some people might need less, less frequently.

Dr. Johnson: Listeners, you obviously cannot see Dr. Tinklepaugh since this is a podcast, but I can tell you he is extremely handsome and wrinkle-free.

Dr. Tinklepaugh: Oh, thank you. Absolutely.

Dr. Johnson: All right. What if I have dark spots I don't like?

Dr. Tinklepaugh: So dark spots can also be treated by topical things like retinoids. Other topicals that I like to use are things like azelaic acid. The brand name would be Finacea. That's actually a rosacea medication or an acne medication occasionally, but one of benefits of that medication is that it can lighten hyperpigmentation maybe from inflammation.

Now, there are a lot of different types of dark spots. You can have hyperpigmentation after an acne bump. Most of the people that come to see me, they want to correct dark spots that are caused by sun aging. We often call these solar lentigos. You see them on the backs of your hand. You might see them on the sides of your face. Areas that really take a lot of sun over time.

There's a variety of different ways to treat them. The topical medications are one way, but the next step beyond that is really resurfacing. That can be done with chemical peels, which are kind of the entry point. And then once you get beyond that, you start thinking about resurfacing devices, and that could be a laser. For example, Fraxel resurfacing or CO2 resurfacing. These are probably the two most common procedures to resurface dark spots that might cover a broad surface area on the body.

Dr. Johnson: So there's a large spectrum of things you can use for dark spots, from fairly inexpensive creams that work okay and take a long time to fairly expensive procedures that work well and are fairly quick. Is that a fair way to summarize it?

Dr. Tinklepaugh: I would say so. Absolutely, the creams do work. But again, they're just like the fine lines and wrinkles, more preventative. When you really want to get the bang for your buck and you want one treatment that's going to do years' worth of work and really turn back the clock, you start thinking about the resurfacing devices, specifically lasers, that essentially lift the upper layer of the skin off and allow that skin to resurface itself without the pigment that you've seen from sun damage or hyperpigmentation.

Dr. Johnson: I know it varies based on practice and across the country, but just as a ballpark for our listeners, how much does something like that cost?

Dr. Tinklepaugh: It varies hugely depending on where you live. So none of these procedures are covered by insurance, unfortunately. Even Botox, sometimes people might hear about getting this covered by insurance, but that's typically for neurologic conditions like migraine. But for cosmetic purposes, whether it's Botox or laser treatments, they're never covered by your insurance.

For example, in our practice, we break the areas of treatment down by body zone or body location. So if you're just treating your cheeks, that would be one price. If you're treating your entire face, that could be more.

Just to give some kind of basic numbers, to do a full-face Fraxel treatment could be anywhere from $1,000 to $1,500 per treatment. A full-face CO2 laser treatment could be anywhere from $2,000 to $3,000.

Now, those numbers are for Salt Lake City. In New York City, those prices can be significantly higher. San Francisco would be the same thing. Los Angeles, obviously the same thing. But most practices assess their community pricing and try to be consistent with other practices in the area.

Dr. Johnson: So if I have some dark spots and I don't want to get laser resurfacing . . . and you mentioned azelaic acid, which is a prescription. Are there over-the-counter products that you recommend to your patients?

Dr. Tinklepaugh: It depends on the type of pigment. So in younger people, we tend to see hyperpigmentation that might be more related to acne hyperpigmentation, post-inflammatory hyperpigmentation specifically. Things like Retin-A, azelaic acid are great, but there are other forms of pigmentation, particularly a condition called melasma, which is a medical condition, but it kind of falls into the world of cosmetics as well.

Now, melasma is commonly called the mask of pregnancy. So this is hyperpigmentation you might see on the upper lip or on the cheeks, on the forehead, on someone who is pregnant or maybe just given birth, but you certainly can see this in other situations too.

There's a prescription called hydroquinone that we often use. There is an over-the-counter version of this called Ambi Fade Cream, which is also hydroquinone-based. And then you can move beyond that to other prescriptions. One is called TRI-LUMA, which is a combination of medications: Retin-A, a steroid, and hydroquinone. So there's a variety of different ways to treat those.

And then when we move into sun-induced pigmentation, you can start thinking about stronger chemical peels, stronger salicylic-acid-based products, other compounds. For example, a Jessner peel. But really, it's when you get into the lasers that you see the best effect on the sun-induced pigmentation.

Dr. Johnson: I've had some success with over-the-counter products containing kojic acid. I think there's some medical data to support that's helpful for hyperpigmentation.

Dr. Tinklepaugh: It's true.

Dr. Johnson: And then some of these chemical peels, you can also buy over the counter, or at least on Amazon.

Dr. Tinklepaugh: Oh, yeah.

Dr. Johnson: I sometimes give my mom glycolic acid peels that I just purchase on Amazon. If you're going to do that, be sure it doesn't get into anybody's eyes or mouth or anything like that. Be super careful. But if you follow the instruction from the packaging, I think you can get good results.

Dr. Tinklepaugh: Glycolic acid is really kind of the starting point for most chemical peels that are done in the clinic. It's excellent. Other chemical peels would be TCA, or trichloroacetic acid, and then you can move into things like Jessner. Kojic is a great compound. It's kind of an old-school chemical peel, but very effective as well.

You can buy these things over the counter, but we really stress to patients, especially on sites like Amazon, really do your research before you apply these because you really don't always know what you're getting. Some products are even boxed in other brands' packaging. So you might not be getting the real product that you think you're buying.

Dr. Johnson: It can be a little sketchy out there. Of course, my mother benefits from the fact that even though it's somebody buying it over the counter, it's still a dermatologist applying it to her face. She's gotten some benefits out of raising me, I suppose, I'll say.

So if somebody says to you, "Dr. Tinklepaugh, I don't really have a whole lot of wrinkles or a whole lot of dark spots, but I want to make sure I don't get any, and I don't have a whole lot of money to spend," what would you recommend?

Dr. Tinklepaugh: Depends on what a whole lot of money means.

Dr. Johnson: I'm willing to spend $100 a month.

Dr. Tinklepaugh: With $100, the best thing you can do is buy excellent sunblock and a large hat. Other things that factor into aging skin and kind of the progression of wrinkles, and this is something I really stress to all my patients, is good diet. So you need protein in your diet. There are a lot of different diets out there. If we don't consume protein in any form, we really don't have things that we need to build the building blocks or the scaffolding of our skin.

Other things? Sunblock. Sun, even just from light that's coming through our car windows or windows at our homes, that has an effect. Hydrating our skin, whether it's water on top of the skin and putting a good lotion on top of that to trap the water or just drinking enough water. And then really protecting yourself not just with sunblock, but with hats, or long-sleeve shirts, or something that will cover our upper chest. These are all areas that take a lot of sun, and over time, it really has a damaging effect.

And probably the single most important thing, if you are a smoker or a vapor, there's probably nothing more damaging to your skin than those two things. And you can see the difference in people that smoke immediately.

So if someone is smoking, especially a younger person that may have just started vaping, I really encourage them to try to kick the habit, not only for the sake of their lungs but also for the sake of their skin health.

Dr. Johnson: Preach it, brother. I agree with all of that stuff. Sometimes people ask me, or they point out that I have such great skin and I half-jokingly say, "Well, dermatologists, we know all the tricks." And the tricks are mostly sunscreen and a retinoid.

Then I tell people, "Well, we're doctors. We went to school for a long time, which means we're nerds. So I stayed inside my house playing StarCraft instead of standing around in the outfield in the sun." So that also helps, but might be too late for some of our patients.

Dr. Tinklepaugh: That's true.

Dr. Johnson: Well, we're running out of time here, Dr. Tinklepaugh. Anything else you want to say while we've got you here in front of the microphone?

Dr. Tinklepaugh: Well, I appreciate you inviting me on the show. It's been an honor. I really enjoy talking about all these things.

I think that the takeaway maybe from this could be that to dip your toe into the pool of cosmetics can be a little bit scary, but it doesn't have to be.

For example, the name Botox kind of has a stigma attached to it, but really, Botox does not represent all of the other things that can be offered. There are extremely basic things, there are very complicated things, but it doesn't have to be scary. There are really good resources. And most dermatologists, even if they don't do cosmetics, know about it and they can guide you and give you suggestions.

There are a lot of good resources out there. There are also a lot of bad resources. So if you have a dermatologist, or even any physician really, just reach out to them and ask them, tell them that you're curious, and get good information.

Dr. Johnson: Excellent. Well, thank you so much, Dr. Tinklepaugh, and 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. Even though she's not here today, I'm sure she is here in spirit.

If you really enjoy hearing me talk, well, then you and I have something in common. And also, you can listen to the other podcast that Michelle and I put out. It's called "Dermasphere." It's really intended for dermatologists and people practicing clinical dermatology, but if you are a dermatology nerd like us, then you might find it useful as well.

We will see you guys next time.

Dr. Tarbox: Hello and happy holidays from Skincast. We’re taking a little break to refresh ourselves over the holidays, but don’t worry we’ll be back soon with more information on how to take the very best care of the skin you’re in.

Dr. Johnson: We are working on some brand new episodes — hopefully with some fun guests — so we will see you then!

Dr. Tarbox: Hello and welcome to "Skincast." This is the podcast that helps you understand how to best take care of the skin you're in. You wear your skin your entire life. It is the most expensive garment you will ever wear so you want to take great care of it.

My name is Michelle Tarbox, and I am a dermatologist and a dermatopathologist. I'm an associate professor at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas, and I love helping people take better care of their skin. And joining me is my co-host...

Dr. Johnson: 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 go over acne basics. Acne is a common skin condition that affects most people at some point in their lifetime, and utilizing a few simple techniques you could really help minimize the impact of this condition on your skin.

Dr. Johnson: So acne is super annoying. I had pretty bad acne when I was a young lad. I still get the occasional pimple even though I'm 40. Really seems unfair. But when I, you know, became a dermatologist, we learned about what causes acne. And actually, I remember being a teenager sitting in my dermatologist's office and looking with fascination at the posters on the wall about the causes of acne.

So, in dermatology, we consider acne a disease of the hair follicle unit. So one of the first things that happens is that the hair follicle gets kind of blocked up with sticky skin cells. And the hair follicles are often connected to oil glands, and the oil glands produce oil. The special term for this kind of oil is sebum. And so since the sebum can't get out of the hair follicle because the hair follicle is blocked up, the hair follicle gets all kind of filled up with this sebum.

Dr. Tarbox: And one of the interesting . . .

Dr. Johnson: Who likes to eat sebum? Bacteria like to eat sebum. So bacteria come to eat it, and then that creates an inflammatory reaction from your immune system and that sort of really gets the whole ball rolling down the hill.

Dr. Tarbox: That's actually one of the things I like to think through as kind of fascinating that these bacteria, which are called Propionibacterium acnes — they're named after the condition that they cause — are almost like little farmers of the oil that they eat. So they actually make our skin cells more sticky to each other so it plugs up the hair follicle more, and that actually makes a little reservoir of oil that these bacteria can use as a food source.

Dr. Johnson: And you might wonder why this tends to get worse around adolescence. And hormones play a big role as you might guess. A lot of the hormones make your oil glands crank out more oil and they make your skin a bit stickier so it makes the whole thing worse.

Dr. Tarbox: Whenever you have that backup of oil, it can actually break open the edges of the hair follicle and then that skin oil and possibly those bacteria and the dead skin cells get into the part of our skin that's not supposed to have foreign bodies in it. So if you've ever had a splinter and it got inflamed and red and irritated, you know how much our skin doesn't like things that don't belong there. And that oil is just as inflammatory.

Dr. Johnson: I think it's helpful to understand why acne shows up because then we can understand how the treatments work. So the treatments for acne affect some of those factors that cause the acne to begin with. And our best treatments are those that can affect more than one of those factors at the same time.

Dr. Tarbox: Here on "Skincast" we are not sponsored, but we are going to mention specific trade products because it makes it easier for patients to find them and I think that it's a little bit less complicated than people scouring an ingredient list looking for a specific and very technical chemical name.

Dr. Johnson: Yes, we have no commercial interests. This is just stuff we found that is good for our patients. And if you've got some acne, then there is some over-the-counter stuff that's fairly helpful. One of my favorites is a medicine called benzoyl peroxide. Not hydrogen peroxide. That's something else. This is benzoyl peroxide. It's in a lot of over-the-counter acne treatment products. So if you stroll down the acne treatment section in your local grocery store, you'll find benzoyl peroxide in various concentrations. Usually it's something like 4% to 10% that's present in cleansers, in spot treatment pads, in creams, and in various other formulations.

Dr. Tarbox: Benzoyl peroxide can be a great help when you're dealing with acne. One thing you do have to be thoughtful about is that it has peroxide in it. So if you've ever bleached your hair or thought about bleaching your hair, you might know that peroxide can lighten things. And it's true that if you have a benzoyl peroxide product on and it gets on a bed sheet or a towel or clothing, it can lighten or bleach the clothing. If you have fine light brown hair, it can also lighten your hair color around the hairline.

Dr. Johnson: Yeah. So this is one reason why I like it as a wash or a cleanser. I figure most people are washing their face anyway. Might as well put some medicine in there so you don't have an extra step to do. I say wash your face in the morning with this stuff because then they're not immediately putting their face on a pillowcase and discoloring their pillowcase. You do want to use white towels though or you'll have some messed up looking towels. That's the main downside with this benzoyl peroxide stuff.

It can also be a little bit irritating to the skin. In general, the lower percentage, the less irritating it is. So how sensitive is your skin? If it's not that sensitive, just buy whatever's cheapest, like I do, the generic brand. But if it's a little bit sensitive, there's a couple brands out there that are especially gentle. There's one called AcneFree. All one word. You might have to get it online. It's 2.5%. And then CeraVe makes a good one called Acne Foaming Cream Cleanser. It's 4% benzoyl peroxide. Also, very gentle.

Dr. Tarbox: I really like that CeraVe product, and I think that patients can do really well with benzoyl peroxide. Some people can't tolerate it, and, in that setting you can potentially use a milder wash made from something called salicylic acid, which is actually a relative of aspirin.

Dr. Johnson: Yeah, I do prefer benzoyl peroxide, but salicylic acid doesn't have this bleaching property and is usually present again in the same sorts of products that benzoyl peroxide is found in. Usually it's 2%. And if the benzoyl peroxide is just too irritating or you hate that half of your clothes are discolored, then salicylic acid is a decent option.

Dr. Tarbox: If you are aspirin sensitive, you would not want to use salicylic acid, and if you're pregnant, you would not want to use salicylic acid as it is a derivative of an aspirin-like chemical.

There's another wash that I really like for patients who have very sensitive skin that can't tolerate benzoyl peroxide or salicylic acid. This is a product from Cetaphil that actually has zinc sulfate in it, and it's an oil control acne wash.

Dr. Johnson: So there's our cleansers. Something else that's really nice that's over-the-counter is a medicine called adapalene. The brand name is Differin, D-I-F-F-E-R-I-N. Differin the brand makes several products now I think. So you want the one that's called Adapalene, is the medicine.

Until about five years ago, this was a prescription product that cost about $220, and now it's an over-the-counter product that costs $12. So a rare example of medication costs moving in the right direction. It comes as a gel, and you put a little blob of it on your finger. I usually recommend that people do it at night. And then you get that blob on your finger and you kind of dot it all over your face and then you rub it in everywhere.

So neither of these approaches is a spot treatment. Both of them go over your whole face because they help prevent acne from showing up as well as treat acne that's currently there.

Dr. Tarbox: If you're looking for adapalene over the counter, there are a couple different brand names. Differin is the original brand name, but you also can buy it as a La Roche-Posay product. That's a French company that retails products across to pharmacies in the United States. And the name of that line is Effaclar.

Dr. Johnson: I did not know that. It can also be a little bit irritating. Usually not too bad. But I usually tell people if it dries you out, just give your skin a break for a day or two, let your skin recover and then come back to it. Most people's skin will kind of get used to it. If you find that you're using it every night and it's not irritating you at all, well, you could probably step it up to a prescription strength version of the same thing.

Also, this is a retinoid. So there are components called retinol that are in a lot of over-the-counter sort of anti-aging products. And they also work. They're pretty similar to adapalene. They tend to be a little bit higher priced though. But the reason that they are in these anti-aging products is because adapalene and retinol and all these things are good not only for acne but also for scarring, for wrinkles, for dyspigmentation, so pigmentary changes in your skin. Basically, anybody who's not pregnant or breastfeeding should probably be putting one of these things on their skin.

Dr. Tarbox: Yeah, I love my topical retinoid. I don't leave home without it. Speaking of irritation, sometimes people, when they have bad acne or acne that they're frustrated with, will really kind of go after it with everything and the kitchen sink and they can end up really stripping their skin and making it too irritated and dry, which can actually make the acne worse.

Dr. Johnson: Yeah. So just as important as knowing what to do, things like benzoyl peroxide and adapalene, are knowing what not to do. So your poor little skin doesn't need astringents, it doesn't need scrubs, and it doesn't need things that are just too expensive. So sometimes I have patients who come in and they bring their Ziploc bag full of products that they've been using and I love it when people bring them, but it kind of breaks my heart that they've been spending 20 or 30 bucks on a benzoyl peroxide cleanser because you can buy one of those for 4 or 5 bucks.

So things don't have to be expensive, in fancy bottles, and advertised on television for them to work well. You just want to look for these ingredients — benzoyl peroxide, adapalene, retinol, things like that.

Dr. Tarbox: Sometimes patients will also over exfoliate. There are products that are coming off of the market because they have microplastics in them with those little beads that sometimes were included in products for exfoliation. And there are also products that have ground up walnut shells and things like that, which are pretty abrasive to the skin and can do more harm than good. If you want to gently exfoliate, a gentle facial brush that you keep clean and use with minimal pressure is a great alternative.

Dr. Johnson: So those are pretty good things that you can do over the counter. But what if you've done those or your teenage kid has done those and they've still got acne? Well, it might be time to go to a dermatologist. Another reason to go is even if you haven't tried those things, if somebody's acne is moderate or worse and all of those over-the-counter things just aren't going to be good enough, come to one of us. There's really good acne medicines these days. Really the only downside for our acne medicines is that they take a little while to work. So I am sorry if you are getting married next week. There might not be a whole lot that we can do. So come early. It usually takes our medicines about three months to really kick in, but after that, modern medicine does a pretty good job of treating acne.

Dr. Tarbox: Yeah, I always remind patients if your acne is leaving footprints, if it's scarring, you want to seek professional help because scarring is permanent and while we can do a lot of things to help improve those sort of scars that are formed over the years, like chemical peels and microneedling, it's better to prevent than to treat those scars.

Dr. Johnson: I would like to have a little myth-busting section of our podcast here because I think there's a lot of myths out there around acne. One of the main things that gets bandied about is diet. So there's been a fair amount of research into diet and acne, and I will admit that, before I read some of this research, I just didn't think diet mattered at all. Now I think that diet matters... just a little bit.

So the research says that if you have a high glycemic diet — so that's a diet where you eat a lot of like sugar and fat and carbs and things — that can make your acne a little worse. And for some reason, skim milk specifically has been associated with acne. Again, I think the effect is pretty mild. So if you have a high glycemic diet and you drink a bunch of skim milk, instead of having five pimples a month, you might get seven. So it's not really going to make or break things, but there is some data out there. So if you want to listen to your grandma and not eat that bag of Doritos, it might help your face a little.

Dr. Tarbox: Yeah, the skim milk connection is really fascinating, because when you have skim milk, it's had the fat taken out of it so more of that product is protein. And our hormones are proteins. Animals that aren't raised organically sometimes have extra hormones added to make them big and strong and overproduce milk, and those can affect some patients. If you are sensitive to that, going for the organic alternative or going for a vegan alternative may help you.

What about cleaning the skin, Luke?

Dr. Johnson: Well, I don't think cleanliness is as important as a lot of, well, to be honest, mothers and grandmothers seem to tell their children and grandchildren. Obviously, you should do something, but blackheads, for example, are not black because there's dirt in there. That's the sebum, remember the oil, and it just gets oxidized when it's exposed to the air and it turns black. So it's not dirt in the skin. And you don't need to be overly vigorous, as we've discussed, with these scrubs and things. So I think washing your face once a day with something gentle, especially with something with some acne medicine in it, like we've discussed before, is probably all you need to do. But having acne does not mean you are an unclean person.

Dr. Tarbox: That is such a good thing to tell people because sometimes there is a stereotype that goes along with bad acne especially. If I have an active young person that's a student athlete, I do like for them to cleanse their skin after exercising, and the product I really like for this is something called Simple Face Wipes because they're little pre-moistened towelettes in a little convenient packet that can go right in the gym bag and the patient can just wipe their face down after exercising or sweating and it helps to decrease that kind of post-exercise gunk that sort of stops up the hair follicles.

Dr. Johnson: When we think about acne, we're often thinking about teenagers, but acne can show up in other people too. It can show up in adults, especially women, in which case it's often hormonal and we do have hormonal treatments. So there is hope out there if you are such a woman. Come in and see us. We can do stuff. And then I can see it in fairly young kids too. So, from hormonal standpoint, puberty supposedly begins around age eight. And, you know, having a couple of little kids of my own, that's rather terrifying. But I have seen acne show up in, you know, eight years, nine years. Usually, it's pretty mild, but I have had some significant acne in kids as young as about 10.

Dr. Tarbox: There's another special form of acne that can happen in young women called acne excoriée, and it actually has a French name. It's acne excoriée des jeunes filles ,which means 'the picked-on acne of the young woman'. And this is usually occurring in young women who are a little bit stressed out, often successful, intelligent, driven young ladies that sort of express a little low-level anxiety by picking at the acne lesions often sub, kind of, consciously. So bringing that to your attention, if you are a person that picks at the skin lesions, is a good idea and you should remember that the little scars and the marks that are left behind after manipulating or picking at an acne lesion are going to last longer and scar worse than the acne lesion itself.

Dr. Johnson: Don't pick at your acne. There. You heard it from some dermatologists.

There are some other sort of special forms of acne. Most of the time, when we see acne, it's standard acne or what's called acne vulgaris. But there's a form of acne called acne mechanica. So if you're wearing something like a mask, for example, on a part of your skin, then that can further occlude those little hair follicles and make acne a lot more likely. So maskne is a form of this acne mechanica stuff. People who wear a lot of sporting equipment, you know, goalie masks and things or fencing masks, I've seen it or surgical caps. I've seen that in surgeons because it occludes their forehead and they get acne there. I see it in military recruits who have to wear backpacks a lot. They get it on their back. That kind of thing.

Dr. Tarbox: You can also get acne from products that are put on other parts of your body. So if you use heavily oil-based products on your scalp, over the course of the day the heat from your body will melt those products and it just sub-clinically trickles down from the hairline to the eyebrows and patients can have a flare of acne on that forehead region because of their hair care products.

Dr. Johnson: Apparently, according to the textbooks, acne is also worse if it's really hot or humid. I live in Utah, where it's really hot, especially today, but it's not humid. But it has its own special name — tropical acne. So if you are a military recruit in some tropical place, I hope your back does okay.

Dr. Tarbox: There's certain medications that can also cause acne. Steroids, either steroid hormones, like the male and female type hormones, or steroids such as glucocorticoids or prednisone can cause acne to worsen as can other kinds of medications that are sometimes used to treat seizure disorders.

Dr. Johnson: But if you are taking one of those medicines and you get acne, we can help. So, you know, if you need to take testosterone or you need to take other hormone replacement therapies and things, then it makes sense to come see one of us if the acne is giving you trouble.

Dr. Tarbox: And especially if it's an anti-seizure medication. Those are not medicines you want to mess around with. So, you know, you would continue to take those based upon the recommendation of the doctor that takes care of you for those and then seek the expert advice from a dermatologist.

Dr. Johnson: I hope that you guys found this helpful. And we want to thank our institutions. Thanks to the University of Utah and to Texas Tech. And if you are a real dermatology nerd, you might be interested to know that Michelle and I co-host another podcast, which is really targeted at people practicing dermatology, but hey, maybe you'll find it interesting as well. It's called "Dermasphere," D-E-R-M-A-S-P-H-E-R-E.

Dr. Tarbox:Ho ho ho and happy holidays from Skincast. We at the Skincast crew are going to take a few weeks to celebrate with our families but we hope that you’ll turn back in in the new year to learn again how to take the very best care of the skin you’re in.

Dr. Johnson: L’chaim! Happy holidays, everybody. Enjoy this episode from our archives.

Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people to learn about skincare. I'm Michelle Tarbox. I'm a dermatologist in beautiful sunny Lubbock, Texas. And I'm being joined by . . .

Dr. Johnson: I'm Luke Johnson, dermatologist at the University of Utah in Salt Lake City, Utah.

Dr. Tarbox: I like it. Dermatologists are medical doctors who specialize in the care of the skin and of the hair and the nails. We're going to talk about skincare in the COVID era. So, Luke, what do you think is the most important aspect of skincare in this very unusual time we're all living through?

Dr. Johnson: Well, everybody is washing their hands a lot more because of the Coronavirus, which I think is a good idea. But a lot of people have noticed that their poor hands just get so dry and chapped afterwards. We say they have irritant contact dermatitis. Dermatitis, inflammation of the skin, because of contact with an irritant, in this case water. And it's helpful to know what to do if your poor hands get all dry and chapped.

Dr. Tarbox: And that definitely can happen in this day and age when we're all having to clean our hands very frequently. I think now more than ever it's really important to have a good skin care regimen that helps protect the integrity or the intactness of your skin, because our skin is important. It helps to protect us from the world, from bacteria, and viruses, and chemicals, and so we need to take the very best care of it. So what's your favorite moisturizer, Luke?

Dr. Johnson: Well, I love just plain old petroleum jelly. The brand name is Vaseline, but you can buy just the generic brand petroleum jelly. It's great for so many reasons. I have written a small love letter to Vaseline. It doesn't rhyme or anything. But first of all, it's super cheap, especially if you buy the generic version. You can get a big tub of it for about $3. It does a great job moisturizing the skin. So, in dermatology, we talk about transepidermal water loss, the water loss through the skin, and petroleum jelly prevents 99% of it. Also, nobody gets allergic to petroleum jelly. Love it.

Dr. Tarbox: It's easy to find, most people have access to it, and it works very well. Now, I know some people aren't always comfortable using petroleum jelly for various reasons. So, if you're one of those people, and we just can't convince you with our passionate love of Vaseline, we can . . .

Dr. Johnson: It's great.

Dr. Tarbox: It is fantastic. But we can recommend some other things as well. For some patients who don't want to use Vaseline or petroleum jelly, the nut butters may be beneficial. So shea butter can be helpful. Some of my patients have liked a product called Waxelene, which is actually derived from beeswax and is sort of a crunchy granola replacement for Vaseline or petroleum jelly. But the important thing is just to use it regularly.

Dr. Johnson: Waxelene?

Dr. Tarbox: Waxelene. I know. That's what it's called. You can find that usually in health food stores or Whole Foods markets.

Dr. Johnson: What I tell my patients often is that I know Vaseline is not for everybody. It's kind of messy and greasy. So, if you don't like it, use something you like. So just find the thickest, greasiest thing that you kind of like putting on your skin. In general, things that you have to scoop out of a jar are going to be more effective than things that squirt out of a bottle.

Dr. Tarbox: I kind of love that analogy, and that's definitely true. So you want your lotion that you're going to use to moisturize your hands in this unusual time to be more like icing and less like chocolate syrup. So when we are talking about moisturizers, if you're wanting to use something that's more of a cream, there are several over-the-counter products that I think Luke and I can agree on are very helpful to the skin and are very minimally irritating, so they don't have any excess fragrances or harsh preservatives.

Dr. Johnson: Well, if people don't buy into Vaseline, I usually don't have anything specific in mind. But the point of all this is not just to make your hands feel better, though it will. But there is a little bit of concern amongst some dermatologists that if you've developed little cracks in your skin, that could actually be a portal of entry for the Coronavirus. So the Coronavirus likes to attach to certain proteins in order to get into cells and those proteins might be present in those cracks in your hand. We call those fissures. So helping them to heal up is important, and these moisturizers will help that happen.

Dr. Tarbox: Absolutely. Now, a lot of people are using hand soap to wash their hands. Your choice of soap is also very important. Some soaps are going to really strip the natural oils from the skin, and others may be irritating because of fragrance or chemical content. So using a soap that's designed to be gentle is a good choice. What's your favorite?

Dr. Johnson: Well, as far as I can tell, the party line among dermatologists across the world is white Dove bar soap. Everyone seems to really like it.

Dr. Tarbox: I like that one. I also like . . . Vanicream makes a bar soap as well that's very hypoallergenic. Another good product is CeraVe Hydrating Cleanser. This is a cleanser that won't foam. It doesn't have the ingredient that makes soaps foam, which is usually something called sodium lauryl sulfate, which can be a little bit more dehydrating to the skin. But you don't actually need the foam to cleanse. It's just something we associate with cleanliness. So that's a great product as well and it's very gentle.

Dr. Johnson: Though I'll admit at my home I use just random generic liquid soap because my hands don't seem all that sensitive, but I do put moisturizer on them afterward.

Dr. Tarbox: It's a good idea. There's also, of course, hand sanitizer that people are using. And remember that it has to have a certain percentage of alcohol in it for it to be effective against the Coronavirus. Now, alcohol is naturally dehydrating. That's one of the ways that it actually works against enveloped viruses like the coronavirus. But that same property where it can be dehydrating can make it a little bit hard on your skin.

Dr. Johnson: And of course, in general in terms of the Coronavirus, as you'll hear everywhere, if you can avoid touching your face, that's great. In dermatology, we learned that people just touch their faces all the time for no good reason. In fact, I think I touched mine over the past two minutes like five times. So just bear in mind that there could be dirt or other nasty things on your hands that you don't want to put on your face.

Dr. Tarbox: Yeah, I think that it's something that we all have to kind of monitor our subconscious activities with and really try to pay attention to that behavior and stop it before it potentially transmits a virus we really don't want to deal with.

Dr. Johnson: Well, we mentioned moisturizers in general earlier, but this is a special spot where my favorite Vaseline really outperforms. So something nice and greasy will help it heal. Wounds heal best when they're kept moist and greasy. So I've talked to a number of patients who have said, "Won't my wound heal better if I leave it to dry?" And it's interesting because the medical community used to feel that that was the case. But something like 20 years ago, we realized it's not. If it's moist, then the new skin cells can crawl across the surface more easily. So, if you remember hearing, "You should leave your wounds dry for them to heal," that's outdated knowledge. Now, keep them greasy with Vaseline.

Dr. Tarbox: I like to think of it like trying to regrow a dead patch in a yard. So, if you think about where you've got your grass and you want it to grow back over a place where the grass has been lost for some reason or another, is it going to grow better if you have a nice moist soil that's easy for the grass to grow back through? Or is it going to grow best if you have hard, dry dirt?

Dr. Johnson: I do not have a green thumb, but I'm guessing the moist one.

Dr. Tarbox: Exactly. So I think that that's a very important thing now.

Dr. Johnson: Just don't wear a mask.

Dr. Tarbox: Ah, ba-dum.

Dr. Johnson: No, a joke. I mean, I guess if you can avoid wearing a mask because you are staying at home or whatever, that's fine. But masks are pretty important to prevent the spread of the Coronavirus, so they're a necessary evil. Avoiding other stuff that's on your face under the mask, specifically makeup. So I admit I don't wear a lot of makeup.

Dr. Tarbox: What?

Dr. Johnson: But it seems to me that if you are going to be wearing a mask anyway, then why put makeup on the part of your face that's going to be covered? It can exacerbate the problem. It also kind of messes up the masks and makes them harder to reuse if we end up needing to do that.

Dr. Tarbox: I agree. I've actually taken this whole time as a little permission to be a little less involved with my beauty routine. So while I'm paying very good attention to my skin health, and I'm trying to kind of baby that skin and be gentle with it, I'm really not using makeup hardly at all, because what's the point? It's underneath the mask and no one is going to see it. So I don't understand why I would do that anyway.

Dr. Johnson: How do you wash your mask, Michelle? Do you just throw it in the washing machine with everything else?

Dr. Tarbox: The masks that I've had, I've had some that have actually been made by people in my community, who are just wonderful, lovely volunteers. So, in my free time, I actually enjoy participating in community theater. And when this whole outbreak began, the seamstresses and costumers that are a part of the theater made this beautiful effort and sewed all of these fantastic masks out of 100% cotton and then took them to the hospitals and gave them to the doctors and nurses there. And I thought that was a wonderful thing that they did. I found that just washing them like you would wash normal clothes is a very appropriate way to take care of them.

Dr. Johnson: I like that one, and I like the Costco version of it. I don't remember what it's called. Kirkland brand Free and Clear, or something like that.

Dr. Tarbox: I found that the Tide cleansers are a little bit more harsh to the skin, and even their Tide Free and Clear still causes problems for me and some of my patients. So I tend to avoid that one.

Dr. Johnson: Sometimes it's not time to do laundry and I still want to wash my mask. So we've just washed them by hand just with a little bit of laundry detergent on our fingers, or wash them in the kitchen sink and then put them in the dish dryer to dry. That seems to work okay.

Dr. Tarbox: I think that's a great way to do that. And then you also want to make sure that if you are having to wear a mask every day, your skin can get really irritated. There are some adaptations that you can make. Some of the masks tie behind the headset instead of behind the ears. So potentially altering the style of mask you wear day to day might help protect that skin behind your ears. There are also little straps or buttons on headbands to clip behind the head that will hold the ear loops of the mask.

Dr. Johnson: And for anybody out there who's an aspiring dermatology nerd, there are medical, fancy terms for all this stuff. So the medical term for maskne is Acne Mechanica, and it can also occur with anything else that's sort of rubbing or lying on the skin. I know it's seen in military recruits who have to wear backpacks all the time, for example. And then the medical term for your poor sore earlobes after you've been wearing a mask all day is acanthoma fissuratum. There you go. We make up words to sound smarter than we are.

Dr. Tarbox: Science! So, before this outbreak, the most common place that I would see what we call maskne, what we technically call Acne Mechanica, was in my football players who were wearing chin straps and masks because they were playing football. And it being Texas, you see a lot of that.

Dr. Johnson: And the other thing I think is that's helpful to know is if you do get some of the acne stuff onto your mask, one of my favorite over-the-counter products is benzoyl peroxide. It's in a lot of acne treatment products. So look for that particular ingredient. It comes in a lot of different ways. It comes as little spot treatment pads or gels or cleansers. I kind of like it as a cleanser, because I figure you're washing your face anyway, might as well put some medicine in there, but it works fine as a spot treatment if you just have one or two spots.

Dr. Tarbox: It will bleach your towels.

Dr. Johnson: And potentially your clothing.

Dr. Tarbox: And if you have lighter colored hair, it can get your hair.

Dr. Johnson: And I want to agree with everybody that the Coronavirus sucks. I'm sick of it.

Dr. Tarbox: One hundred percent. It is not our favorite thing. If you are treating the acne, you want to be a little bit more gentle than you normally would be. So I wouldn't go for the mega acne control hot lava cream. Use the sensitive skin products right now. Take it a little bit easy on your skin.

Dr. Johnson: Yes, I'm very proud to be part of the University of Utah Department of Dermatology. It's a great place to live, Salt Lake City. It's great place to work. And if you are a super dermatology nerd and are interested in sort of some of the research behind it, Michelle and I have another podcast. It's called "Dermasphere" and it's really intended for dermatologists. Maybe you're a dermatologist. What do I know? But maybe you're just dermatologically curious. If so, you can check out "Dermasphere" on your podcast platform as well.

Dr. Tarbox: Well, we'll be releasing a new episode in two weeks and we hope to see you there. Thank you for learning with us about the skin today here at "Skincast."