Gotcha, Blotchy Skin

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Dr. Furnas (00:10):
You've heard of 3D printing? Well, Chanel is bioprinting skin with pigmentation spots. Now, why on earth would they do that? Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:27):
And I'm Josh Korman. From pimples to wrinkles, our skin affects how we feel about ourselves. As two plastic surgeons, we discuss what's new, what's safe, and what to look for when you're ready to hit refresh.

Dr. Furnas (00:42):
Today we're gonna talk about hyperpigmentation, that's a big word, but I think we pretty much know what it means. Hyper a lot, pigment a lot. And so we get these irregular patches of dark pigmentation that don't match the rest of our skin and they can be caused from sunspots or healing or hormones, a lot of things, but a lot come from UV rays.

Dr. Korman (01:13):
So what are UV rays?

Dr. Furnas (01:16):
Well, ultraviolet come from, they come from the sun. They also come from tanning beds. And so when we always talk about a healthy tan, which we don't so much anymore, but certainly in years past, we talk about how good people look with a tan, which is really the body's buildup of melanin, the pigment to protect the skin from the harmful rays of the sun, the UV rays that can damage cells, damage DNA, even cause cancer and wrinkles.

Dr. Korman (01:51):
So I was once in Hawaii and one of the people at the location in the resort found out I was a plastic surgeon and wanted to know whether the H P F 50 was better than the 30 was better than the 20, but you know, which is better. And I remember telling him, well the one that actually has been on for half an hour before you go in the sun and not just the one that goes on five seconds before you jump in the pool and wash it all off and pretend like you put it on all day.

Dr. Furnas (02:21):
Exactly, it's the one you're gonna use, the one you're gonna replace. And if you are in the ocean, you wanna, particularly if there's a reef around, you want reef protective sunscreen because some sunscreens are bad for reefs and we don't wanna contribute to that. But number one, you wanna protect your skin. S P F 30 or above something with zinc, titanium, all of those will be protective. But you do wanna have something that you're not sensitive to that you do replace and that you'll replace about every two hours when you are out in the sun.

Dr. Korman (03:02):
And probably almost nobody does that. So then we'll move along in life and we get different pigmentations. So one of the big times people get hyperpigmentation is during pregnancy and sometimes that goes away, but sometimes it doesn't. And age causes different pigmentation and birth control pills. Yeah, birth control pills, hormones. Hormones I think have a lot of effect on the skin, including pigmentation. So the question is how do we best treat it? I think we're all pretty observant at seeing pigmentation and specifically hyperpigmentation. And maybe I'll get hyper on the hyperpigmentation, but you know, I think on our bodies we seem to be less concerned about it than on our faces. Obviously we wanna make sure that it's not potentially something cancerous. And obviously mold checks and all that are important, but predominantly people talk about hyperpigmentation on the face and I think that's what we're gonna focus on today is hyperpigmentation on the face.

Dr. Furnas (04:09):
And I'm gonna mention one other thing because particularly you and I are surgeons, so we also see hyperpigmentation related to healing. So we will see surgical scars, but any cut, whether it's a pimple you've been picking at, or a mosquito bite, or burn, or scrape, anytime your skin is healing, there is something about the inflammation that triggers melanocytes to kick out pigmentation. And so that is another cause. But Josh is absolutely right. We're gonna focus on hyperpigmentation of the face, which is what brings us around to what was Chanel doing, creating bioprinted skin with pigmentation? Well in fact, the hyperpigmentation market is expected to explode as we get older as a population. We've got increased sun exposure, increased urban and in-home pollution. And so the industry is expected to explode to almost 9 billion in another five years. So people are gonna be spending money on the things we're gonna talk about. So what do you do when you have hyperpigmentation?

Dr. Korman (05:25):
Do you run to see the doctor? Yes, <laugh>

Dr. Furnas (05:29):
Run to see the doctor.

Dr. Korman (05:31):
What might people do first? I think that's also, there's so many products in drugstores and online and how do you even know where to start?

Dr. Furnas (05:42):
Well I think even before you start with the products, we talked about sunscreen, but also uv, protective sunglasses, occlusive clothing and good hats. You know, it's people wear hats but they sometimes aren't occlusive hats or they may be just a baseball cap that doesn't provide enough of a shade. But once you do walk into that drugstore, you wanna look for, I know we talked about sunscreen and then there are various forms of retin retinol that you can put on at night and those products actually will spread out or help spread out the melanin that's already been produced so that it can even out some of those spots. It's not a miracle, but it can help even out the damage that the UV has done.

Dr. Korman (06:36):
So how does it different? You know, they have these different kinds of skin from type one to type six with type one being very, very fair. Caucasians all the way to type six, very dark-skinned African-Americans or African skin and everything in between. So it's really important, like anything in medicine to diagnose before you treat. And it's important to understand that you uh, recognize what type of skin you have before you figure out what might be good because it's not a one size fits all.

Dr. Furnas (07:12):
This is oftentimes called the Fitzpatrick typing that Josh is talking about. And so whenever we approach, whether it's surgery or laser or sometimes products, we will assess how great the risk is that a patient will hyper pigment or scar. And that is related to that Fitzpatrick typing one through six. So one would be very pale and oftentimes associated with light blue eyes, blonde hair, and then six would be very dark pigmentation and dark eyes, dark skin, dark hair, the darker the skin, four, five and six. The greater the risk of hyperpigmentation, particularly after healing, scarring, that type of thing. So we have to be very careful when we're doing an aggressive say, heat type treatment when we're dealing with someone with a Fitzpatrick four, five or six.

Dr. Korman (08:11):
But I would say in my experience in terms of surgical healing, it's not linear. It's not just because you have a six, it's gonna be a worse scar than a type four. There's lots and lots of patients that I've treated who are type six who heal with almost an imperceptible scar when there are type twos, type threes, type fours that have a much more significant uh, scarring pattern. So I think it's not just completely related,

Dr. Furnas (08:41):
No, they're genetics and you're absolutely right Josh. I have taken care of very dark skin with the most beautiful scars and very pale skin with thick ray scars. So genetics plays a huge role and other factors like tension of a wound closure or tension over a joint. But that said, there'll be sort of, it's a little bit trying, like trying to predict the future of uh, stock market performance of a company. You have some information in the background but it's really not predictive. So we've come out with little retinol and sunscreen as far as treatment. A good place to start is getting that cell turnover to start ramping up. So exfoliation is a great start.

Dr. Korman (09:29):
Yeah, actually I think Ellen DeGeneres was the graduation speaker at Tulane University several years ago and her message to the graduates was exfoliate, exfoliate, hydrate what to do for your skin. I think that's certainly an important exfoliation is really, really important.

Dr. Furnas (09:49):
That's funny. I wouldn't have thought of that as advice at a graduation, but that is really good. Lifelong advice, exfoliate, keep your skin rejuvenated and fresh. And one interesting part of exfoliation that a lot of people don't think about is that by scraping off those dead cells, you provide a better entry for topical medications that your cos pharmaceuticals that you're putting on, such as the Retin or the retinol or vitamin C can be protective, can help with hyperpigmentation and alpha hydroxy acids can help contribute to physical exfoliation their chemical exfoliants.

Dr. Korman (10:31):
So one more time. What's a cosmo-ceutical?

Dr. Furnas (10:35):
A cosmo-ceutical, isn't that a great word? Cosmetics and pharmaceutical as those really results-oriented cosmetic substances, topical medications, you could think of it. And so oftentimes you'll find cosmos in med spas or physicians' offices and weaker forms in department stores. So the stronger forms you're gonna find in physician's offices simply because occasionally there will be a side effect and the companies want you to be in the presence of a physician who can help you out so that they don't get a lot of phone calls asking about why am I so red and flaky? Which can happen and dry, which can happen after Retin A.

Dr. Korman (11:24):
Well, I think Retin A is a really go-to product because it's been shown that it's one of the main things that can reorient aging collagen to more youthful collagen. But people often forget that it's very drying and if you live in a dry climate, which includes California and many parts of the United States, you need to hydrate, hydrate and hydrate because you know, otherwise it's like the raisin and the grape. And so if you put a lot of retinols and Retin A's, which are all vitamin A derivatives and you put that on a raisin or a grape and you basically come becomes a raisin, how do you make it a grape again? And it's super important that we remember about that. And hydrate doesn't just mean putting moisture on, it means hydrate from the inside, hydrate from the outside. But if you starting to put retinols on or Retin A on, it's not such a good idea to run to like more, it's not necessarily better. It doesn't mean you put higher strength that you can buy twice a day in thin skin areas like eyelids or around the eyes, you, you really need to be careful because drawing is more susceptible to burning sunblock is imperative. So it's really important that Retin A is not just like, oh, it's the wonder drug, just put that on because you have to be careful.

Dr. Furnas (12:44):
Yeah. And put it on at night because it does make people photosensitive, meaning that when exposed to light, the skin can become red and hot. If you start out at a certain dose and you are just, as Josh described, red and dry and warm and then go down on that dose or stop putting it on every day, dilute it with a moisturizer, but people will become accustomed to a certain strength and then be able to go to a higher strength. But you don't get a better result from overdoing, as Josh said, you just look red and you can look a little bit like a tomato.

Dr. Korman (13:22):
Not that tomatoes are bad, but you know, you don't want to start

Dr. Furnas (13:25):
No offense to tomatoes,

Dr. Korman (13:27):
<laugh>. Yeah, exactly. So what other things are there besides, there's so many go to different med spas and read about things, there's so many other things to choose from besides re so what are some of those, Heather?

Dr. Furnas (13:43):
As far as products,

Dr. Korman (13:45):
Yeah,

Dr. Furnas (13:46):
Vitamin Bs can help the B vitamins like niacin and vitamin B five can help increase the cell turnover and brighten the skin. Something called azalaic acid can help. So anything that, and I mentioned vitamin C, anything that really brightens a skin like that can help.

Dr. Korman (14:08):
So I think that's one of the important things. Like you can actually go to a drug store or you can go to expensive product counters and there's many, many products that have lots of different things in them like vitamin C and peptides and lots of different things and, and it's hard to know like I don't know which one is the right, I don't wanna buy 20 bottles of things and occupy too much of the bathroom with with things I don't even know what they do. So it's hard to know where to start. So what would you do, Heather?

Dr. Furnas (14:38):
Well first I'd go to someplace where there's an expert physician, somebody who works in a physician's office or a med spa, dermatologist, plastic surgeon because you really need your skin examined. Some people with hyperpigmentation may have melasma due to hormones, others it'll be sunspot, sun damage. Others, it could be an illness. There are certain illnesses that carry the risk of hyperpigmentation, in which case it's the hyperthyroidism and Addison's disease and some medications cause that hyperpigmentation. So all that really needs to be addressed. And then the individual should be treated as an individual. So there's no, unfortunately with hyperpigmentation, no one single easy way to handle this. So we talked about products, we talked about a chemical peel, there can be a superficial peel, alpha-hydroxy acid. There can be something that gets deeper like trice acid or TCA peel that will get deeper actually into the dermis. The hydroxy acid, very superficial, although it can be deeper. And then there's laser. And I think laser is probably the most aggressive treatment at the 1,927 or 1927 at nanometer wavelength. And this wavelength will target water. That's what absorbs the heat. And it's done typically as a series anywhere from one, some people just need one to up to four and treatments are spaced about four to six weeks apart. And ironically we're heating the skin and we're trying to get rid of that pigmentation, but we also have to guard against hyperpigmentation during the healing.

Dr. Korman (16:41):
So let's back up just a second and explain what a laser is. So the word laser is actually an acronym. And it's an acronym that stands for light amplification by stimulated emission of radiation, which I realize is a mouthful. But what it really basically means is it's not natural light, it's focused, stimulated, light stimulated radiation. And it's important to understand that because when people always think, oh, just laser it off or laser and there's a lot of different kinds of lasers, often they break down to two different categories, ablative lasers and non-ablative lasers. Ablative lasers are ones that literally sand off certain layers and they're non-ablative lasers which target certain components like water and things we were just talking about. So it's important to understand that one laser is not the same as every kind of laser. And when you are going to a med spa physician's office, it's important to understand that lasers are expensive devices and certainly they recommend lasers that they have.

(17:51):
It's also important that you can understand the language a little bit because a lot of lasers that are competing lasers from different companies do treat the same thing. So when you read about some laser that, oh, that sounds really good for some product, and you go to a med bar or call around and you say, well do you have that laser? They may not have that exact company name laser, but they have a laser that does the same thing or has the same wavelength. It's, it is important to be educated enough to understand what it means. And I think we all recognize that when you have a refrigerator that's broken, you don't really wanna know too much about the refrigerator, you just want to have the refrigerator repair man come and fix the refrigerator. But when it comes to lasers in your skin, it can get very confusing. So it is worth the effort to try to have it explained to you so that you can understand it better because skin is actually the largest organ in the body and it is one of the least understood actually because it has so many different kinds of cells and there's a lot of treatments, but there's not too much magic. And it's good to understand what lasers can do and what they can't do.

Dr. Furnas (19:05):
Yeah, and when you're exploring, one question to ask is, can I see before and after photos, particularly with something visible like I wanna see what hyperpigmentation looked like before and after treatment. And so if they have the right laser, and this should not be company photos from the laser company, but you wanna see photos of of place's own patients.

Dr. Korman (19:29):
And be careful if they show you pictures of histology name, you say, what's histology? Histology are microscopic pictures. And they say, look, see how much improvement there is and and it, there are a lot of treatments that will improve skin at a microscopic level, but then you look at the before and after of patients and you go, Hmm, I can't see that much of a difference. Well that is important to understand because it's not just what treatments do histologically, it's what they do visibly. And ultimately we're all trying to do the same thing, improve the quality and also how the skin looks.

Dr. Furnas (20:11):
So as far as how the skin looks, if you're going for something aggressive like laser, there's a pre-treatment and a post-treatment. And if you are told, say to prepare with hydroquinone for example, that is a skin bleacher, then it's best to do as you're instructed. And you may be instructed to use hydroquinone for a month before and maybe in between treatments and a month or six weeks after your final laser just to keep those melanocytes, those pigment cells from producing extra pigment during that healing phase.

Dr. Korman (20:53):
So when you have different hydroquinone, they come in different strengths. So there's like 2%, 4%, 6%, 8%, 10% or more. How should you figure out what works?

Dr. Furnas (21:05):
Well, I think most commonly 4% is used for this type of treatment. How about you Josh?

Dr. Korman (21:12):
Well, I think it depends a little like you can start with 4%. If it doesn't work, then you can go higher. Regular pharmacies don't often have much higher than the 4% you have to go to compounding pharmacies and you certainly stronger is not necessarily better and it certainly can have more reactions, but sometimes if a certain strength is not working, then you can try a higher strength. Obviously you have to be careful and you have to do under the physician guidance. But it's important to understand the hydroquinone does come in higher strength than just 4%.

Dr. Furnas (21:43):
Now let's say that you are there ready to get your laser, what comes next? Well, you wanna numb first. And so it's best if they put some topical numbing ointment and that should remain in place for 45 minutes to an hour typically, depending on the numbing medication that they give you. And then once you are actually under the laser ready to be lasered, then oftentimes they can give you a cooling device that will blow like refrigerated air. And that makes a big difference because that laser is hot and that cooling device can really help make it much more manageable. And so lasers typically will burn some, but you can tolerate that. And with this type of laser, it's a come and go. You can go home, you may be red scab a little bit after a few days and you should sleep with your head elevated for at least 48 hours to minimize the redness and the swelling and then of course protect your skin from sun as we've been talking about.

Dr. Korman (22:54):
One thing also, if it's really painful, there's pronox also many officers have pronox, which is basically laughing gas and it makes it all very comfortable. It doesn't necessarily take the pain away, it just makes the experience more tolerable.

Dr. Furnas (23:08):
Yeah, pronox has very few risks except if you're pregnant, you don't wanna be pregnant or have the person doing the laser be pregnant. But otherwise it's short acting. It just sort of relaxes during the treatment. And I totally agree that's a great addition to making this more tolerable.

Dr. Korman (23:27):
So after it's all done, after you've had the lasers and often the lasers treatments are not one treatment, there are three treatments, which I guess is figured out by the results with studies. But how do you decide if you want one treatment? Like maybe I don't wanna do a second treatment. Why are they making me pay for three treatments all at once? How would you respond to that?

Dr. Furnas (23:50):
Well, if the practitioner is recommending three treatments, and that could be as many as four treatments, if you just have the one, you're gonna get a minimum result. And these treatments are not cheap, which means you're basically throwing your money away. And so if the practitioner is recommending three, save up for three and then get them 1, 2, 3, and you want to space them apart as recommended six, sometimes eight weeks apart, sometimes four weeks, depending on the depth and the what the practitioner is advising because each treatment builds on the one before. And so if you wanna get the best results, then do the whole plan, the whole series, just as instructed, it may require scheduling when your own schedule can accommodate that, wait until you can do that.

Dr. Korman (24:44):
So in the nutshell, it seems like hyperpigmentation really is a big deal. It happens to most of us and there are many, many treatments and continuing treatments for making it good. You have Chanel looking deep into the cause of hyperpigmentation and what to do. I think ultimately that healthy glow of the sun may not be nearly as healthy as it seems, and lighter may be better than darker in terms of the sun's ray. But it is really important to recognize what your genetics are, what your skin tone is, because as the skin tone is naturally darker, you can tolerate the sun more, but our sun keeps us warm, gives us light, but is actually quite unforgiving to our skin. Of course, with vitamin D, which is one thing we didn't mention, vitamin D is actually really important and sun does help with vitamin D, but vitamin D tablets may be a more healthy way to get the vitamin D we need.

Dr. Furnas (25:51):
Thank you for joining us. This is Skintuition. We'll see you next time.

Dr. Korman (25:57):
Bye-bye.