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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. 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 welcome to Skincast, the podcast about skincare. I'm Michelle Tarbox and I'm a dermatologist. Dermatologists are medical doctors who take care of the skin, hair, and nails. And joining me is . . .

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

Dr. Tarbox: I practice in beautiful sunny Lubbock, Texas, at Texas Tech University Health Sciences Center.

Dr. Johnson: We are going to be talking about various products on this episode because our goal is to keep your skin, hair, and nails as healthy as possible. And to do that, sometimes you need to use stuff. But we're not paid by any of the people who make these. We have no commercial conflicts of interest.

Dr. Tarbox: Exactly. So, speaking of hair, let's talk about hair loss. There are lots of different kinds of hair loss that can affect patients throughout their lifetime. The most common type that most people probably think of when you say ‘hair loss’ is going to be Androgenetic Alopecia, which is an inherited type of hair loss. It affects both men and women. It affects men a little bit more severely in most cases, but women can also be affected. And it's relatively common actually.

Dr. Johnson: Androgenetic alopecia is a fancy name for male-pattern hair loss, which some people call ‘female-pattern hair loss’ in women. But if you have an uncle who's balding, then that person has androgenetic alopecia in all likelihood.

Dr. Tarbox: Other people also have hair loss after stressful events. This can happen after a severe illness or a period of hospitalization or a surgery, but can also happen with severe stress. And this form of hair loss is called telogen effluvium, but you can think of it as just stress-related hair loss.

Dr. Johnson: And the classic example if you're a dermatologist is when a patient comes into you complaining that she's been losing her hair lately and she brings her 5-month-old baby in with her. Giving birth is a really stressful event on the body, and what basically happens . . . the way I explain it to my patients is that the body decides it has better things to do than put resources toward growing hair. So it stops growing hair.

Dr. Tarbox: Absolutely. There are other kinds of hair loss that are a little bit less common. Some of those include something called Alopecia Areata. That is a kind of autoimmune hair loss that causes usually small circles of hair loss to occur on the scalp. But occasionally, it can be very severe and involve the whole scalp.

Dr. Johnson: There are a few other kinds as well that dermatologists have to learn about. They have names like Trichotillomania, which is when people pull their hair out, and Anagen Effluvium, which is when people lose their hair because of chemotherapy. Those are fairly uncommon, but if you're worried you might have something like that, then obviously you should probably see a medical doctor. And then there are some potentially nutritional causes of hair loss.

Dr. Tarbox: Yeah, it actually takes a lot of nutrients to make hair. That's one of the reasons why if a person is having trouble with caloric intake, like a crash diet, your body doesn't really know the difference between that and you starving because there's a glacier and you're being chased by a tiger or something. And so it starts to shunt nutrients away from the hair.

Dr. Johnson: So you need enough protein and you need enough iron. Those are what I usually think of when I think of vitamins, for lack of a better word, or nutritional products that are related to growing hair.

Dr. Tarbox: Zinc is also helpful, as are some B vitamins. And we'll talk about that a little bit more later.

Dr. Johnson: So, if you have an autoimmune disease, something like lupus, and you feel like you've got areas of hair loss, please see somebody like us quickly so that we can help and hopefully stop it from getting any worse.

Dr. Tarbox: Fortunately, most kinds of hair loss are non-scarring, and that means the hair can be recovered through different treatments.

Dr. Johnson: And I want to spend most of this episode talking about the most common kind of hair loss that I think people will be wondering about, which is that male- or female-pattern hair loss. Again, the medical term is Androgenetic Alopecia.

Dr. Tarbox: It is very common and it causes a lot of problems for people both emotionally as well as sometimes socially. And so it's a good idea to treat it early if it's something that distresses you.

Dr. Johnson: I think most of us have a pretty good idea of what this looks like in men because it's more obvious in men. In women, it's more like kind of diffused thinning of the hair, especially along the central part. So, if you're a woman and you worry that that might be what's going on with you, probably you have this androgenetic alopecia thing, female-pattern hair loss.

Dr. Tarbox: So we always want to know "How bad is it going to get? What is the prognosis?" And that does vary somewhat based off of the individual and their unique genetics, but it is a progressive process. So, if you don't do anything to interfere with it, it will continue to get worse in most patients.

Dr. Johnson: But the good news is that we can do stuff to interfere with it.

Dr. Tarbox: We have the technology. We can repair it.

Dr. Johnson: Dermatologists are, again, medical doctors when it comes to the hair, so one of the things we treat is various types of hair loss. And our goal with this pattern hair loss, male or female, is mostly to slow it down or stop it. And if we can recover hair that's already been lost, that's kind of a bonus. So that's an argument in favor of getting to your dermatologist early to jump on this so that you don't lose more hair than you have to.

Dr. Tarbox: So the most common and easily accessible treatment for androgenetic alopecia and really useful in all types of alopecia is topical minoxidil. Minoxidil goes under the brand name of Rogaine, but there are a lot of generic producers of this medication as well. And it has sort of a fascinating origin story. Luke and I are both comic book nerds, so we love a good origin story, and minoxidil has a great one.

Dr. Johnson: Interestingly, my great uncle was involved in the team that developed this drug in the first place.

Dr. Tarbox: What? I never knew that.

Dr. Johnson: Yeah, Herschel Schnapper. We called him Uncle Hershey. The only other medical doctor in the family before my brother and I. But that's an aside.

Dr. Tarbox: Absolutely. Topical minoxidil works where it is applied. So it's been used in both liquid form as a solution, there are sprays, and there are foams. The strengths over the counter typically are 2% or 5%, but there are some manufacturers that will go up to about 8% over the counter. It's a very safe medication if it's used topically. We don't recommend it's used during pregnancy. However, if you are not pregnant, it is safe to use.

Dr. Tarbox: My adult teeth did not start to come out, yikes. I still have them all. Thank you.

Dr. Johnson: Oh, I'm sorry. What happened when your adult teeth started to emerge? You shed your baby teeth, right?

Dr. Tarbox: I did. I put them under the pillow and got money from the Tooth Fairy.

Dr. Johnson: Exactly. So, when minoxidil is used in a patient who has alopecia, sometimes that will trigger a new hair shaft to just start growing out of the hair follicle. And if there is an old hair shaft in that follicle, it can get pushed out by the newly growing hair shaft. And that means that you can end up having some shedding after starting minoxidil. Some people panic when this occurs and they stop the medication. But the thing is if you have that shed, it actually means you're responding really well to the minoxidil and a whole new bumper crop of baby hairs is trying to grow. And if you continue the medication, you can continue to get that benefit.

Dr. Johnson: Minoxidil works pretty well. There's an old "Simpsons" episode where Homer uses it and gets impressive hair. I think Harvey Fierstein is a guest voice in that one. Usually, it's not that impressive in real life. Give it a good six months before you decide whether or not it's really working for you.

Dr. Tarbox: And it's really safe in most people. If you have a severe cardiac problem, a heart disease that's very bad, the heart doctor that treats you should be asked if you should start that medication, as it is, when used orally, a blood pressure altering medication.

Dr. Johnson: There are some other over-the-counter products that can be helpful for hair loss regardless of the kind. But again, usually, it's this androgenetic type of hair loss. And one of them is a vitamin called biotin. So biotin has been shown to be good for hair and nails. Don't take too much of it because that can play around with some lab results that your doctors might want to get for some reason. Just follow the instructions on the bottle and it's shown to be good for hair and nails.

Dr. Tarbox: Yeah, I've seen some supplements that have crazy mega-doses of biotin and you really don't need that much of it. Now, biotin being a B vitamin, there is some good news about that. All our B vitamins tend to be fat . . . they tend to be liquid soluble, so they dissolve in water, which means that if you take too much of them, they are excreted in your urine. So taking too much doesn't really help so much.

Dr. Johnson: Yes, I remember a hair loss expert talking to us once how she knows a number of very fit, healthy young women who eat nothing but salads. And because they don't have enough protein intake, they can't grow their hair properly.

Dr. Tarbox: So Viviscal is a different kind of oral supplement for hair loss. It has a couple of ingredients in it that are a little bit novel. So it has some marine minerals. It has actually shark cartilage, but they're not murdering sharks to make this product. It's a cultured cell line of shark chondroblasts. So it's the cells that make cartilage.

Dr. Johnson: So they don't get it actually from sharks. They get it from cells that make cartilage that is the same type of cartilage that sharks have.

Dr. Tarbox: Exactly. And there's some apple enzyme in the Viviscal. They have some pretty decent studies to show that it has some benefit. In my personal experience using it for a lot of hair loss patients, I find that it slows down the rate of shedding if somebody has one of those stress-induced moments of hair loss we talked about earlier, that telogen effluvium. And in patients who have androgenetic alopecia, it tends to help thicken the hair back up.

Dr. Johnson: Do you like Viviscal or Viviscal Professional?

Dr. Tarbox: Well, I personally like Viviscal Professional. Viviscal Professional is a little bit more expensive than the regular version of Viviscal, but both are effective. Viviscal without the professional branding, that is available I think at Walgreens. The Viviscal Professional is often sold through doctor's offices. I don't sell any products in my practice because I'm at a university and it just doesn't work well to do that. But I do think that that's a good product and a lot of people use it and tolerate it well.

Dr. Johnson: So massage, this Viviscal, biotin supplements, and minoxidil that you put on your scalp, those are all over-the-counter things that can help. It's important to know that if you stop them, especially minoxidil, you will lose all the hair that it gave you. So one of my colleagues likes to talk about it like toothpaste for the scalp. You brush your teeth twice a day to keep your teeth healthy. You can put this stuff on your scalp twice a day to keep your hair healthy.

Dr. Tarbox: I think that's a great way to think about it. It's like any other cosmetic product. So I find that a lot of people's hang-ups about using it are, "Well, I'll have to keep using it." I'm like, "If it works for you, you do have to keep using it. You'll lose the benefit of it if you stop." But it's not that cumbersome of a thing to do and it's really quite effective. And if people do stop it, they would only lose what they gained from it. So you're not going to be worse off for having used it.

Dr. Johnson: There are a couple of other out-of-the-box ideas. So there are ways to disguise your hair loss rather than actually correcting it by getting hair back or slowing the hair loss. So I think there are . . . they look like markers or pens and you sort of just color in the scalp where you don't have the hair or where you have thinning hair, so it becomes less obvious.

Dr. Tarbox: That's one product to use. The ones I like better actually . . . they have these powders that are keratin fibers that are electrostatically charged, so they stick to the hair. Just like when you were a kid and you'd rub a balloon on your hair and then you could move the hair around with the balloon. So these particles of keratin are electrostatically charged and dyed to match different hair colors. You can actually spray them onto the area where the hair is thinner and they will adhere by electrostatic forces to those hairs and make them seem fuller and thicker and they help to camouflage in the areas where the scalp is showing. And then they just rinse out in the shower.

Dr. Johnson: Do you remember the name of that product?

Dr. Tarbox: There are a couple of different ones. One is called Toppik. Viviscal also makes one that are the hair fibers. There are a lot of different ones. There's another one that you can kind of buy at the salons, but most of them are well made. The ones that I've found that work the best . . . I like the Viviscal one because they actually have a little atomizer. It's kind of a squishy thing that blows little fibers out onto the areas where you have the areas of thinning. So it's very easy to use.

Dr. Johnson: So those are some over-the-counter things that can be helpful for the type of hair loss you have, mostly regardless of what kind you have, but there's lots of stuff that's not available over the counter, but that a dermatologist can help you with. So how can a dermatologist help if you have hair loss, Michelle?

Dr. Tarbox: So, if you are a person who is a gentleman, we really only have one . . . well, we have two prescription medicines that we can use kind of with some routine usage. So one of them is Finasteride. Finasteride is a medication whose first indication was actually to treat patients with prostate cancer or prostate hypertrophy. It is a medicine that inhibits an enzyme that is called 5-alpha reductase, and it basically turns testosterone into super testosterone.

Dr. Johnson: So, if you wanted to go see a dermatologist for your hair loss, dermatologists can help by getting the right diagnosis so we know what kind of hair loss you have, and they can do that through numerous ways. They can look at your scalp, they can sort of tug on your hair to see if it comes loose easily, they have special magnifiers that they can use to take a really close look at the hair follicles, or we can draw labs. So sometimes we'll check iron and vitamin levels and thyroid levels and things like that. Some patients get a skin biopsy of their scalp so that we can look at some of the scalp skin tissue under the microscope to figure out what's going on.

Dr. Tarbox: And so finasteride can be used for men. It is also able to be used for women, but women have to be very careful that they might not be pregnant, because if you were taking finasteride and you were pregnant, it could have effects on the fetus, especially if the fetus was a boy.

Dr. Johnson: But very good for some people, and a dermatologist can help you with it. So come to somebody like that and we'll help you out.

Interviewer: They're ugly, and, for some, nail fungus can be painful and also very tough to get rid of. Dermatologist, Dr. Christopher Hull, what's the first thing you do when a patient comes in with nail fungus?

Dr. Hull: Well, first, I like to make sure that it actually is nail fungus, because there are other nail conditions that can look very similar to and mimic nail fungus. So first that usually involves assessment of the nails. Sometimes we'll do some confirmatory testing with clippings and cultures and scrapings. And then, once we're comfortable that it's a fungal infection and not another condition of the nail that looks like nail fungus, then we talk about how it's affecting them and what they're hoping to achieve as far as treatment.

Interviewer: Got it. So if it's something else, the treatment options would be different. That's why you really want to find out, what . . . it is fungus, right?

Dr. Hull: Right. And treating nail fungus is notoriously very challenging, often with failures along the way. And so it's important to be sure that before you start going down the path of treatment, that you've actually got a correct diagnosis.

Interviewer: And it can take a long time to treat. So you wouldn't want to go down this path of treatment and then . . . yeah.

Dr. Hull: Right. And some of the treatments require monitoring and have some risks associated with them.

Interviewer: Got it. So you find out it's a nail fungus. At that point, what are the treatment options?

Dr. Hull: There are a number of treatments. There are many things that are you know, available over the counter. You go to the internet and Google "nail fungus treatment," you'll come up with 10,000 hits, I bet.

Interviewer: Yeah, pills, polishes, creams?

Dr. Hull: Right.

Interviewer: Yeah, all sorts of things. What do you tend to like to use?

Dr. Hull: Most of those have not been investigated with really good clinical trials. But I think there's things that people have used and have found to be helpful. One common thing that comes up are products that contain menthol. So Vicks VapoRub is a common nail remedy for nail fungus. It probably won't help. But it won't hurt anything either.

Most of my conversation is usually discussing medical therapy, so things that are available by prescription only. And those come in two main forms, which are topical antifungal medications, and then oral antifungal medications. There are other surgical or procedural options, so you can remove nails as well. And then there's starting to be more interest in technologies like lasers for nail fungus.

Interviewer: So you would said at one point that you have a conversation with the patient, what is it you're trying to accomplish. I understand for some people it can be very painful. So it might be to alleviate the thickness of the nail and the pain.

Dr. Hull: Right. And it gets difficult to clip, trim, and groom nails when they get very thick. It can be associated with pain because of ingrown nails. And in some cases, it can also predispose people to infection, so cellulitis and so forth. So there are medically important reasons to treat them. Some people just don't like the appearance of the nails.

Interviewer: Yeah. Because doesn't look good in your flip-flops, does it?

Dr. Hull: Right. Wearing sandals in the summer time with thick, yellow nails is something that a lot of people would like to not have to do.

Interviewer: So if it isn't necessarily painful, do you recommend treatment? Do you really leave that up to the patient at the point?

Dr. Hull: Yeah. My personal philosophy is to leave it up to the patient. So I give them the different options, talk about the length of treatments, the monitoring, the likelihood of success, and then have a conversation with them about whether they want to move forward with those treatments. And a lot of people like not to do anything and many people are very motivated to treat their nails.

Interviewer: Sure. What about the oral drugs? I understand that some people are concerned about the side effects those can cause. So are the oral drugs, generally, better than the topical or . . .

Dr. Hull: Yeah. The oral medications are more effective than topical treatments.

Interviewer: Sure.

Dr. Hull: The good news though is that the safety of most of these oral medications is very good. And the treatments are also much less expensive. So there's quite a bit of cost benefit from using the oral medications.

Interviewer: What are some of the concerns with the oral medication side effects?

Dr. Hull: The primary concern is liver toxicity, because these medications are metabolized by the liver. Looking at cost effectiveness of oral versus a topical medication, I'm really sort of arguing for the oral medication because it's so much less expensive. But then, also, looking at a lot of the safety information about the medication and the risk of serious liver adverse event is very low in that medication. That said, I still will recommend appropriate monitoring. And that's laboratory testing, usually a baseline and then midway through the treatment.

Interviewer: Are they antibiotic based?

Dr. Hull: They're antifungal, so they're specific towards fungus. So they have no effect on bacterial like an antibiotic would.

Interviewer: So people that are afraid of antibiotics for whatever stomach reasons they might have.

Dr. Hull: Yeah. It won't have any effect on the flora of the gut. And actually, interesting, they don't . . . this particular one, terbinafine, doesn't have an effect on the natural yeast that we see in the intestine called candida. So it shouldn't have any effect on that. Some people can get rashes, and there's, you know, other less common side effects. But for the most part, I find them to be well tolerated.

Interviewer: Some of the home remedies that I saw, you mentioned Vicks VapoRub, snake root extract, tea tree oil . . .

Dr. Hull: I haven't come across snake root extract yet. But it sounds like it might eat away a nail pretty well.

Interviewer: Sure.

Dr. Hull: Yeah. There's a lot of those things out there. A lot of people use vinegar, tea tree oil. The hard part with any of these topical medicines is they don't penetrate the nail unit very well. So getting them, actually, to the fungus in the nail unit is very difficult. And that's why a lot of the prescription topical medicines have such limited effects.

Interviewer: What about do-it-yourself at home trying to thin that nail out like, you know, by coating it with . . . what do people coat it with?

Dr. Hull: Well, I think doing debridement at home is, actually, helpful. So a lot of times, I'll have people file their nails down, clip the nails back, because that helps to kind of trim away some of the infected nail as well.

Interviewer: Would your recommendation, generally, be for somebody to use the oral pills if possible just because it's such a shorter treatment time?

Dr. Hull: Well, I think it just depends on the person. There are some people who have other risk factors, who have a history of liver disease or something where I wouldn't be comfortable putting them on that medication. So I use both medications, and sometimes I use them in combination. So I'll have them do a first course with an oral antifungal and then follow up with a topical. And that may help prevent reinfection, too, down the road.

Interviewer: Which is pretty common from what I understood.

Dr. Hull: Yeah. So it's common. You can get the nail clear, and then people are just exposed to the fungus in their environment, in their shoes and so forth, and they can get reinfected easily.

Interviewer: So it sounds like that if somebody does have nail fungus, for the most part, does it bother you because it's ugly? If there's pain involved, then for sure, you would recommend some treatment. For some people, there could be other medical reasons to treat it.

Dr. Hull: Right, yeah. Somebody with, you know, for example, diabetes who's at risk of ulcerations on the feet, cellulitis infections, they are people that may be . . . they may be more proactive about treating to help reduce their risk of infections.

Interviewer: But for the most part, it sounds like if you don't really have many symptoms, it's just kind of a personal choice?

Dr. Hull: That's true.

updated: August 26, 2020
originally published: July 19, 2017

Announcer: Seven questions, seven answers. It's "7 Questions for a Specialist" on The Scope.

Interviewer: We're here with Dr. David Smart, dermatologist at the University of Utah and these are seven questions to ask a dermatologist. Dr. Smart, what is the most common skin issue in Utah?

Dr. Smart: Brown spots. That's what I'm going to go with. Brown spots is the most common issue in Utah.

Interviewer: What is the absolute best thing I can do for my skin?

Dr. Smart: Don't smoke and protect from the sun. I'm going to go with two. That's cheating but that's all right.

Interviewer: What is the absolute worst thing I can do for my skin?

Dr. Smart: Smoking.

Interviewer: What is the one thing you know about skin that everyone should know?

Dr. Smart: Protecting your skin from sun damage will keep you looking better, younger for longer.

Interviewer: Is there any foods that are particularly good for my skin?

Dr. Smart: Yes. Foods that are high in antioxidants, mostly fruits and vegetables do a lot to protect your skin and rejuvenate it.

Interviewer: What is the best technique to keep my skin moisturized?

Dr. Smart: Frequent application.

Interviewer: Why do you chose to specialize in dermatology?

Dr. Smart: The doctor patient relationship. Patients have very visible concerns that they're very worried about that. So they're happy to come to the doctor. It's very gratifying. The interaction is very positive.

Announcer: If you like what you heard, be sure to get our latest content. Sign up for a weekly content updates at thescoperadio.com. This is The Scope, powered by University of Utah Health Sciences.

Interviewer: Newborn acne, is it something to worry about? What should you do about it? We'll find out next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Amy Williams is a pediatrician with University of Utah at the South Jordan Clinic. And a parent has a child and the child gets a rash. And I understand that's a call you get a lot.

Dr. Williams: Yes.

Interviewer: They tend . . . a little freaking out happens. So let's talk about when you should be concerned about that rash, and when it's probably not a big deal, and what to about it.

Dr. Williams: Yeah, great question. I think it's a really difficult thing sometimes to know what a rash is. And quite honestly, a lot of times, doctors have to get second opinions. Rashes can be sometimes very easy and sometimes they are just confusing. So the newborn, usually, they come out with a lot of rashes and I think that's something we can focus on because a lot of them are things that parents can do at home and they don't need to bring them in.

The rash that I most commonly get questions about is the newborn acne, and it usually start to show up a couple of weeks after they're born and they get something that looks very much like a teenager's acne: the white pimples and the red on the cheeks, on the forehead. Sometimes it's all over the neck. And parents get really concerned because it shows up and we . . . they don't know what to do.

A lot of times, this is all just related to the changes that are happening in the baby during that first couple of weeks: they came out of mom, they were exposed to mom's hormones and everything and they're having this changes in their body. And the acne shows up, but quite honestly, it's a very healthy, happy, non-urgent rash. And it's something that parents can do nothing about and just allow the baby to recover from it. It usually takes a couple of weeks, sometimes a couple of months.

Interviewer: And no harm done?

Dr. Williams: No harm.

Interviewer: No skin damage?

Dr. Williams: You don't have to start buying over the counter acne medicine.

Interviewer: It's a little early to start, right?

Dr. Williams: In fact, we encourage you not to do that for a baby. Their skin is so sensitive that they really can't handle any of the medication we do for teenagers or adults. It's very healthy rash and you don't have to do anything about it all, and it will go away on its own.

Interviewer: Are there ever any instances where it doesn't?

Dr. Williams: Sometimes they are so severe that we will have a dermatologist look at it and have an evaluation to see if there's any treatment. Obviously, if there are any signs that it's getting infected or the rash is changing, those are things I would definitely bring the in for. And you can always bring them in for a concerning rash and we can always talk to you about it. If it doesn't feel all right to you, bring your baby in.

Interviewer: Yeah. And you said this lasts for about two weeks, generally?

Dr. Williams: It lasts a couple of weeks to sometimes a couple of months. Sometimes, it lasts until they're four months old and then it resolves on its own. But it's not related to food, it's not related to anything else other than their body just changing.

Interviewer: So if the acne is kind of coming and going and a new one appears, and then disappears and the new appears that goes on for a couple of months, that's totally normal?

Dr. Williams: Totally normal. Don't pop them.

Interviewer: Okay. That more good advice. For the rest of your life, that's good advice, right?

Dr. Williams: Don't ever pop them. It is something that is natural and although maybe they won't look great in baby pictures, it is absolutely normal and fine. Please don't put makeup on the baby. Just let them be who they are, let them transition.

Announcer: Thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Announcer: Health tips, medical news, research and more for happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Sometimes it just doesn't seem right. You exercise. You're leading a healthy, active life. Maybe in another life, you have a little too much fat, but you fixed that, right? You're trying to lose it, yet some of those stubborn areas just won't go away. Well, I want to talk about two non-invasive fat reduction techniques. One is called the CoolSculpting; the other is Kybella. Dr. David Smart is a dermatologist with the University of Utah Health Care.

First of all, I always get little bit skeptical when I hear about non-invasive fat removal. I mean, I kind of hear the ads on the radio. I'm told there's no such thing as a quick fix. So your job . . .

Dr. Smart: Yet, here I am with quick fixes.

Interviewer: So your job is to convince me.

Dr. Smart: Got you. Let's take CoolSculpting. That's a great example. Cool Sculpting is a machine that was invented and developed by dermatologists. It's all based on this principle: fat cells are more sensitive to cold than skin cells, and muscle cells, and all the cells around it.

Interviewer: So they freeze easier?

Dr. Smart: They freeze easier and then they die from being frozen more easily. This has been well known in dermatology for some time. With frostbite, even sometimes, equestrians, it's called equestrians. It's equestrian fat loss. When they're riding horses in the very cold, those inner thighs that are really cold on that saddle, they'll actually start to lose fat on the inner thighs.

Interviewer: Because their fat's freezing?

Dr. Smart: Because their fat's freezing. Also, little children with popsicles, those popsicles sometimes will cause . . . if the popsicles been in the mouth too long, it will cause a fat loss in certain areas. So it's just this cold is killing off the fat. CoolSculpting has been around now for a long enough time, several years.

There have been hundreds of thousands of cases of CoolSculpting done and the results are very reliable. It's not a brand new fad, although there are a lot of machines in the same sector of non-invasive fat loss that I personally do not believe in and have used and thought, "Hey, this doesn't do anything." CoolSculpting is not one of those. CoolSculpting does show results.

Interviewer: So as a doctor, I would think that you would be more to encourage somebody to exercise to get rid of that fat. You know? That last five pounds or those little stubborn areas, "Just keep going and you'll get there."

Dr. Smart: It's important to remember or at least recognize that you can't spot treat fat when you're working out. No matter what exercise video says, you can't do more sit ups, necessarily. "If I really do crunches just very hard, I'm going to get rid of that fat right around the belly button or I'll do these side bends and that would get rid of my love handles." That's just not how the body works. You don't spot treat fat when you exercise.

The ideal candidate for one of these procedures, whether it's Kybella, CoolSculpting, is a person that is in relatively good shape, you haven't just started your weight loss journey, you're not necessarily more than 30 pounds outside of your weight goal, but you have a few stubborn pockets of fat that just don't seem to go away.

Interviewer: Because each one of us has our own little . . .

Dr. Smart: We've all got.

Interviewer: No matter how lean you are, like for example mine is right here on the backside, right?

Dr. Smart: Exactly. So are mine.

Interviewer: I could have a six-pack and I'd still have this roll a little bit.

Dr. Smart: On the back. This little love handle, it just wouldn't do away.

Interviewer: Is that what the CoolSculpting would treat?

Dr. Smart: Precisely, that is what is why it's developed to treat. It was rigorously studied by the scientists that made it in Harvard. It was not created by some company looking to make a quick dollar.

Interviewer: So there's actual evidence-based support?

Dr. Smart: Significant evidence to support this. It is a really great treatment for those areas. For men, right around the love handles, that's a very common area for men to have little pockets of stubborn fat. Women, outer and inner thighs and around the belly button. All these places are potential areas of opportunity to get rid of.

Interviewer: So can I use multiple treatments to treat multiple areas?

Dr. Smart: You sure can. Now CoolSculpting, that treatment was not designed to be a treatment course in the sense that very reliably with one treatment of the area that's treated, about 20% of the fat will leave. But depending on how much fat you have, you might need to do more than one.

Interviewer: So CoolSculpting works different areas of the body. Kybella works primarily for fat under the chin?

Dr. Smart: True. Now that's because it's FDA approved for that area. Kybella is actually a very, sort of groundbreaking, very exciting product. It's less than a year old now, as far as the FDA is concerned. It was FDA approved less than a year ago for the treatment of the submental fat pocket, which is just the double-chin area. That doesn't mean that fat in other areas doesn't respond to it, it just means that the studies were done to get FDA approval were done just there.

Interviewer: Is it the same technique? Is it freezing the fat or is it different than CoolSculpting?

Dr. Smart: It's different. So Kybella is a liquid. It's a chemical that's naturally found in the body. It's produced by the liver and helps to absorb fats in your diet, but if you inject it directly into the fat, it dissolves fat cells. So it's been done for many years in different countries, but it's not just been regulated. Finally, a company here developed a formulation and went through the very rigorous testing to get it safety and efficacy approved by the FDA.

You inject it in a series of injections, so similar to Botox, in very small needles under the chin and it dissolves fat. Most people need to do that injection anywhere from two to four times and it really sharpens the jaw and gets rid of the fat under the chin.

Interviewer: Side effects for either one of these two treatments?

Dr. Smart: With CoolSculpting, there's no cutting, there's no downtime, there's no nothing. As you can imagine, it's destroying some of the fat there. You do get some bruising and a little bit of tenderness that would come from feeling like, "I got a good bruise in this area." Those are the most common side effects. They happen pretty regularly.

Interviewer: What about Kybella?

Dr. Smart: Kybella, those are injections. You do have to be okay with some very small needle pokes. And then I would say that the most common side effect with Kybella is swelling. Most of the time, it's pretty mild. But about one in 10 get a good amount of swelling under the chin, to the size of almost like a golf ball or an Easter egg. So you definitely don't want to do Kybella right before you have some sort of event or some pictures to be taken. You'll most likely be okay, but pretty normally, like I say, about 10%, one out of 10 people, I feel like, get pretty appreciable swelling under the chin.

Interviewer: If somebody is interested in the Kybella treatment, that's physician only.

Dr. Smart: That is available only to physicians and specifically only to physicians that have been trained in Kybella. Allergan, the company that owns Kybella, was very particular about this when they released the medicine. A lot of things in cosmetic medicine get taken up by people that don't know how to use them and it gives the product a bad name because they're using it incorrectly, getting side effects and that's bad for the product, it's bad for the company. So the company was very sure to only release it to physicians that they have specifically trained to do this that have the pathology knowledge to handle any potential side effect that may come up and that aren't going to use it irresponsibly.

Interviewer: So with the case of CoolSculpting and Kybella, what else would a listener need to know to make an informed decision about using one of these procedures? What do they need to know?

Dr. Smart: The amount of people that could benefit from these procedures is enormous. We all have these areas of fat that really tend to bother us. What they should know is that it really does work. It is not a substitute for weight loss and that's probably what I would say to someone who's interested in CoolSculpting.

Whenever anyone comes in and they're interested in body shaping, whether that's liposuction, CoolSculpting, Kybella, we have a discussion about what your outcomes are and where you're starting from, as long as your expectations are realistic. It is not going to change your weight. If you're looking to lose weight, these aren't the treatments for you. If you're looking to simply sculpt some areas of the body, you're the perfect candidate.

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Interviewer: Mole crowdsourcing: it's an innovative way to discover and identify melanoma and that's coming up next on the scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs, The Science and Research Show is on The Scope.

Interviewer: You know, it sounds a little gross. Take a picture of what you suspect to be a cancerous mole and then post it to the Internet for others to see, but it turns out that might be a really effective way to screen for melanoma. Jake Jensen is from the Department of Communication at University of Utah and he won a $2.2 million grant, part of the 2015 and NIH New Innovator Grant to look at that. So first of all, is that an accurate way to screen for skin cancers, take a picture and have non-trained people look at it?

Jake: Well, a dermatologist might quibble with the phrasing of that. Whether it's a form of screening or not, we could debate. What it is is it's a really effective way to potentially move people to go to a dermatologist.

Interviewer: So let's talk about the way things are and why that's not necessarily getting the job done and the way that you hope your research points to the way things could be.

Jake: What happens right now? Well, right now, we say to people, "You should engage in monthly skin self-exams where you look at your body and look for strange moles, strange growths. And when you see them, you should make note of them and you should go into a dermatologist for a clinical skin examination." That's our basic game plan.

There are lots of problems with that game plan. The first problem with a game plan is skin self-exam is not very effective. People are very bad at finding odd-looking lesions and moles on their body. And so I spent the better part of a decade doing research on skin self-examination, trying to improve the technique. And study after study, people were horrible at it. No matter what we did, they were horrible. The only consistency in the research was no matter what we did, people were horrible at skin self-examination and that's what other researchers were finding as well.

We were all frustrated in one day, in my frustration, I walked into one of my colleague's offices because he has a wonderful couch in his office. And I flop myself down on his couch and I said, "I'm so tired of skin self-examination research. No matter what I do, it won't work. There is no solution." And we talked about it for a while as I vented and eventually, he said something that forever changed the way I thought about this. He said . . . keep in mind, he's not a health researcher. He's somebody who studies new media so he was a good person to vent to in that he was like, "I don't know what you're talking about, but I know you're angry." And he said, "Well, is it that individuals are bad at skin self-exam or is it that groups are bad?" And I thought, "Individuals are bad so groups are bad. So I don't understand the question."

Interviewer: Yeah. Because if one person's bad, how are 20 of those people any better?

Jake: I said, "I don't understand the question." He goes, "Well, there's this thing called collective effort that says sometimes a group is good at something when an individual is not. You can take a group of individuals who are bad at a task, but as a group, the group somehow can be used and mobilized to be good at a task." And I said, "Okay. Rather than, 'Are individuals good,' here's what I want to ask." I took a rock or a curve. It's a type of statistical analysis. I said, "Is there a rock curve that fits to this data?"

And there was, at the group level. And here's what it looks like, for most moles that people look at, they're not suspicious. Take a photo of any mole on your body or any mole that you encounter. Take any mole imagery and you show it to people, generally, they say, "That looks fine." However, when more than 19% of people say a mole looks suspicious, now we're in a different world. If you use that as a cutoff, you can find 90% of melanomas because there's something there that the group picks up on. Here's why I kept missing it: because when you're thinking about the individual level of ability, you're saying, "Well, I want individuals to find it 90% of the time." But individuals can't do that. Groups can when we use a cutoff and we say, "Well, if it's more than 19% of the group that's concerned, let's use that as an indicator."

Huge implications for that. It doesn't matter whether you train people. In a sense, the best group is a group where you say, "Just tell us whether you think that's a weird image or not. Is that a weird mole? Just yes or no." Sometimes, people would say to me, "Can we have laypeople doing this?" It's risk factor. They're not trained. When it comes to laypeople, I see no evidence that training them makes them better at this intuitive, sort of "Is it weird or not" because I'm only going to look at them on the group level. I'm not going to look at them as individuals. So I just want to know if the herd finds it weird. And the answer is when they do, we kind of find melanoma.

Interviewer: Let's go back to the original problem. The original problem is individuals aren't good at self-screening. So they see a mole and maybe they might not think it's a problem. Is that the problem? Or is the problem that they don't do anything about it?

Jake: Yeah. Well, chicken or the egg in some ways.

Interviewer: I guess what I'm asking is will this solve the problem that you've laid out?

Jake: So here's what we want to do. I want to tell a real quick story because it'll help you to understand where we want to go with this. Imagine there's a farmer and the famer's name is Joe. Joe is out in the field and Joe sees that he has a weird mole on his arm. He comes home that night and he tells his wife, Martha, "Hey, I've got this weird growth on my arm." Martha says, "You need to go in to a dermatologist."

Joe is reluctant to go to the doctor for any reason and Martha knows this. So she rails on him for the rest of the night. But Joe, "Eh, it's harvest." He'll go later. Eighteen months pass by before Joe eventually goes in. By the time he goes in, he has late-stage melanoma. There's very little they can do for it at that point in time. Joe passes away within the next few months.

I'll give you an alternative ending to that story. Everything is the same about the story, except this: when Joe comes in from the field and shows Martha the mole, Martha pulls out her phone. She snaps a photo of the mole. She doesn't even bother arguing with Joe because she knows Joe will not listen. The next morning at breakfast, Martha slides the phone across the table and says, "Ten thousand people have looked at your mole and 47% of them think it looks weird." And that's such a high score that it was flagged in the tele-dermatology system and a dermatologist who does rural rounds, who will be within 40 minutes of us next week, wants to see you at 9:00AM next Tuesday because she's looked at the mole and she is suspicious as well."

Joe goes in next Tuesday. It's pre-cancerous. The dermatologist chops it off. Joe lives. Now, that cell phone system I just described is what we're trying to build.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research Show is on The Scope.