Pamper your feet for summer

Summer is the time for pretty nails in sandals. A pair of cracked and dry heels can detract from even the most gorgeous shoes. Thickened calloused feet is a common concern I get from female and male patients, and is something I also struggle with given my affinity for high heels and the extensive walking I do daily. Today, I’m going to share some easy tips that anyone can do at home to get that baby soft feet back.

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Get your skin ready for summer

This is always an exciting time of the year for me. As the weather warms up, I eagerly pull out my stored skirts, blouses, and dresses that cannot be worn during the brutal Minnesota winter. This also means showing more skin and we all want to have healthy and glowy skin to show off.  Below are some of my favorite and easy tips that anyone can try at home get your skin summer ready!

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Review: Neutrogena Light Therapy Acne Mask

Handheld skin care devices are currently en vogue. They range from skin tightening to fighting acne. During my recent American Academy of Dermatology Conference, I came across the Neutrogena LED Acne Mask, and have been testing it out for the past month. Light base acne treatment is an old concept that I’ve briefly touched upon in a previous post (here). Today, I would like to expand on this with some personal experience and review the Neutrogena Light Therapy Acne Mask.

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Dermatology Hospitalist: how we take call

Many of you have asked me to do a post on what is it like to be on call as a dermatologist. First, I would like to clarify the terminology “Dermatology Hospitalist.” Unlike true internal medicine hospitalists who admit patients and are the primary physicians for hospitalized individuals, dermatology hospitalist is a new term coined to describe medical dermatologists that care for hospitalize patients with “a focus on education, research, development of new treatment algorithms, and identification of emerging patterns in disease.”  This is the goal of the Society of Dermatology Hospitalists, which I am a member of.

Essential on-call kit: punch biopsy tools.

With increasing complexity in medical care and drug interactions, skin findings are often one of the first signs of an underlying problem or even the primary problem for someone to be hospitalized. This is especially true for any hospital with a burn center, where patients are often transferred due to their life-threatening skin diseases. At my hospital, we have a busy inpatient consult service that our residents are an integral part of. Those of you who are in medicine know that patient’s responses and symptoms can be in constant flux and require diligent follow through in order to ensure the proper diagnosis and treatment. My philosophy on how a consult service should be is to offer prompt advice and maintain follow up throughout someone’s hospitalization, both of which are much appreciated by our medicine hospitalist colleagues.  We are available 24/7, but thankfully there are very few dermatologic emergencies at night that cannot be taken care of the next day.

My team is made up of three residents and four attendings who take turns being on call. Our residents, drawn from the best medical students, take care of all the information gathering and communications with the various hospital teams. This is the educational and service opportunity for our residents, who must change their mental gears towards a completely different set of problems and take their time to review the latest research. Overwhelmingly, our residents are correct and then it is up to the attending physicians to challenge the residents to think more broadly and systematically. The fun part is when the diagnosis and treatment is elusive, and everyone is able to pitch in to find the right diagnosis. This is probably the closest we come to being Dr House, but more collegiality and less snark.

In a future post, I will be sharing some of the rare and challenging cases that we’ve seen inpatient!

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Science Behind the Cosmetics

Today’s post is to introduce you to the popular injectable cosmetic procedures performed in a dermatologist’s office. I will be discussing the science behind these treatments and in a future post, I will discuss how they are performed and the associated complications.

 

Botox (BOTOX®/BOTOX Cosmetic®, Dysport®)

The most commonly performed cosmetic procedure in the US is Botulinm toxin injections (brand name Botox). Repetitive facial movement along with thinning of the skin as we age leads to these visible lines and wrinkles.  Botulinum toxin helps to reduces these findings.

Botulinum toxin (BTX) is a neurotoxin derived from the bacteria Clostridium botulinumClostridium botulinum produces eight different types of the BXT proteins (A, B, Cα, Cβ, D, E, F, and G), Serotype A is the most potent and is used most commonly. Medical uses of BXT includes upper arm spasticity, painful neck muscle contraction (cervical dystonia), eyelid spasms (blepharospasm), and migraines.

BTX works to reduce muscle contraction by preventing the release of a neurotransmitter (acetylcholine) from the nerves to the muscle. This occurs at the nerve endings on the muscle where BTX degrades proteins that are needed for the neurotransmitter to be extruded out of the nerve and onto the muscle. Technically, this is achieved by BTX A, C, and E cleaving the SNAP-25 protein. Additionally, BTX B, D, F, and G degrades synapobrevin, which also results in a lack of vesicle fusion and subsequent neurotransmission.

Courtesy of Bolognia Dermatology. Botulinum toxins A, C and E catalyze the cleavage of the SNAP-25 protein. Botulinum toxins B, D, F and G catalyze the cleavage of synaptobrevin (or the vesicle-associated membrane protein, VAMP).

OnabotulinumtoxinA (trade name Botox®) and abobotulinumtoxinA (trade name Dysport®) are the 2 common brands of BTX used in dermatology.

When BTX is injected into the muscle, it causes temporary muscle relaxation, that overtime with repeated injections can even lead to muscle atrophy. The FDA has approved Botox injection for forehead wrinkles and crow’s feet. M­ost dermatologists also perform off label cosmetic use including masseter muscle hypertrophy, bunny lines (on the nose), gummy smiles, and even neck wrinkles.

Response usually starts at day 3 with maximal reduction in muscle movement seen by 1-2 weeks. By month 4, the results will start to wear off and follow-up treatments are needed for maintenance.

Image taken from Allergan website. Botox for forehead wrinkles.

 

Courtesy of Bolognia Dermatology. Botox for glabellar lines. A) and during frowning (B). Subject at rest (C) and attempting to frown (D) 1 week after.

 

Courtesy of Bolognia Dermatology. Botox for bunny lines. X marks sites of injection.

 

Hyaluronic acid fillers

Dermal fillers are used for soft-tissue augmentation to help—in addition to botox—in reducing lines and improving facial volume that are lost overtime. With age
there is decrease in the subcutaneous fat around the nose, bilateral temples, superior brow, and buccal cheeks, attributing to an aged face.

Courtesy of Bolognia Dermatology. Besides the wrinkles there are changes in volume from fat redistribution, and bone as well as cartilage resorption.

 

There are various types of dermal fillers approved by the FDA but I will discuss hyaluronic acid (HA) fillers as these are most commonly used.

Hyaluronic acid is a type of glycosaminoglycans (GAGs), molecules made from chains of sugar molecules, normally found in the dermis of the skin, admixed collagen fibers. These sugar molecules are charged and therefore attract and bind to water, essential for giving our skin turgor and a “plump” appearance. Glycosaminoglycans decreases over time, which partially attributes to the wrinkly swallow look of aging.

Cosmetic hyaluronic acids are either derived from rooster combs (Hylaform®) or bacteria Streptococcus fermentation (Restylane®, Belotero® and Juvéderm®) When injected deep into the skin, HAs integrate with the connective tissue in the skin and attracts and bind to water to create the augmentation effect. Overtime, the HA is broken down by enzy­mes in the skin.

In the US, the FDA approves HA fillers for correction of nasolabial folds. Commonly off-label use includes enhancement, marionette lines, oral commissures, cheek augmentation, acne scar revision, and many more.

We use Juvederm in our office. This line has 4 different types of hyaluronic acid fillers, approved for various cosmetic concerns. Juvederm Voluma XC*, Ultra XC, Ultra Plus XC, and Vobella slightly differ in HA molecule size, concentration (crosslinking), and viscosity, allowing for the different contouring abilities on the face.

 

Courtesy of Allergan

 

Voluma is used to improve the midface, specifically volume loss of the cheeks and temple area. This product’s tight crosslinking allows the results to last up to 2 years.

Courtesy of Allergan. Voluma treatment before and after.

Juvederm Ultra XC and Ultra Plus XC are the more bread and butter fillers that we think of to soften the nasolabial folds, the marionette lines, vertical furrows around the mouth, and lip augmentation. Ultra lasts about 6-8 months; Ultra plus up to 1 year. Ultra plus’ higher concentration draws in more water, is better for deeper wrinkles. Ultra and Ultra Plus can both be used for lip augmentation. Ultra Plus may be better suited for individuals with minimal lip to create the foundation; whereas Ultra is great for plumping the lips.

 

Courtesy of Allergan. Treatment of the lower face with a combination of Juvaderm Ultra and Ultra Plus

 

Vobella is the newest approved lip only filler, similar to Ultra XC, but approved by the FDA for lip augmentation. It can last longer and is better to creating a soft look around the lips without looking overly done.

Courtesy of Allergan. Vobella treatment before (left) and 1 month after (right).

Kybella

The newest injectable cosmetic procedure this year is Kybella (deoxycholic acid), for improvement of double chin (submental fat). Weight gain, genetics, or aging can all lead to accumulation of extra fat tissue in the chin, which is often difficult to get rid despite healthy eating and exercise. Surgical procedures can be expensive and risky. Enter Kybella, which through a series of injections (up to 6, at least 1 month apart), can permanently destroy the submental fat.

Deoxycholic acid is a detergent solvent that destroys fat cell (adipocyte) membranes leading to fat cell breakdown (adipocytolysis). Adipocytolysis generates inflammation that recruits immune cells, macrophages, which eats up the dead adipocytes permanent.

 

Courtesy of Allergan.

 

 

*XC= extra comfort, has lidocaine mixed into the filler to decrease pain during injection

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