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.
