Index
Lip Service: Healing Chapped Lips
Sun Damaging Your Skin? The Photos Don't Lie
When Psoriasis Gets Under Your Skin and in Your Joints
Booting Up: Don't Forgo Foot Care During Winter
When Psoriasis Gets Under Your Skin and in Your Joints
Booting Up: Don't Forgo Foot Care During Winter
At First Blush: Dealing with Rosacea
Are You Allergic to the Sun?
Caution at the Cosmetics Counter
The Nuts and Bolts of Nail Care
Two Feet Under: Treating Fungal Infections
Dermatologic Uses of Lasers
Skin, Hair, Bath and Body Products You Can Make At Home

Lip Service: Healing Chapped Lips   By: Karen Barrow
Winter can be idyllic: white snow blankets the ground, children bundle up to play outside and couples cuddle in front of a fireplace. But as the winter winds whip, and the arid heat indoors becomes too much, your lips can peel and crack.
Chapped lips are caused by overexposure to wind, sun or dry conditions in any season, but winter is especially troublesome. As tempting as licking your lips can be when they feel like a desert, the saliva will quickly evaporate, leaving your chapped lips feeling even worse.

The best way to care for your aching lips, according to the National Institutes of Health, is to protect them from the elements:

Use a non-flavored lip balm, petroleum jelly or even a skin moisturizer to heavily coat the lips. These products help to both moisturize the lips and prevent them from drying out. 

Avoid flavored lip-balms. They can be more fun and certainly taste better, but also give you an excuse to keep licking your lips, making them wear off quickly.

Remove the dead skin by rubbing a wet, warm washcloth over your lips to gently loosen the flakes. You may need to do this more than once as your lips heal.

To prevent lips from becoming chapped in the first place, the best offense is a good defense:

Apply an unflavored lip balm with sunscreen whenever you go out.
Wear scarves or jackets that block the wind from getting to your lips.
Use a humidifier to moisturize the air in your home, helping to prevent both dry lips and skin.
For women, wear glossy lipstick, as matte lipstick may dry out the lips.
 
In some cases, ill-fitting dentures can also cause lips to dry out. If you suspect that this is the source of the problem, see a dentist to get a proper fit.
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Children and Psoriasis
More than one fourth of those who have psoriasis develop the condition before the age of 18, and between 10 and 15 percent develop it before the age of 10. Although the condition can be effectively managed at any age, people who develop psoriasis at an early age face special challenges-both emotionally and treatment-related.

Emotional Challenges
During childhood and the teenage years, it can be especially difficult to deal with a disease that affects your physical appearance. Young people may feel anxiety about the possibility of rejection because of their skin condition. Younger children also may have a difficult time responding to comments or questions from their classmates.

To help your child, teach him or her the facts about psoriasis. You can do this by buying a book on the condition, or directing your child to a web site such as the one run by the National Psoriasis Foundation (www.psoriasis.org). This will allow your child to confidently explain that psoriasis isn't contagious or caused by a problem like not bathing.

If your child is getting teased at school, you may wish to get involved by speaking to the teacher or having an expert come speak to the class. You can also help your child come up with appropriate responses to any comments made at school.
 
Some children will cope very well with having psoriasis, but others may feel embarrassed, angry or sad. If this is the case, don't attempt to minimize your child's feelings. Assure your child that it's okay to feel unhappy about psoriasis. At the same time, make sure your child understands that although psoriasis is a condition they have to live with, it doesn't define who they are.

Children and teens with psoriasis may benefit from posting to a message board designed for people with the condition or by joining a Pen Pal Club. Both of these options are available from the National Psoriasis Foundation. There's even a summer camp for kids with serious skin conditions, sponsored by the Children's Skin Disease Foundation (www.csdf.org).

The Five Types of Psoriasis
A number of different forms of psoriasis can affect the skin. The five main types are plaque, guttate, inverse, pustular and erythrodermic. Here's an explanation of each of these types.

Plaque: About 80 percent of people with psoriasis have plaque psoriasis. The medical term for this form is psoriasis vulgaris, meaning "ordinary psoriasis." It appears as red, inflamed lesions—also called "plaques"—covered in a silvery-white scale. The scale is composed of dead skin cells that have made their way to the skin's surface. Skin affected by plaques is usually dry, but it also can be painful, itchy and may crack. Lesions may appear anywhere on the skin, but they are most commonly found on the elbows, knees, scalp and lower back.

Guttate: Guttate psoriasis appears as small, red spots on the skin. The spots are not usually as thick and dry as the lesions found in plaque psoriasis. Common triggers for the disease are strep throat and upper respiratory infections, so anyone experiencing guttate psoriasis for the first time should have a throat culture.

Guttate psoriasis often occurs in childhood; nearly a third of people with the condition have their first episode before the age of 20. In some cases, the spots go away on their own; in others, they merge into the larger lesions of plaque psoriasis. Remission is permanent in some cases; in other cases, the condition re-emerges as either guttate or plaque psoriasis.

Inverse: Inverse psoriasis affects areas of the body where the skin bends or touches other skin, such as the groin, the armpit, behind the ear, under the breasts and buttocks and beneath the foreskin of an uncircumcised penis. The plaques are deep red in color, smooth and shiny with a moist, white surface. Infection, friction and heat can contribute to the formation of lesions.

Pustular: In pustular psoriasis, white, pus-filled blisters form over reddened skin. This is a relatively uncommon form of psoriasis, accounting for fewer than five percent of cases. It can affect specific areas of the body, such as the hands and feet, or it can cover large areas of skin. Pustular psoriasis can be the first sign of psoriasis, or it can develop in people who have plaque psoriasis. It is unclear what causes pustular psoriasis, but it may be triggered by certain medications, overexposure to ultraviolet light, pregnancy, corticosteroids, infections and stress.

There are several subtypes of pustular psoriasis. One of them, Von Zumbusch pustular psoriasis, is characterized by widespread eruptions of pustules that dry and peel off after one or two days. This type of psoriasis requires immediate medical attention because it leaves the skin unable to maintain proper fluid balance and fight infections. In palmo-plantar pustulosis, small pustules form on the palms of the hands and soles of the feet. There is also a rare form of psoriasis—called acropustulosis—that affects the ends of the fingers and sometimes the toes.

Erythrodermic: In erythrodermic psoriasis, large areas of the skin become severely inflamed and red. The condition often causes pain and extreme itching. It usually occurs in people who have unstable plaque psoriasis, in which the lesions are not clearly defined. It also may occur in combination with Von Zumbusch pustular psoriasis. Anyone experiencing a flare-up of erythrodermic psoriasis should seek immediate medical attention.

Questions to ask your doctor:
What type of psoriasis do I have?
What can I do to reduce the risk of developing another form of the disease?
Under what circumstances should I go to a hospital or make an emergency appointment to see you?

Can Psoriasis be Cured?
The ideal treatment for psoriasis would clear the disease completely and have no drawbacks. Unfortunately, many of the most effective treatments for psoriasis have unpleasant side effects, are risky when used for long periods or are so new that their long-term safety is unproven. As a result, trying to completely clear psoriasis is not always realistic. A better goal for many people is to see a significant improvement, while keeping side effects to a minimum.

Dermatologists rate the severity of psoriasis using the Psoriasis Area Severity Index (PASI) score. This score takes into account both the size of the area involved and the severity of the lesions. A 75 percent decrease in the PASI score is considered a significant improvement. However, patients may have a different view of what constitutes success. Some people want their skin to be completely clear and view a single dime-sized patch as a problem. For someone else, the goal might be to have arms and legs that are free of the disease so that they can wear short-sleeved shirts and shorts in the summer.

When you consult with a doctor about your psoriasis, it’s important to explain how severely psoriasis affects your quality of life, the results you would like to achieve and how comfortable you are with taking a medication that could have long-term side effects. If the doctor understands your priorities, the two of you will be in a better position to design a plan that balances the benefits and risks of treatment.

Light therapy includes treatments with ultraviolet A and B and laser treatments. Ultraviolet A can cause skin cancer, freckling, skin aging and cataracts. Ultraviolet B is less likely to cause skin cancer and other side effects. Excimer laser treatments can cause redness, blistering and the formation of shallow ulcers; there is a small risk of skin darkening or scarring. Pulsed dye lasers carry a small risk of scarring; the most common side effect is bruising.
 
The Causes of Psoriasis
It is unclear exactly what causes psoriasis, but a variety of factors appears to be at play: genes, an outside trigger and an immune response. Scientists are investigating all three of these to better understand how to treat—and possibly cure—the disease.

Genes: Researchers know that the more genes you share with someone who has psoriasis, the greater the chances are you'll have it, too. For example, the risk of having psoriasis increases if you have one parent with the disease and increases even more if both parents have the disease.

People who have an identical twin with the disease have a 70 percent chance of developing it themselves. This illustrates how important heredity is in determining who gets the disease. Because identical twins have 100 percent of their genes in common, it also shows that genes don't tell the whole story.

Triggering factors: Scientists theorize that a specific trigger, such as emotional stress, an injury to the skin, certain infections (especially streptococcal infections) or a reaction to medication may trigger the disease in people who have a genetic predisposition. The precise nature of these triggers is unknown.

The immune response: People with psoriasis appear to have abnormally activated T-cells, which are a type of white blood cell. T-cells are designed to circulate through the body and trigger an immune response when they encounter a foreign substance, such as bacteria or viruses.

In psoriasis, T-cells are mistakenly activated and respond by multiplying and entering the circulation. They travel through the walls of the blood vessels into the two top layers of the skin.

Once in the skin, the T-cells are reactivated by additional substances causing them to release messenger proteins called cytokines. The cytokines tell specific skin cells to multiply rapidly, forming the scaly plaques that are characteristic of psoriasis. The cytokines also tell the skin to become inflamed. Finally, the cytokines tell more T-cells to become activated, creating a self-perpetuating cycle.

Normally, skin cells take 28 to 30 days to mature, move to the skin's surface and fall off unnoticed. In psoriasis, skin cells mature and move to the skin's surface in just three or four days. Instead of simply falling off, the cells pile up on the surface of the skin in a thick, white, scaly layer. Along with the increase in skin cell growth comes an increase in the growth of blood vessels, causing redness.

Advances in treatment: The most recent therapies for psoriasis are designed to break the cycle of an immune system gone awry. For example, one of the errant cytokines involved in the disease is tumor necrosis factor; several biologic agents that inactivate this cytokine have been approved as treatments for psoriasis. Researchers are developing additional agents to block different parts of the cycle.

Psychological Effects of Psoriasis
While psoriasis may only affect the surface of your skin, its impact can cut to the core. In many cases, the disease influences how others treat you and how you feel about yourself. So one of the major issues when treating psoriasis becomes not only treating the disease, but helping a patient through it with their pride intact.
One of the worst parts of having psoriasis is the way others may avoid you, thinking that psoriasis is contagious or a sign of bad hygiene. In a study that looked at 137 patients with moderate to severe psoriasis, 26 percent reported that during the previous month they had experienced an episode when "people made a conscious effort not to touch them" because of their psoriasis.

Such avoidance can be painful and makes it difficult to maintain a healthy self-image. You may feel self-conscious, helpless, embarrassed, angry or frustrated. And the more battered your self- image, the harder it becomes to expect that people will accept you. Constant worrying about people's perceptions and avoiding certain social situations may become a major source of stress in your life—stress that, ironically, has been shown to make psoriasis worse. Up to 60 percent of people with psoriasis identify stress as a key factor in worsening or triggering the disease.

Moreover, people with psoriasis are at increased risk for emotional problems such as depression, anxiety, thoughts of suicide and body image issues. In a study published in the International Journal of Dermatology, researchers found that about half of psoriasis patients became depressed and anxious when they were first diagnosed. A separate study suggested that up to 10 percent had thoughts of suicide.

One way to counter low self-image and negative feedback from strangers is to have a strong support network. Family and friends who understand what psoriasis is won't judge you and will be able to give you the positive reinforcement you need. Many people find it helpful to share their concerns with other people who have the same condition, such as in online discussion groups. Also, try speaking with your dermatologist about how having psoriasis affects your life: your doctor may recommend a trusted mental health professional who can provide good coping strategies.

Hopefully, with time you can begin to lower the emotional stress of psoriasis and help others see beyond the disease.

Sexual Issues Related to Psoriasis 
Psoriasis can not only affect one's appearance, but it can also have a significant effect on one's quality of life, especially sexual function. 

In a study published in the International Journal of Dermatology, 40 percent of participants reported that their sex life worsened after the symptoms of psoriasis began. Part of this worsening can be explained by the emotional factors that accompany psoriasis, such as depression and embarrassment. Physical symptoms such as pain and irritation also may inhibit sexuality, especially if psoriasis affects the genital area.

Indeed, it is not unusual to have genital psoriasis, and the condition can be extremely distressing. Genital psoriasis usually appears as reddened skin with little itching or scaling. The condition can affect the skin above the genitals or near the anus, the upper thighs, groin, the genitalia themselves and the crease between the buttocks. And since physical examinations don't always include fully undressing, be sure to tell your doctor if you have psoriasis in any of these areas. Untreated genital psoriasis can cause cracking, bleeding and infections. It usually responds well to topical therapy, such as creams and lotions, but caution must be taken because the skin in this area is very sensitive.
 
Overcoming the problems of psoriasis often involves treating both emotional and medical factors. If you have psoriasis and you're feeling depressed, be sure to speak to a doctor—depression is a serious but treatable condition. If you're embarrassed by your condition, remind yourself that having psoriasis is not your fault. You may find that it helps to write down any negative thoughts you have, consider how realistic they are, and recognize that reality is unlikely to match up to your worst-case scenario. Make a point of sharing your concerns with your partner, so that he or she can offer emotional support. Listen to your partner's concerns as well; some people are afraid that psoriasis may be contagious, and it never is. You also may benefit from joining a support group or participating in an online discussion group for people with psoriasis.

Sun Damaging Your Skin? The Photos Don't Lie   By: Karen Barrow
If a picture is worth a thousand words, a special type of photography may be more powerful than any lecture or educational campaign in convincing you of the dangers of sun bathing.

In a recent study published in March 2005 in the Archives of Dermatology, researchers studied the impact of showing UV-filtered photographs to 146 college-aged Californians. One month after seeing the hidden damage that sun exposure had caused, the use of sunscreens by the test subjects increased significantly.

When a UV filter is placed on an ordinary camera, photos will show the amount of damage that the sun has already caused to your skin. The filtered UV light is absorbed by the areas of the skin where there is more melanin, a pigment that is produced to prevent skin damage. The difference between a normal and UV photograph can be quite striking. Freckles, wrinkles and lines caused suddenly appear, making a beautiful, young girl with clear skin look old and speckled.

Regular Photo UV-Filtered Photo
The idea behind this study was to see if the appearance shown by UV photography can scare tanners into the shade. To date, health-related warnings have done little to lower the rate of skin cancer.

"If you take these photographs, they can see that it's not that they will have damage to their skin at some point in the future," said Heike Mahler, professor of psychology at California State University, San Marcos and lead author of the study, "they have the damage now."

In this study, researchers asked college students the amount of time they spent intentionally tanning or were incidentally exposed to sun and how much they knew about skin protection; all participants were informed about the dangers of sun exposure. Then, half of the participants were shown UV-filtered and regular photos taken of their face.

"We'd get an audible gasp when people first looked at their pictures," said Dr. Mahler. "Some people would say, 'Oh no, what does this mean? How bad is this?'"

A month later, the students were called and asked about their adherence to any skin protection plans. Participants did not expect the phone call, so they had no reason to think that their future skin protection, or lack of it, would be monitored. Those who had seen their UV photos were more likely to regularly use sun block or another forms of UV protection than those who did not see their UV photograph. Additionally, 61 percent of those involved told at least one friend or family member what they had learned about UV damage and sun protection; those who had UV photos taken told many more.

Similar studies have shown that UV photography has a similar impact in deterring people from using tanning beds and convincing older beach-goers to protect their skin. Many dermatologists have UV cameras in their office and some skin care companies also offer UV photos, but simply seeing the immediate damage that sun tanning causes in other people, "would provide individuals with yet another reason to take care of their skin," said Dr. Mahler.

Skin cancer is increasing at a rate of 3 percent every year. "I would hope that if awareness of the health risks hasn't motivated individuals to protect their skin up to this point in time, that this added threat to appearance would," she added.

Finding the Ultimate Cause of Psoriasis
Nobody knows exactly what causes psoriasis, but the disease clearly has a genetic component. It is believed that a specific trigger, such as emotional stress, injury to the skin, certain infections (especially streptococcal infections) or a reaction to medication can trigger the skin condition in people who are genetically predisposed to the disease.
One way researchers have been able to learn about the role genes play is by looking at families who have the disease. About 2 percent of the population has psoriasis. But if you have a brother or sister with psoriasis, you have a 50 percent risk of eventually developing the disease if both parents have the disease, a 16 percent risk if one parent has the disease and an 8 percent risk if neither parent is affected.

An especially useful source of genetic information has come from studies involving twins with psoriasis. Fraternal twins have a 20 percent chance of also having the disease, while identical twins have a 70 percent chance. These family studies illustrate that the more genes you share with someone who has psoriasis, the greater the chances that you'll have it, too.

The studies also show that genes don't tell the whole story, which is why researchers are working to learn more about what triggers psoriasis. The genetic theory is complicated by the fact that up to a dozen genes may play a role in psoriasis, and people must inherit a combination of these to develop the disease.
 
Over the past ten years, scientists have identified a number of these genes. The most important one identified so far: psoriasis susceptibility 1 (PSORS1), which appears to be the cause of as many as half of cases of psoriasis.

Scientists hope that learning more about these genes will allow them to develop treatments that counteract the underlying cause of psoriasis. People with this skin disease may be able to help by providing a blood sample for their doctor to send to the National Psoriasis BioBank (formerly called the National Psoriasis Tissue Bank). By examining these DNA samples, scientists may eventually find a cure.


When Psoriasis Gets Under Your Skin and in Your Joints   By: Karen Barrow
More than 4.5 million adults suffer from psoriasis, a chronic condition that causes red, flaky patches of thickened skin. This uncontrollable overgrowth of skin cells can appear on the scalp, hands, feet and genitalia. But the lesions most commonly appear on the elbows, knees and lower back, which might give a hint as to why almost one third of psoriasis sufferers also have a compounding disease, psoriatic arthritis, which affects the joints and can be crippling.

Psoriatic arthritis, however, can be effectively treated in most patients if it is recognized early enough. Alan Menter, MD, chief of dermatology at Baylor Medical Center in Dallas, Texas outlines this potentially disabling disease and the treatments available for it.

What is psoriatic arthritis?
Psoriatic arthritis is an inflammatory joint disease that is almost always associated with a skin disease called psoriasis. There are five different subtypes of the joint disease: anything from just a few swollen fingers and toes to more severe involvement of large joints to very disabling involvement where the hands and feet and the spine get pretty inflamed and chronically destroyed, actually. [It is mainly associated with a decrease in the range of motion, more so than pain.] So, it's a whole range from very minor disease to very severe disease, which can be disabling in about 20 percent of patients.

What causes psoriatic arthritis?
As with a lot of other diseases, there's a genetic component, but there's an environmental component as well, possibly illnesses, infections, stress. There are eight different genes associated with the skin disease, and some of those are also associated with the joint disease.

Psoriasis an immune-mediated disease, whereby T cells, [normal immune cells] are increased in number. As these cells circulate into the skin and the joints, they produce a chemical by the name of TNFα. This chemical leads to the destruction of the skin and the destruction of the joints. But the exact trigger factors of psoriasis, outside of the genetic factors, all remain to be elucidated.

Does skin psoriasis always lead to psoriatic arthritis?
Psoriasis usually occurs five to ten years before the joint disease develops. One out of three patients with the skin disease will develop the joint disease. And the severity of the skin disease does not correlate with the development of psoriatic arthritis. In other words, you can get just a few small patches of skin disease but devastating joint disease, or you can get devastating skin disease with no joint disease. However, psoriatic arthritis is going to present as skin disease in nine out of ten cases before it ever occurs in the joints.

When Psoriasis Gets Under Your Skin and in Your Joints   By: Karen Barrow
How can you tell psoriatic arthritis from other types of arthritis?
Psoriatic arthritis can look identical to rheumatoid arthritis. The big difference is that the blood test for rheumatoid factor, which is positive in rheumatoid arthritis, is negative in people with psoriatic arthritis. Osteoarthritis can also look like psoriatic arthritis in the early stages, particularly because they both affect the fingers and toes. There are some X-ray differences, too. Psoriatic arthritis has some very specific X-ray findings, which rheumatoid arthritis and osteoarthritis don't have. But probably the most important thing when looking for psoriatic arthritis is found on the skin.

Obviously, if you have skin involvement, it makes it much more likely that the joint inflammation is caused by psoriasis and not by the other diseases.
 
What advice do you have for people with psoriasis?
I think the most important message is if you have psoriasis, then at each doctor's visit, the physician or the patient themselves need to be aware that they have approximately a one in three chance of getting the joint disease. And if a doctor is not asking, the patient has got to be telling the physician about symptoms such as, "I'm waking up with swollen joints. My hands are sore. My knees are stiff for about 30 minutes," so that they can be worked up for possible psoriatic arthritis. The sooner we treat them, the less disability there will be. At the moment, we think about one out of five patients with psoriatic arthritis will eventually be disabled. But if you start treatment early, we should be able to prevent disability in most patients.

Saving Face: Cosmetic Procedure Smarts
In a culture that celebrates youth, it can be hard to accept new wrinkles and other skin "imperfections." So many people are turning to doctors to smooth out wrinkles and fix the unevenness and discoloration of the skin that can occur over time.

But these procedures can carry risks of their own. Below, Roy Geronemus, MD, director of the Laser and Skin Surgery Center of New York in New York City and a clinical professor of dermatology at the New York University Medical Center, reviews some of the most common cosmetic skin procedures, and offers advice about how to help ensure you are protected from scarring and other permanent complications.

What are common types of cosmetic skin surgeries?
Dermasurgeons perform a wide variety of cosmetic procedures, including Botox injection, filler substance injection, laser procedures and chemical peels.

What are Botox injections?
Botox injections come from a substance from botulism toxin. When used properly and appropriately, Botox provides a safe and effective method of relaxing muscles under the skin. In doing so, you can diminish the lines on the forehead, the eyes and even the neck. It is a fairly simple procedure performed right in the office. Botox can last anywhere from three months to eight months, depending upon the condition and the needs of the patient. The treatments do need to be repeated at some point in the future.
 
Who is a good candidate and who is not a good candidate for Botox?
A good candidate is someone who is interested in Botox and who has furrow lines between the eyes, horizontal forehead lines across the forehead, crow's feet around the eyes or some bands under the neck. Somebody who is not a candidate for Botox is somebody who has lines on the upper lip or on the cheeks. Botox would also not help somebody who has significant sagging of the skin. In terms of safety, it would not be appropriate to use Botox in people with neurological diseases.

What are the risks?
The risks of Botox, when administered properly and when using the appropriate substance, are very small. The most significant risk is a temporary drooping of the eyelids and that's something that doesn't last very long and does not occur very commonly. It occurs in less than 2 percent of patients and, oftentimes, it's very subtle. You can get some bruising from the procedure or some asymmetry and much of this can be corrected with subsequent treatments.

What are filler substances used for?
Filler substances are used to help plump up the cheeks, to add to the chin and to improve scars. In the past, we used collagen and collagen-like material, such as CosmoDerm and CosmoPlast. There has been an explosion of new filler substances that have come onto the marketplace, such as new hyaluronic acids, including Restylane and Hylaform, and Radius, which is a calcium hydroxyapatite material.

How long do fillers usually last?
The fillers last for varying amounts of time. Some of them just last a few months, others can last up to a couple of years. By and large, most of these filler substances do require a refill. One has to continually augment the area to maintain the benefit that you see from the initial injections.

What kinds of problems can arise from the filler substances?
Risks from the use of filler substances are generally small. In the past, when collagen was available as the only agent, we would see allergy, requiring skin testing before one would go ahead and inject into a larger area. By and large, the only problems we see is some bumpiness of the skin due to over-correction.

What are the different types of laser treatments?
You can use different lasers for different purposes. For example, we'll use one laser to treat redness of the skin, such as from a birthmark or enlarged blood vessels on the face. We'll use a second type of laser to treat brown spots and that same laser to treat tattoos of the skin. We'll use a wide variety of lasers to remove unwanted hair. We'll use different lasers to remove the signs of aging skin, such as wrinkles, loss of skin tone or a generalized discoloration of the skin. The choice of laser may also vary based upon the color of the hair and the pigmentation of someone's skin.

What are the risks of a laser treatment?
With any laser procedure, you can get scarring, burns, changes in pigmentation. That's all the more reason why one should go to someone who's experienced like a dermasurgeon. If you are considering a laser procedure, it is particularly important that you ask your physician a simple question: "Do you have the correct laser for my condition?"

What are chemical peels?
Chemical peels involve applying a substance, oftentimes acids, to the skin, to create a rejuvenation effect. Chemical peels are used to give one a fresher look and improve skin tone, to remove discoloration of the skin and improve mild imperfections in skin texture. Many of the chemical peels result in significant peeling or sloughing of the skin surface. There are some very superficial peels, like a glycolic peel or some of the fruit acid peels. With more mild peels, the effect is much less noticeable.

What are some of the risks of chemical peels?
The more aggressive chemical peels (the trichloroacetic acid, a phenol peel) will result in more wounding of the skin and a need for more downtime after surgery. Risks from chemical peeling would include risk of scarring from the procedure itself, risk of change or loss of pigmentation and some prolonged redness.

How does one go about selecting a physician?
Ideally, you should see a dermasurgeon, a dermatologist who has specialized training in the use of these procedures, whether it be laser or Botox or filler substance injection or chemical peeling. You would like to make sure that physician is board-certified. If need be, you can check with the state regulatory bodies to make sure that the physician is licensed and is in good standing.

You can also go to a society website, such as the website for the American Society for Dermatologic Surgery, or ask your primary care physician or dermatologist who the appropriate person would be to treat your condition.

You also want to make sure that the physician has the appropriate treatment or technology for your condition. For example, if you're a dark-skinned patient and you want to go in for a laser hair removal procedure, there are a few lasers you could use and many you can't use.

You also want to make sure that the physician has experience in treating that particular condition over a period of time. A fair question to ask the physician is: "Have you done this before? Can you show me photographs?" If you want to confirm it ask, "Can I speak to another patient who's had this procedure performed?"

What is the difference between going to a spa or a skin surgery center?
In a spa, you're looking for beauty treatments or treatments to improve the condition of your skin, like facials, very light chemical peels, massages and other procedures that do not necessarily injure the skin. Spa treatments are generally delivered by aestheticians or other nonmedical professionals. But there are many procedures that are considered the practice of medicine, such as laser procedures, Botox injections and deep chemical peels, which should not be performed by an untrained medical person. These are procedures that should be done either by a physician or by a trained medical person under a physician's direct supervision.

Are there any red flags to watch out for?
First of all, if someone promises that there's a procedure that's totally safe, I would be very concerned. All procedures, no matter how many times they've been performed and how safe they may be, still carry some risk. The other thing that I would be concerned about is if you are guaranteed a cure. There are many procedures where the success rate is extraordinarily high, and most people are very happy with the procedures that are performed properly in today's dermasurgical practice. But, if a physician guarantees you that you'll be 100 percent satisfied, I would probably walk away.

Booting Up: Don't Forgo Foot Care During Winter   By: Christine Haran
As people store their sandals and other airy summer shoes for the winter, they are probably not thinking about how their feet will adjust to boots. In fact, people in the colder parts of the country may not be considering their feet much at all since they will no longer be on public view. But the truth is, the feet often need more care in winter, not less.
"Feet tend to sweat more when they're enclosed in heavy socks and shoes, so the feet smell more and there are more fungal infections," says Arnold Ravick, DPM, a spokesperson for the American Podiatric Medical Association and a podiatrist in private practice in Washington, DC. "Feet also dry out more in the winter."

Foot Fungus
Fungi, which are organisms that grow on dead or dying tissues, can appear on the skin of the feet as athlete's foot or on the toenails. People tend to pick up foot fungus by walking barefoot in public locker rooms, and that fungus can thrive inside a wet sock or a rubber boot. In fact, a fungus may live inside a winter shoe over the summer, just waiting to re-infect a foot or toenail.

Unfortunately, people don't always immediately realize that they have developed a fungal infection. "While people think of athlete's foot as the cracking and blistering between toes, it can also appear as dry, flaky skin on the back of the heels and little bubbles or bumps on the arch area or on the sides of the foot," Dr. Ravick says.
 
Sometimes a fungal infection on the skin of the feet can spread to the nails, or a nail fungal infection starts when the nail is damaged or cracked. Nail fungal infections usually appear as a yellow or brownish discoloration of the toenail and can become thick and disfigured. Cutting the toenails straight across and avoiding pointy shoes that crush the toes may help prevent ingrown toenails and minimize nail damage that can lead toenail infections.

Fungal infections can be treated with a range of medications, including creams such as Lotrimin, a nail lacquer such as Penlac, or oral antifungals such as Lamisil or Sporanox. Because nail fungal infections can be particularly resistant, one may ultimately need a podiatrist remove the affected nail.

People with fungal infections are at high risk for re-infection, Dr. Ravick says, especially if they don't treat their shoes. "When people have fungal infections, microscopic skin and nail pieces get into your socks and shoes," he says. "You're figuring people wash their feet and socks, but they don't wash their shoes. I have my patients spray all of their shoes once a week with an anti-fungal spray like Tinactin."

Dryness Dangers
The colder months also leave people more vulnerable to dry and even cracking feet. The lack of moisture in the air can dry out the feet, and heavy socks and shoes may prohibit dead skin from shedding, leading to flaky feet.

To keep your feet from drying out, podiatrists advise moisturizing the feet once or twice a day, especially around the heels and sides of the foot. Although you may be tempted to take a near-scalding shower or bath when it's chilly outside, Dr. Ravick warns that hot water damages and dries out the skin. Instead, bathe or shower in warm water, then pat your feet dry and apply moisturizer. Don't moisturize the nails or the area between the toes too heavily, he says, as that may create an inviting environment for fungus.

To make sure dead skin is removed from the foot, you may also want to pumice your feet weekly. Dr. Ravick suggests adding some baby oil or moisturizing lotion to warm water, and soaking the feet. After patting the feet dry, pumice gently and then moisturize afterwards.

This routine may be particularly helpful to people who develop cracks, or fissures, in their heels, which is a part of the foot that takes a lot of stress during walking. If the foot does start to crack, apply a heavy lotion such as Vaseline or cocoa butter, then cover the foot in Saran Wrap and then socks before you go to bed. If the cracks are bleeding, apply an antibiotic cream and a Band-Aid to prevent them from getting infected with bacteria.

Poorly fitting shoes may contribute to cracking, Dr. Ravick says. If you're shopping for winter shoes, do so at the end of the day when your foot is swollen and make sure you can stick an index finger in the back of the shoe. "My advice to go to a store where they measure your feet," he says. "People think they should wear the same size when they're 16 and 60, but your feet change."
 
Frostbitten Feet
Although frostbite of the foot is preventable with the appropriate socks and shoes, people do leave themselves at risk when they spend time outside in wet socks and shoes in extremely low temperatures, such as below 15° F (-9.4° C).

Dr. Ravick warns that you shouldn't expose frostbitten feet to hot water because you are likely to burn your feet, which may be numb from the cold. He suggests using lukewarm water instead. If the socks aren't stuck to the feet, they should be removed. Otherwise, they should be left until the area is re-warmed. People with severe frostbite, which can cause blisters and a blackening of the skin, should go to the hospital, where antibiotics may be administered.

Given the many threats to feet in the colder months, podiatrists advise that you take the time to protect your feet during the winter, so they will be healthy for their unveiling next spring.

Follow these important tips to prevent winter fungal infections:

Change socks daily
Keep feet clean and dry
Wear 100 percent cotton socks
Use foot powder in socks and shoes
Caring for feet exposed to cold:
Soak feet in tepid, not hot, water
Do not warm feet near a heat source such as open flame or use a heating pad
Receive immediate medical attention if there are signs of tissue damage

At First Blush: Dealing with Rosacea   By Christine Haran
Some people will blush easily when faced with an embarrassing situation, but others seem to be almost continually flushed. Men and women who develop a chronic redness in their face, and sometimes red bumps and visible blood vessels, are likely to be among the 14 million Americans with the skin condition rosacea. While the cause of rosacea is not well understood, it is theorized that it is due to factors such as sensitive blood vessels, inflammation and possibly infection.

James Del Rosso, DO, a dermatologist in private practice at the Las Vegas Skin and Cancer Clinic and a clinical assistant professor in the department of dermatology at the University of Nevada School of Medicine, emphasizes that avoiding one's personal triggers for rosacea flare-ups, as well as a commitment to a treatment plan, is key in successfully controlling this chronic condition. Below, Dr. Del Rosso explains how to care for skin affected by this commonly misunderstood condition.

What is rosacea?
Rosacea is a very common condition that predominantly affects the face. It's characterized by the development of redness, which is usually on the cheek, though it could be on the forehead and the chin area and the nose. Patients will notice a fluctuating redness. Some will have more of a tendency to flush than others. It's not uncommon for the redness to be associated with some red bumps, similar to what you would see in acne, and also some pus-filled bumps. It's also common for patients to develop little, thin, visible red blood vessels on their skin; they develop more of these than they would develop normally with age.
 
In some individuals with rosacea, the nose will become very bulbous. That's actually fairly uncommon and it only occurs in a small subset of men. This bulbous nose has been talked about as the W.C. Fields nose. That's why people equated rosacea with being caused by alcohol, but the bulbous nose is not caused by alcohol. Alcohol is only a flare factor.

Rosacea is not a condition that is curable, but there are ways that you can try to control the severity of it: the intensity and frequency of the flare-ups and the associated symptoms, which include a feeling of warmth, burning, stinging and skin that is easily irritated.

Who gets rosacea?
Rosacea usually develops after the teenage years, probably after 30, but it could also develop later. It tends to be more common in Caucasians, especially very fair-skinned Caucasians that are of Northern European origin such as people from Ireland, England, Scandinavia, Celtic origins, though it can affect anyone.

I think it's relatively equally distributed between women and men, though there is some suggestion that it may be a little bit more common in women. That may be because more women come in to the doctor even if they have a milder rosacea, whereas not as many men are as bothered by the milder cases. But many men and many women want to improve their condition.

Does rosacea affect other parts of the body?
It's not uncommon for individuals with rosacea on the skin to also have what's called ocular rosacea because there's an inflammatory process that's going on in the skin that also affects the eye. Many patients that have rosacea will have a gritty sensation in their eyes. Their eyes will be easily irritated and sensitive, and they may have some redness of their eyelids.

People will sometimes think that they have allergies or something else that they don't correlate with their skin condition. So when they go in to see someone for their skin, they don't tell them about their eye symptoms. And, if they're not asked, the diagnosis will be missed, and they will miss out on the appropriate treatment.

What can trigger or worsen rosacea?
Anything that causes the blood vessels in the skin to dilate will tend to cause flares of rosacea. That includes anything that creates a lot of heat, such as drinking hot liquids, eating hot foods and drinking alcoholic beverages, especially red wines. Medications that dilate the skin like niacin, which is a vitamin, can also cause flushing. Rosacea can sometimes worsen with menopause because flushing is a part of menopause. Ultraviolet light exposure, whether from the sun or tanning beds, will worsen rosacea and make it more difficult to control.

What is a good treatment approach?
The first thing to do in treatment is to make sure you understand your condition. There is no quick fix. People will have rosacea for their entire life, so they will need treatment indefinitely.

One of the first things in treating rosacea is for the individual to address what they think might be flaring it. If someone wants to have two glasses of wine a day, and if that's a flare factor for them, then they are accepting that they are going to worsen their rosacea.

The second part of treatment is gentle skin care. It's very important that patients with rosacea not run to pharmacies or department stores and buy the expensive XYZ product that's being promoted. They need to use gentle skin care products, and those are best selected by a dermatologist or a professional at the dermatologist's office. They need to cleanse very gently, not use astringents, drying-type products or products with a lot of additives like glycolic acid, which will further irritate their skin. 

What is your advice to someone with rosacea?
If a patient has what they believe to be rosacea, they should seek the care of a dermatologist, write down their symptoms, write down the products that they are currently using on their skin and embark on what is selected as an appropriate skin care program and treatment program and follow it through, realizing that it may take two to three months to evaluate the initial benefits. It may take a few adjustments in their treatment until they get control of the condition, and then they need to follow through on the long-term maintenance of the condition.


Are You Allergic to the Sun?   By Christine Haran
Although die-hard sun worshipers continue to oil up to better catch the sun's tanning rays, most Americans choose to slather on sunscreen instead. Sunscreen can help protect them from most of the harmful effects of ultraviolet light, but it will do little for certain sun-sensitive individuals. These would-be sun seekers wind up with an itchy, bumpy rash that is sometimes called "sun poisoning" even if they're wearing SPF 50.

"Sun poisoning" is really an allergic reaction to the sun that occurs when skin is exposed to sunlight for the first time in the early spring, or during a winter vacation. While people with light skin are most susceptible to sunburn, sun allergy affects people of all skin colors.

If people with sun allergy venture to the beach at all, you can probably find them in a floppy hat, under an umbrella. Or, at least, that's where they should be. Below, Henry W. Lim, MD, chair of the department of dermatology at Henry Ford Hospital in Detroit, Michigan, talks about how to prevent and treat allergic reactions to the sun, as well as rashes triggered by sunscreen ingredients.

Can someone have a sun allergy?
There are certain skin reactions to the sun that have nothing to do with sunscreen or other external factors, which we call an intrinsic type of photodermatosis. People with photodermatosis develop skin rashes following exposure to the sun. Polymorphous light eruption is the most common type of photodermatosis. It is most likely due to an abnormal immune system reaction to the sun. Polymorphous light eruption occurs in approximately 10 to 20 percent of otherwise healthy individuals, so it is a relatively common condition.

Then there is another group of people who develop what they think is a sun allergy because of medications that they have ingested or agents that they have applied, including sunscreen. These people develop an irritant reaction, which is a rash or a tingling, itchy sensation on the skin. The chances of getting a true allergic reaction to sunscreen are actually very low.

What are the symptoms?
People usually develop reactions within a few hours of sun exposure. The typical scenario would be that they get exposed to the sun during the day, and then at the end of the day they start noticing the development of red bumps or blisters in the exposed area. It tends to be somewhat itchy. The polymorphous light eruption produces a rash that looks more like hives or insect bites. Sometimes people have no symptoms. If the reaction is untreated, it usually lasts for a few days, or up to two weeks. Then it would go away by itself.

Does it get worse or better with repeated exposure?
It tends to occur most commonly in the springtime in a temperate climate when people first start getting sun exposure. Typically as the season progresses, the person becomes less sensitive to developing this reaction; the thought is that the skin adjusts to this effect of the sun. But any kind of sudden and relatively intense exposure to the sun would bring this up. A typical scenario in the winter is when patients from Northern climates go to the Caribbean or Hawaii, for example, for their winter vacation.

Can someone develop sun allergy at any time in their life?
It can occur at any time in someone's life, but typically it occurs in people in their 20s and their 30s. And it can occur in people of all skin types. So not only Caucasians, but also Asians, Latinos and black people can develop photosensitivity.

Is sun allergy ever a sign of an underlying condition?
There have been some reports of an association with lupus and with thyroid problems, but those are exceptions rather than the rule. We do evaluate patients for those conditions on a routine basis. We ask them questions and take some blood tests, if necessary. But the vast majority of patients are perfectly healthy otherwise.

What kind of ultraviolet light causes the reaction?
It's usually UVB light, but it could be UVA also. So it varies from person to person and one would have to test for it. The testing is usually conducted in a clinic setting. We can use light sources that emit predominantly UVB or light sources that emit predominantly UVA to see which one would induce the lesion.

That would help to guide the treatment somewhat. Realistically, however, the testing is not that widely available because only specialized photodermatology centers would be able to perform it, and it is not 100 percent positive in all patients.

How can people avoid allergic reactions to the sun?
As a first-line treatment, we usually ask the person to avoid the sun if possible, and if they do go out in the sun to use photo-protective measures. So in addition to staying in the shade, they should wear a long-sleeve shirt if possible and use what we call broad-spectrum sunscreen that has UVB as well as UVA blockers. If someone knows that they are only sensitive to UVB, it's not as essential that they use the broad-spectrum sunscreen.
 
We ask people to look for sunscreen that has SPF 15 or above because the probability of having UVB and fairly good UVA protection is quite good. People should specifically look for the word "broad-spectrum" on the label.

How can people avoid sunscreen reactions?
If the reaction is due to irritation secondary to an ingredient in the sunscreen, clearly an avoidance of that ingredient is the first step. Usually I tell the person to try different types of sunscreens. A lot of the time sunscreens for children or sunscreens for the face tend to be better tolerated because they have less alcohol content, so sometimes I recommend trying those. Another approach is using sunscreen that contains only titanium dioxide and zinc oxide. Those two ingredients have never been reported to cause allergic reactions.

When should you see a dermatologist or a doctor if you think that you might have a sun allergy?
I think if you have more than one episode, or if you have a very severe episode of skin eruption following sun exposure, it would be worthwhile to consult a dermatologist at that time. You might also see a dermatologist if your first-time reaction doesn't go away after a few days, or if it's very itchy, very red, very bumpy, very extensive. If untreated, the area will continue to be uncomfortable and could lead to an infection or skin breakdown

Fighting Facial Infections: Folliculitis and Friends   By Christine Haran
Although you might not like to think about it, millions of microorganisms, including bacteria, are living on your skin. Most of the time, bacteria inhabit the skin without causing any problems. But if you get a cut or scrape or even an insect bite, everyday bacteria such as Streptococcus and Staphylococcus may take the opportunity to slip under the skin and cause an infection.

Streptococcus and Staphylococcus may sound familiar because these bacteria are responsible for a wide range of infections throughout the body. For example, Streptococcus can lead to mild illness such as strep throat, or much more rarely, necrotizing fasciitis, also known as "flesh-eating bacteria," which damages not only skin tissue but also muscle and fat. And Staphylococcus can cause illnesses such as meningitis and toxic shock syndrome.

The most common bacterial infections of the skin are folliculitis, cellulitis and impetigo, a contagious skin infection often seen in preschool children. Below, Susan Taylor, MD, a clinical professor of dermatology at Columbia University College of Physicians and Surgeons in New York City, explains the causes and symptoms of bacterial skin infections and how to keep your skin clear and free of these annoying and sometimes painful conditions.

What is folliculitis?
Folliculitis is an inflammation and infection of the hair follicle caused by bacteria that live on the skin's surface such as Staphylococcus aureus. We know that bacteria and sometimes fungus are introduced into the follicle, where they reproduce. Men and women who shave are most at risk, so folliculitis is somewhat common. Most often, it appears as pus bumps on the legs and bikini areas of women and the beard area of men. Folliculitis is more common among women when the weather gets warm and they start shaving more often. Hot tub folliculitis is contracted from hot tub water contaminated with a gram-negative bacteria called Pseudomonas aeruginosa.

How can folliculitis be prevented?
Discontinuing shaving is often helpful. So, for men who frequently develop folliculitis, a good option might be growing a beard. Razor bumps, also known as pseudofolliculitis barbae, which is an inflammatory reaction due to ingrown hairs, produces a painful bump. A curly hair grows out of the hair follicle and then turns and pierces the skin. An infection from S. aureus can then develop within the bump. This also improves when men grow a beard.

If people do choose to shave, shaving in a downward fashion, as opposed to against the hair growth, can help. Shaving with a sharp razor so you only need one pass reduces risk. Sometimes using shaving creams that contain benzol peroxide or antibacterial agents can also help.
 
How is folliculitis treated?
Hot tub folliculitis usually goes away without treatment if you avoid contaminated hot tubs. Regular folliculitis is treated with topical and/or oral antibiotics for one to two weeks. Over-the-counter antibiotics such as Neosporin can have a mild antibacterial effect.

What is cellulitis?
Cellulitis is a bacterial infection of the skin that is much less common than folliculitis. Like folliculitis, it's usually caused by either Streptococcus or Staphylococcus that live on the skin. Usually, there's some type of inciting event, such as an injury or a wound, which leads to the infection. Sometimes even a significant scratch will introduce the bacteria beneath the surface of the skin, where it multiplies.

What are the symptoms?
The skin becomes red, hot, tender and swollen, and the surface may resemble the skin of an orange peel. Patients sometimes develop a fever or nausea. Symptoms usually develop within 24 hours of the injury. If cellulitis spreads to the face or the hands, it can impinge on important structures. For example, in the hands, swelling can compress nerves and tendons, so you wouldn't be able to use your fingers. On the face, cellulitis can be catastrophic if it involves the eye. With severe infection, you can sometimes see a red streak across the affected area that represents an infection of the lymphatic system. (The lymphatic system gets involved because cells that fight infection exit the area via the lymph system.)

Who is most at risk?
There are some people who seem more prone to cellulitis, particularly those with diabetes. People with diabetes, who are more likely to develop leg ulcers, are at higher risk because bacteria can be introduced beneath the surface of the skin in the area of the ulcer. Cellulitis can also follow surgeries because surgical wounds can create an entryway for the bacteria.

How is cellulitis treated?
Warm compresses or soaks, and pain relievers, which can also reduce fever, can help. We would also treat with oral antibiotics for about 10 days, although intravenous antibiotics are sometimes necessary.

What is impetigo?
Impetigo is a bacterial skin infection caused, again, by S. aureus or Streptococcus. It's generally seen in children, although it can occur in adults. Usually, you will see what's described as a honeycomb, which is a yellow, sticky type of crusting. It can be painful, though you don't usually have a fever. There's a variety that presents with blisters that's called bullous impetigo. Rather than cause a honey-colored crust, this type of impetigo leads to bumps with fluid inside that oozes.

Impetigo can affect any part of the body, including the face, hands, arms. And it can be contagious—it's an infection of the top layers of skin that is often spread by scratching—whereas cellulitis isn't usually infectious.

And how is it treated?
Impetigo can be treated with oral antibiotics and/or topical antibiotics. Sometimes it resolves spontaneously.

What is erysipelas?
Erysipelas is skin infection usually caused by hemolytic streptococcal bacteria. It can make the skin look very angry, meaning very red and hot. It can involve any part of the body, although we see it more commonly on the face, the legs and the ears. It can be associated with fevers and chills. It is primarily a disease of adults.

In contrast to cellulitis, where the border spreads, with erysipelas, you can have a very defined, sharp, raised border around the affected area. It is a more superficial skin infection than cellulitis. Erysipelas is also treated with antibiotics.

What are furuncles?
Furuncles look like boils that usually occur in adults. They are also caused by Staphylococcus and Streptococcus. Like folliculitis, furuncles are an infection of the hair follicle, but this infection produces a large, round, tender area, or nodule, whereas folliculitis produces a bump or pustule.

Furuncles are usually not associated with fever. We usually treat them with compresses and antibiotics; sometimes we lance the nodule to drain the pus.

What are carbuncles?
Carbuncles are larger and usually involve several hair follicles. Carbuncle infections run a bit deeper than furuncles; it usually involves the dermis and the subcutaneous tissue. Sometimes carbuncles are associated with fevers and chills. Treatment is essentially the same: we lance them, we put soaks on them and we use antibiotics.
 

Caution at the Cosmetics Counter   By Christine Haran
Anyone who has wandered through the maze of cosmetics counters in their local department store, or even just hit their neighborhood drugstore, knows that thousands of products have been developed to cater to people seeking flawless skin. But in certain people, skin care products, including make-up and sunscreen, as well as hair and nail care products, can lead to an allergic reaction on the skin called contact dermatitis. Sometimes it's even difficult for people and their doctors to discern the cause of the allergic reaction because the rash may not appear in the area where the product was applied.

Unfortunately, avoiding allergic reactions isn't as simple as choosing products labeled "hypoallergenic." And products designed "all natural" aren't any less likely to cause allergic reactions than other products, either. Below, Frances J. Storrs, MD, a professor of dermatology emerita at Oregon Health and Science University in Portland who specializes in contact dermatitis, explains how to wisely choose your skin products.

What kinds of allergic reactions to skin products do people usually have?
They usually develop contact dermatitis, which is the allergic reaction similar to the one you would get if exposed to poison oak or poison ivy. So someone might just have dry skin, and as they begin to use a product, their skin becomes more and more red and they might develop what we call vesicles. These are little tiny blisters on the skin that become crusty and ooze and then spread to other parts of the body. The dermatitis might spread up an arm or the whole face or the eyelids might be involved. Depending on how strong an allergen you're dealing with, you may get an allergic eczema, which is an itchy rash. The allergic reaction just gets worse and worse until the person stops using the product.
 
Who is most likely to have an allergic reaction to a skin product?
Occasionally allergic reactions occur in people with normal skin, but more often then not, they occur in people in which the barrier has been broken so that the skin is no longer completely intact. This includes someone with a little bit of flaking on their face—something we call seborrheic dermatitis—or someone with eczema or someone who just has dry skin.

What products cause allergic reactions?
Lotions and creams, foundations, moisturizers, sunscreens, shampoos, salon hair care products and nail care products are most likely to cause allergic reactions.

What ingredients in skin care products are most likely to cause an allergic reaction?
It depends on the product you're talking about, but the most common problems are caused by preservatives. Any agent that contains water requires a preservative to keep bacteria or funguses from growing in it. The most common preservatives associated with allergy are those that release formaldehyde. A good example of that is quaternium 15 found in various lotions or creams or even shampoos and cleansing agents. There's also a collection of moisturizing lotions that are preserved with a chemical called methyldibromo glutaronitrile.

If you are allergic to those chemicals, you will need to avoid products that contain them, so you will have to learn to look for them on the label of all skin and hair care products. Parabens are another type of preservative that are used in thousands of products, and they cause fewer allergic reactions.

What ingredients other than preservatives can cause allergic reactions?
In addition to the preservatives, some people think perfumes are common causes of contact dermatitis. I think fragrances are probably overrated, frankly, as a cause of allergic reactions. But fragrances are very complicated compounds that contain hundreds of chemicals that might cause an allergic reaction.

An ingredient we're seeing more and more of right now are the botanicals found in products like shampoos. Botanicals are plant extracts, or the so-called "natural" chemicals. They may have an odor, but they are not officially designated as fragrances on the label. In my office, I've seen three people who were using a deodorant that contained some extracts of lichens who developed severe underarm dermatitis. Lichens are little primitive plants that grow on trees.

Can people have allergic reactions to products that are too old?
They can but I can honestly say I've never seen anybody develop a skin infection from using a product that was too old. When bacteria and fungus grow on the product because the preservative is no longer active, you can see them, and it looks awful. It's like seeing a piece of moldy bread. If you ate the moldy bread, probably nothing would happen to you, but it's going to taste awful and it looks awful.

There is some concern about bacteria and fungus in products that are used around the eye though. So the advice for using products around the eyes, such as mascara, is usually to replace them every six months to make sure that it's properly preserved and fresh.

Why do sunscreens cause allergic reactions?
In the United States, some sunscreens contain chemicals called oxybenzone and octyl dimethyl PABA, which have been associated with allergic contact dermatitis reactions. Unfortunately, the cosmetics industry does not require that those chemicals be designated by those names on the label, so they may use alternative names for these chemicals. Now there are excellent alterative sunscreens that are advertised as being what they call chemical free. Now they're not chemically free. When they say "chemical free," it means they don't contain the sunscreens that have been most commonly associated with allergic contact dermatitis reactions. Instead, they contain zinc oxide or titanium dioxide, which are pretty inert substances and excellent sunscreens.

Why do hair care products cause allergic reactions?
Far and away the most common cause of allergic reactions to hair care products in the United States are certain kind of hair dyes. These are the two-part hair dyes, which contain a chemical called paraphenylenediamine. Fortunately, there are lots of substitutes for permanent hair dyes. So the semi-permanent hair dyes or ones that don't last quite as long usually don't contain that chemical.

And the second most common hair product to cause allergic reactions is permanent waves that contain a chemical called glyceryl thioglycolate. These are usually three-part permanent waves, or so-called "acid perms." Cysteamine is a new chemical in permanent waves that can cause allergy. However, I think it's going to be a very rare problem. And another good alternative are two-part perms, which contain ammonium thioglycolate. These are the old-fashioned cold permanent waves, and they hardly ever cause allergy problems.

What about nail care products?
We see extremely interesting problems from chemicals in both nail polishes and artificial fingernails. An artificial fingernail problem can actually be quite horrendous because they are caused by complicated acrylate chemicals. These are chemicals that are used by mechanics to use as adhesives on screws when they're putting them in things like motors, and they might be used as sealants for a glasswork.

If you're allergic to some of these acrylates in artificial fingernails, or you're allergic to some of the formaldehyde resins that are used in nail polishes, you may break out in a very interesting way. You'll break out on your eyelids and around your mouth and on the sides of your neck. So people come in and the skin around their nails and hands looks perfectly normal, and the reason is because the technicians who apply these artificial fingernails are very good at what they do. They don't get any of the acrylate on the surrounding normal skin. However, before these nails get hard, when these clients then touch their eyelids or rub their hands around their mouth or on the side of their neck, they deposit the chemical there and then break out there. So people come in and they're broken out on their face and no one suspects their fingernails.

All these reactions are rare, however, so you shouldn't think of these products as containing poisonous or toxic compounds.

What does treatment involve?
Avoiding the allergen is the best treatment. If people don't know what's causing the allergic reaction, a dermatologist will figure out what people are allergic to with what's called "patch testing." We apply chemicals in very low concentration, but high enough concentration to elicit an allergic reaction, so we can tell people what they're allergic to.

Allergic dermatitis is usually treated with corticosteroid derivatives, either by mouth or by a topical application such as a cream.
 
What does it mean when a product is labeled as hypoallergenic?
That's pretty much meaningless. There's no good cosmetic company definition of hypoallergenic, and the so-called hypoallergenic products are just chock full of botanicals.

What should people look for when they're purchasing products?
Cosmetic products used on the skin have a fabulous safety record, and as we all know, there are many, many products that get tons of use. So when one considers the magnitude of the products out there and the number of reactions we have, it's a real testament to their safety.

But people with underlying skin conditions should try to use products with as few ingredients as possible in it. For example, I encourage people, particularly older people, to use plain 100 percent petrolatum as a moisturizer. People should avoid products with preservatives such as the formaldehyde releasers or methyldibromo glutaronitrile. And as a general rule, products that are preserved with chemicals called parabens and products that are fragrance free tend to cause less difficulty.

The Nuts and Bolts of Nail Care   By Christine Haran
Not everyone has the time or the inclination to spend lots of time grooming their nails. But experts say nail care is more than an exercise in vanity. Without the proper attention, irritating and sometimes painful problems can develop, including ingrown nails and persistent fungal infections. And nails can sometimes reveal that someone is suffering from an underlying illness.

Below, Darryl Haycock, DPM, a spokesperson for the American College of Foot and Ankle Surgeons, explains what you need to do to keep your nails healthy.

What are the different parts of the nail?
There is the cuticle at the base of the nail and then a whitish area that's called the lunula. Then you have the nail plate itself, which grows out on a nail bed.
 
Why do we have nails?
It's felt that it's an evolutionary leftover. A lot of animals have claws, and nails were a means of allowing us to use our fingers and toes to grab things and hold onto things. Basically it helps stabilize the end of the finger or toe.

What should a healthy nail look like?
A healthy nail should look smooth, pink in coloration and the white portion near the cuticle should be nice and clear, and it shouldn't be excessively thickened. In the drier weather, however, you'll get more cracking and hangnails.

Are nail problems ever a sign of a medical illness?
There are a lot of medical illnesses that are diagnosed through the fingernails or toenails. These include nutritional deficiencies, such as calcium and protein deficiencies, and diseases like psoriasis, which can cause a pitted look and white discoloration.

It might be lichen planus, which is basically a thickening of the skin. White spots under the nail are usually due to some kind of trauma, or injury. Sometimes even you can see a malignant melanoma, a type of skin cancer, as a black discoloration underneath a nail. That doesn't mean that every black discoloration is a cancer; sometimes those are just normal changes in the nail color.

What causes ingrown nails?
Ingrown nails have a number of different causes. Some people have a lot of thick skin around the nail itself, and it's hard for the nail to grow out through that thick skin. Some people have nails, particularly toenails, that become curved, almost like an old covered wagon that buckles around and pinches in. Trauma such as having the nail stepped on can also cause ingrown nails by putting pressure on the nail and forcing it to grow into the skin; this causes a cut between the side of the nail and the skin, which can become infected and irritated.

Trimming the nails poorly can cause ingrown nails. We see a lot of ingrown nails in teenagers. It seems that teenagers who are going through a rapid growth spurt also have faster-growing nails, so they need to cut their nails more often.

How can you prevent and treat ingrown nails?
Just try to cut your nails properly. It's recommended that you go straight across. If you prefer to cut in a curved fashion on the corners, you can do that, but you have to be aware that you have to frequently trim your nails in the corners so the nail doesn't grow into the skin. Be careful not to pull any thickened skin that may grow in the corner of the nails but to clip them. If you get a cut in the side of your nail as you're doing that, it's important to disinfect that area. Put an antibiotic ointment on there to keep it nice and moist, and to give it a chance to heal up. If it does become infected, then it's probably going to be best to see your podiatrist or dermatologist about it.

What about blood under the nail?
Blood underneath the nail is usually from a trauma, such as if someone drops something or sets a table leg on their toe, or crushes or pinches their finger.

People can have shoes that are too short or too small for them, so when they walk or run, the toenail is continually driven into the end of the shoe. This is what we call microtrauma; the toenail can either separate off completely or it can cause a build up of blood underneath that toenail. We see it a lot in soccer players and distance runners. It is also common in ballet dancers who wear pointe shoes. Likewise, typists who have long nails may have microtrauma to their fingernails from chronically hitting the keys.
 
If the area with the blood clot is painful, we'll try to relieve the pressure by drilling a hole in the nail and allowing the blood underneath the nail to come out.

How do you identify and treat nail fungus?
It can start in several different ways. But usually it appears as a yellow, brownish discoloration of the nail. It usually starts at the end of the nail, then works its way back underneath the nail. It makes the nail thick, yellow, crumbly. Sometimes you'll see yellow streaks on the nail as the fungus progresses.

Is it possible to get a fungal infection from a manicure or pedicure?
If someone has a manicure or pedicure from an establishment that does not properly clean instruments a fungus could spread from person to person.

What should proper nail care involve?
Examine your nails and frequently trim them. If they get too long, they can cause a number of other problems from being torn to being completely lifted off because the nail catches on something.

Don't push the cuticle back all the time. The cuticle is actually a nice barrier that keeps infection from coming into the nail. You might need to slide it back a little bit, but you have to be careful about pushing it too hard.

As far as putting anything onto the nails, it's tough to say whether that has a real benefit. I know some people have a natural split in their nails, and they'll put superglue in that split and that seems to help keep that from splitting and giving them problems.

Nail polish does strengthen the nails a bit and doesn't seem to create problems. But if you put on too much, it will stain your nails. And nail polish covers up your ability to see your nails and see if they're healthy. Nail polish remover may dry the nails.

When should someone go to the doctor?
If they have any concerns about their toenails or their fingernails. If they see something that just doesn't look right such as a dark discoloration. If they've had a trauma to their nail. If they have an ingrown nail; sometimes we see people come in with some serious infections because they waited too long to come in. It's best to get on the road to recovery as soon as possible, so that you can have a healthy nail and not have to worry about it.

Two Feet Under: Treating Fungal Infections  By Christine Haran
If you're not careful, you might pick up something other than a fit fellow exerciser at the gym or yoga studio. Foot fungus, which can appear as athlete's foot or as a toenail fungus, is likely to spread from person-to-person in communal locker rooms and other public facilities where people walk around barefoot.

Below, Darryl Haycock, DPM, a spokesperson for the American College of Foot and Ankle Surgeons, discusses how you can prevent and treat these itchy, sometimes painful and always unwanted infections.

What kinds of fungal infections affect the feet?
Basically there are two different kinds of fungal infections. One is a nail infection, which is called onychomycosis, and then the other one is a skin infection, what is called tinea pedis, commonly known as athlete's foot.
 
What causes these infections?
Fungus is in the same class of organisms as mushrooms, yeast and molds. They're basically organisms that grow on dead or dying tissue. The outer layer of our skin and our nails are dead tissue. In other words, they don't have blood flow to them, and they become hard and thickened and allow us to have kind of a water-proof surface. So when someone has a fungal infection, the fungus gets into those tissues and starts to grow.

Who is likely to have these infections?
Older individuals are more likely to have it. We're not sure why. It might be that their immune system is diminished, or just that they've had more trauma to their toenails over the years.

Because of the association with trauma, you also see fungal infections in individuals who are in sporting activities such as soccer or ballet because they frequently injure their toenails. They might get a blood clot underneath the nail and, over a prolonged period of time, the fungus can get underneath the toenails. The blood clot creates a nice environment for the fungus to set up shop because fungus likes areas that are warm and moist.

But fungal infections can occur in most anyone, and the incidence of fungal infection has been increasing over the last 100 years. It may be due to the spread of the fungus in communal locker rooms and spas and showers. It may even be because of its association with diabetes.

Why is diabetes a possible risk factor?
People with diabetes often have a poor blood supply to the extremities, therefore the foot is not as healthy and fungus can set up more easily. Maybe it's also that many people with diabetes have decreased sensation, so any trauma—which they may not notice—plays a role.

We also see an association between foot fungus and immune deficiency diseases such as HIV and AIDS.

Wound Healing and Pressure Sores   By: Gregory A. Buford, MD
Before you can understand how a wound heals, you need to first know something about skin. Our skin, perhaps the organ most commonly disregarded, must withstand assault from a daily barrage of factors including sunlight and UV irradiation, wind, temperature extremes, and the daily insult of cuts, nicks, and scrapes, which leave it susceptible to invasion by fungus, bacteria, and viral invaders.

In addition to keeping the harsh external environment away from our own critically sensitive internal biological environments, skin acts as a regulator of body temperature and a sealant against fluid loss. You can appreciate its many roles by looking at its two major layers-the outer epidermis, and the deeper underlying dermis.

Epidermis
The epidermis is continually exposed to the environment and sustains most of the injury to the skin. As a result, it is shed and regenerated on a daily basis. Its major role is to produce the stratum corneum-a waterproof, semi-permeable membrane on the outermost portion of the epidermis that acts to prevent water loss from the tissues it surrounds. When this upper layer is injured-as can occur with minor scrapes and cuts-it simply regenerates itself without scar formation. The same is not true for deeper injuries.

Dermis
Residing just below the epidermis is the dermis, which constitutes 90% of total skin thickness. Because of its rich collagen content, the dermis is the strength layer of the skin. In addition, it contains blood vessels, nerve endings, hair follicles, and immune cells that act as sentries against infection and cancer.

These two layers are draped over a deeper subcutaneous layer comprised of fatty tissue, blood vessels, and nerves which is generally protected from injury by the overlying epidermal and dermal covering.

Wound Healing
Under normal conditions, the process of healing occurs in three overlapping phases. Roughly speaking, these are divided into inflammatory, proliferative, and remodeling phases and involve contraction (downsizing of the wound), epithelialization (creation of new epithelial cells), and deposition of connective tissue.

Inflammation
When skin is injured-whether in a planned injury such as a surgical incision or as the result of trauma-an inflammatory phase begins. This is initiated by the release of several chemicals from both platelets (tiny cells which initiate the clotting mechanism) and the surrounding injured tissue. The site of injury turns red, becomes swollen, and displays all the normal properties we commonly associate with an acute wound.

This initial inflammatory reaction is critical because it sets the stage for a cascading process that eventually should lead to normal wound healing. Chemicals released during this phase signal messengers to draw critical inflammatory cells into the site of injury. These cells break down and remove injured, devitalized tissue and clean the wound in preparation for the laying down of new tissue. During this phase, cells of the immune system are also attracted by these chemical messengers and modulate the overall generalized inflammatory reaction, though their specific functions are really not known.

Proliferation
The initial inflammatory phase sets the stage for what comes next -the proliferative stage. During this phase, tissue integrity is restored as the release of various growth factors and chemical messengers stimulate the creation, migration, and proliferation of new healthy cells. Specialized cells called fibroblasts lay down a collagen matrix to restore tensile strength of the wound. In addition, in-growth of new blood vessels ensures that adequate nutrients and oxygen are delivered to the site of the healing wound.

Remodeling
The final segment, the remodeling phase, can last for several weeks to several months and involves fine tuning of the wound bed. During this time, collagen is produced and degraded at about the same rate so that overall collagen content remains essentially unchanged. What does change is the organization of the collagen. By structurally remodeling and rearranging orientation of the collagen, the wound is able to approximate-though never fully reach-the strength it had prior to injury.

Scars
A scar is the end result of your body's attempt to close a wound, and it is a normal process that occurs whenever an injury involves the dermis. Superficial cuts and scrapes that injure the epidermis and superficial dermal layer alone generally heal without scarring. If the wound is closed under optimal conditions (for example a surgical incision) and the edges are brought together under minimal tension, there is a good chance you will achieve that fine thin scar that in time will be barely visible. The body wants to take a wound and make it smaller, and has specialized cells called myofibroblasts that draw the wound edges together during the healing process and convert a large wound to a smaller wound.

If instead, the wound is dirty, very large, or requires a lot of force to bring it together, your long-term result may not be optimal and you may see a thick scar.

Scars take time
It's important to remember that a scar takes up to a year-and sometimes longer-to attain its final appearance. Many people get frustrated as their early scars take on a reddened, heaped-up appearance in the first few months after injury, and look worse as the days progress. If this same scar is evaluated at twelve months, it usually looks much different and has healed close to its final appearance.

But what happens when this final appearance is not optimal?

Hypertrophic scars
Some scars-the result of variables such as infection, excessive tension, or generally poor wound healing- develop into thick raised lines that are simply not attractive. When a scar is heaped-up and prominent but does not extend beyond the zone of original injury, it is referred to as a hypertrophic scar.

Hypertrophic scars can be treated in several ways. If you have always healed poorly, chances are you will continue to heal poorly. Some people simply do not form attractive scars. But if previous injuries led to more satisfactory healing, you may want to consider a scar revision in which the scar is cut out and the incision re-closed. Sometimes this will provide an acceptable long-term result but there is no guarantee. Before your embark on revision, make sure to discuss the procedure with your physician and gain his or her impression of the likelihood of success before jumping in.

Keloid scars
Another group of scars is the keloids. Keloids are generally the result of a poorly-understood genetic tendency to develop large scar growths at the site of even the smallest injury. The most common keloid scars develop after ear piercing. Although certain areas of the body are more susceptible to this (e.g: earlobes, chest wall, shoulders), if you previously healed with a keloid, chances are you will heal again with a keloid. These are very difficult to treat and commonly recur.

Factors That Affect the Wound Healing Process
Because of the complexity of the wound healing process, several factors can discourage adequate wound healing. Some of these factors we can control-others we cannot-and include the following:

Age
Wounds heal slower and less effectively as we age. Numerous studies have documented that our cellular healing mechanisms are slower to respond and operate less effectively as we get older leading to less optimal wound healing.

Infection
An infected wound takes much longer to heal because the body's local resources are divided between the healing process and the need to fight the infection. Because of this, the wound stays in the inflammatory phase for a much longer period of time and the overall results are generally poorer than if the wound bed were clean.

Poor nutrition
The complex process of wound healing requires a number of vitamins and other chemical cofactors to complete its job. Without these building blocks, wound healing takes longer and is generally compromised. An example of this involves the early sailors who developed scurvy (vitamin C deficiency) because of their lack of access to fresh fruit. They commonly developed bleeding gums and had tremendous difficulty healing even the most minor wounds.
Unfortunately, poor wound healing from a lack of vitamin C does not suggest that overcompensating or megadosing with vitamin C will speed up the normal healing process. To provide the appropriate building blocks for repair, just make sure to follow general nutritional guidelines and eat a healthy diet.

Immunosuppression
Patients whose immune systems are compromised (whether the result of disease or the result of chemotherapy) generally display poor wound healing. The normal wound healing process requires the recruitment of the immune system to properly clear the wound of debris and prepare the local environment for repair. When this arm of the healing process is compromised, the result is not only delayed healing, but often ineffective healing as well.

For example, chemotherapy medications attack rapidly dividing cells in an attempt to fight cancer. The problem here is that the drugs do not distinguish between the rapidly dividing cancer cells and those that are dividing to heal a wound. Because of this, wounds generally take much longer to heal in patients on chemotherapy and will continue to do so until the drugs are stopped.

Other medications
Many drugs can affect normal wound healing at various levels. There is a long list of medications that may either prevent or at least slow down normal wound healing. Because of this, it is critical to discuss all current medications with your physician to determine if any changes can be made.

Radiation
Radiation impairs the cells responsible for collagen production, and may actually shrink the numbers of these cells, which disrupts the wound healing process, and also creates a wound generally weaker in strength. Radiation also can harm the delicate blood vessels that course through the area exposed to it. The tissue is left with a poor oxygen supply and as a result; the healing process is again compromised. The effects of radiation on wound healing are felt right after exposure, and for many years thereafter.

Diabetes
When wounds develop in people with diabetes, their chronically elevated levels of blood sugar incapacitate the wound healing response. And not only can diabetes interfere with the healing process, it can also cause the development of new wounds. Long-term diabetics commonly develop nerve damage in their legs. This damage to the nerves reduces their protective capacity and increases the likelihood of new wound development. It also increases the risk that the body will not recognize new wounds when they develop.

Peripheral vascular disease
Peripheral vascular disease is a problem with narrowing of the limb arteries, which results in poor oxygen delivery to the areas beyond the narrowing. All tissue requires a baseline level of oxygen for survival. When this level is reduced, the local tissue dies and with it the capacity to regenerate. Patients with peripheral vascular disease should be treated in conjunction with a vascular specialist to assure that the appropriate steps for restoration of adequate blood supply and tissue oxygenation are undertaken in tandem with attempts at wound healing.

Systemic illness
Any major illness that affects the whole body also affects the body's ability to repair itself. During    a systemic illness, the body requires tremendous energy and resources to repair itself, and wound healing is temporarily compromised. Healing will not stop entirely, but the process will not operate as efficiently or effectively as it would in a healthier state.

Smoking
Cigarette smoke contains a number of harmful substances including nicotine, carbon monoxide, and hydrogen cyanide.

Aside from its extreme addictive potential, nicotine has been shown to cause constriction of blood vessels in the subcutaneous tissue for up to 50 minutes after smoking a single cigarette. This constriction decreases the blood flow to the area and therefore decreases the ability to deliver oxygen to the wound. In addition, smoking also inhibits the production of several cell types critical to the healing process and promotes the clumping of platelets, which increases the risk of blood clots.

Carbon monoxide is a poison that competes with oxygen in the bloodstream. It decreases the process of oxygenation in the tissue, which can actually lead to tissue death.

Hydrogen cyanide is a poison that selectively blocks intracellular metabolism and the ability of cells to use oxygen.

Stress
Although temporary periods of stress can be motivating, chronic stress can become a destructive force that effectively disturbs the healing process. During prolonged periods of stress, your body's level of hormones (more specifically the steroid hormones) become markedly elevated. Your body reacts to stressful conditions by marshalling its energy and resources to manage the stressful condition at hand. When the stress is temporary, this is referred to as the "fight or flight" phenomenon. When the stress is more long-lasting or becomes chronic, instead of creating conditions conducive to healing, the elevation of various stress hormones and internal messengers creates and environment that favors tissue breakdown.

Chronic Wounds
When healing stops, for whatever reason, an acute wound can develop into a chronic wound that simply will not heal. When this happens, the local wound environment can become unfavorable to healing. For example, chronic wounds tend to have a much different composition of growth factors present in the wound bed, which actually favor non-healing. If these destructive factors are allowed to persist, the wound will either never heal or will only heal over a very long period of time. The wound must be cleaned of these harmful factors before normal healing will occur.

Treating a chronic wound
A wound must be clean and free of infection in order to heal. If the wound is clean, the treatment is easy. Gentle, daily dressing changes allow the body's own mechanisms to continue the healing process. If the wound is infected, however, the body has to divert a majority of its resources away from healing and focus on fighting an active infection. Devitalized or grossly infected tissue must be removed in order for the healing process to continue. After the removal of devitalized tissue, special dressing changes can be made to eliminate any residual infection.
 
Another way to encourage wound healing is to use vacuum-assisted closure. This involves placing a sealed sponge system over the wound, which is then placed on a low vacuum setting for a period of weeks or months as the wound heals. Several studies have shown this device to be very effective in speeding up the wound healing process in acute and chronic wounds. And, most importantly, the device is painless and the cost is generally covered by insurance.

The wound that still won't heal
If the measures above are taken and do not speed the wound healing process, then other underlying causes must be identified and addressed.

For example, if the patient has peripheral vascular disease and has severely compromised blood flow, the wound will not effectively heal until blood flow is improved. This patient may need a surgical procedure to improve blood supply before there is any chance of healing the wound.
This same scenario applies to the many other reasons for poor wound healing. If we don't address the reason the wound hasn't healed in the first place, we'll probably never be able to heal it.

Pressure Sores
The next time you sit for a long time, notice how often you feel the need to shift your weight or reposition yourself. This is generally an unconscious act, but it's actually critical in reducing pressure on various key pressure points throughout the body.

Sustained pressure on any area of our body can impede local blood supply and cause tissue ischemia or tissue death, and there are some people who cannot avoid sustained pressure. One example are paraplegic patients who not only cannot move their lower extremities but who also cannot feel pain or pressure as a result of their injury. These people must be closely watched for local tissue compromise and impeding skin breakdown. Elderly bedridden patients are also prone to pressure sores, as they often remain in the same position for prolonged periods of time. They can develop pressure sores (decubitus ulcers) at pressure points on the lower back, hips, heels, and the lower extremities.

Who is at risk? The following are risk factors for the development of pressure sores:

• Altered mental status or sensory perception
• Inability to control bladder or bowel functions
• Exposure to moisture
• Immobility or inability to shift weight in an effective manner
• Exposure to friction or shear forces
• Poor nutritional status
• The best treatment for pressure sores is prevention. Unfortunately, pressure sores are a common problem, very often they are the result of oversight or simple negligence. Once recognized, appropriate treatment can begin.

Conclusion
Preventing wounds can be as simple as alleviating daily pressure or as complex as addressing a chronic or acute underlying medical condition. Whatever the cause, prompt intervention can often be the difference between a wound that heals and a wound that does not.

Dermatologic Uses of Lasers   By: Peter S. Halperin, MD
Patients commonly assume that lasers represent a fairly new technology. Many would be surprised, however, to learn that the first working laser was developed around 1960. Today's lasers still rely on the same principles and have much in common with the original laser.

Lasers work by a basic concept—they produce an intense beam of light that travels in one direction and imparts so much energy to a target, that the target vaporizes. Properties such as the wavelength of light, energy of the beam, and exposure time differentiate lasers and allow them to be used for various types of treatment.

Laser Basics
Let's say you want to have small blood vessels removed from the bridge of your nose. One of several lasers would allow your physician to specifically remove blood vessels and only blood vessels from that area. Aside from the removed blood vessels, the skin of your nose would be unchanged. This specificity of a laser to address a particular problem (blood vessels, in this case) is what gives lasers a great advantage in many different types of treatments.

Every laser has a target. The target of the laser in the example above is hemoglobin, a protein found in red blood cells. The laser imparts great energy to the hemoglobin, causing changes in its form, and ultimately causes the blood vessel to disappear. A different laser could target melanin, which is the tan- or brown-colored pigment found in skin. A laser that targets melanin would be useful for removing dark marks commonly called liver spots.
  
Pigmented Lesions
Superficial brown-pigmented lesions such as liver spots can be vastly improved or made to disappear in many cases. These lesions are often located on sun-exposed skin. The skin lesion may change somewhat in appearance immediately after laser surgery, but complete resolution generally follows two weeks later.

The same class of lasers that treat benign superficial pigmented lesions may also be appropriate to lighten or even completely remove tattoos. Professionally placed tattoos, which are generally more complex and contain several colors, tend to be more difficult to remove than tattoos placed by amateurs. In most cases, tattoo removal requires repeated treatments. Even cosmetically similar designs placed by different artists may exhibit varying difficulties for removal due to the chemical differences of the ink.

It is important to recognize that not all pigmented lesions can be improved with laser. Lesions felt to be suspicious by your dermatologist may require observation or removal for analysis under a microscope.

Vascular (Blood Vessel) Lesions
Many vascular lesions can be safely and effectively removed with a variety of lasers specific for this purpose. Problems such as tiny blood vessels that develop from sun exposure, hemangiomas (red marks on the skin), or conditions like rosacea (an entity partly characterized by blood vessels) can be improved or eradicated without scarring. Medical conditions that were once impossible to treat, such as port-wine stain hemangiomas, which are flat vascular patches present since birth, may now be substantially improved or even completely eliminated.
Blood vessels of the legs, sometimes known as spider veins, can also be greatly improved or even made to disappear. Ideally, the laser treats very small blood vessels most effectively. If the blood vessels are large enough, another medical technique known as sclerotherapy (injection of special solutions into the veins) may be employed along with lasers to produce disappearance of the leg veins.

Other dermatologic conditions improved by the vascular laser include scars and stretch marks. Reddish, elevated, and itchy scars can be made less red, flatter, and less bothersome by treatment with the proper laser. Another area where lasers can be appropriately used is the soles of the feet, where recalcitrant warts can occur. Even stretch marks have been noted to improve after laser surgery.
 
Laser-Assisted Hair Reduction
Reduction of hair by laser is now available. Women commonly request hair reduction on their upper lips, underarms, and bikini areas. Men frequently request removal of back hair. Laser-assisted hair reduction is far easier to withstand and less traumatic for normal skin than electrolysis or waxing.
 
For this type of hair reduction, the pigmented hair sitting in the hair follicle is the target. Thermal damage is limited to the hair follicle and the surrounding normal structures remain unaffected. This method differs quite dramatically from electrolysis, whereby an electric needle is inserted down the hair follicle, causing excessive thermal damage and scarring of the follicle and the surrounding tissue.

Hair reduction works better if your hair is darker and your skin complexion is lighter. That's because the hair reduction laser does a better job of targeting the darker pigment structures (hair in the hair follicle) against the background of lighter skin. Reduction of hair still might be a possibility if your skin is darker but you should request the advice of your physician.

Hair reduction requires repeated treatments. That's because hair grows on a cycle and different hairs are in distinct phases of the cycle at any given time. No hair-removal laser system has demonstrated permanent hair removal after one treatment. Rather, depending on the situation, multiple hair-reduction treatments might be used during the first year with fewer treatments during the following years. It is believed that some amount (up to 15 percent) of permanent hair removal occurs with repeated treatments.
 
Laser Resurfacing
As we age, the effects of sun and time cause a thinning of the skin and fine lines to develop around our eyes and lips. Improvement in wrinkles, fine lines, and acne scars might be achieved by use of carbon dioxide or erbium lasers . These lasers allow thermal destruction of the most superficial skin layers without causing damage to surrounding normal tissue. In general, erbium lasers are used for more superficial resurfacing whereas carbon dioxide lasers are used to resurface skin to a deeper level.

Resurfacing procedures may require local or even general anesthesia depending on the specifics of the case. Although superficial, these treatments require a great deal of postoperative care. Initially, the skin is quite red and weepy. Depending on the depth and type of laser procedure performed, considerable redness or other pigmentary changes of the skin might occur and even persist for many months. Delayed healing has also been reported. In my opinion, laser resurfacing of skin is highly operator-dependent and tends to have a more favorable result when performed by physicians experienced in the field.
 
Treatment Evaluation
No single laser is capable of treating all dermatologic conditions. Most lasers have a fairly limited spectrum of conditions that may be treated. Your laser surgeon should carefully evaluate your particular problem, medical history, skin type, and pigmentation. Then an appropriate type of laser system may be suggested for treatment.

It's important to select a surgeon who has laser expertise. New lasers are continually introduced and it may not be possible for a physician to have years of experience with each and every laser. Your physician should have experience in general with lasers, their safety, and their principles of use, as well as an awareness of what other practitioners in the field are striving for and achieving.
 
Conclusion
The benefits of laser surgery can be remarkable and include improved therapeutic results, reduced risk of scarring and infection, and precisely controlled surgery that limits injury to normal skin. Additionally, lasers may offer an alternative to traditional scalpel surgery and may provide effective same-day surgery (you have surgery and are able to go home later that day ) for many skin conditions.

Unraveling the Mystery of Autoimmunity
Everybody wants to have a strong immune system. The immune system is the body's own personal Department of Defense, protecting its health and integrity from invading armies of harmful viruses and bacteria. Its specialized cells, called lymphocytes, normally do a fine job of keeping illness at bay, but sometimes they slip up, sending us home with the flu.

Even with all the smart weaponry at its command, the immune system can sometimes go awry, attacking targets inside the very body it was designed to protect. This is the explanation behind over 80 suspected autoimmune diseases, including psoriasis, rheumatoid arthritis, multiple sclerosis and juvenile diabetes.

Noel Rose, MD, Professor in the Department of Pathology at Johns Hopkins School of Medicine and Director of the Johns Hopkins Center for Autoimmune Disease Research, has spent the better part of his distinguished career following the common thread that weaves these diseases together. In the following remarks, he shows how autoimmune diseases of the skin, joints, nerves and pancreas are fundamentally linked.

What is autoimmunity?
Traditionally, the immune response has been understood as the body's method of defending itself against disease, which it does by identifying and destroying foreign invading microorganisms. By contrast, autoimmunity involves an immune response to something within the body itself.
 
How does the immune system distinguish between what belongs in our bodies and what doesn't?
The job of the immune system is to produce antibodies against antigens which cause harm. In fact, our immune systems accomplish that task very well. Not only do we produce antibodies to newly emerging infectious agents but also to molecules produced in the laboratory that may be used in certain types of medications. So why don't we normally produce antibodies to molecules in our own bodies? The answer lies in the complex mechanisms that govern self-recognition and self-tolerance.

We all produce lymphocytes that are potentially capable of recognizing and even attacking "self." Normally, these cells are either deleted very early or they're held in check by regulatory controls. When these safeguards fail us, so-called autoantibodies develop. All of us have autoantibodies - antibodies in our blood that react with something in our own bodies.

Are you saying that autoantibodies and autoimmunity are normal?
Autoimmunity is mostly harmless. Some immunologists even believe it may be helpful. Autoantibodies may help to remove worn out or dead cells, but firm evidence for this is not yet at hand. Clearly, though, an autoimmune reaction can go too far, and that's where the problem begins.

What is autoimmune disease?
The definition of an autoimmune disease is sometimes very hard to pin down. There is no universal agreement on which diseases are autoimmune and which are not autoimmune. Autoimmunity may be present in the disease, but may not be actually causing it.

What causes some people to develop autoimmune diseases in the first place?
The tendency to develop an autoimmune disease has roots in both genetics and the environment. Autoimmune diseases are different from other genetically determined diseases that we're more familiar with, like sickle cell anemia, where there's a single gene and either you have it or you don't. In autoimmune disease, there's an accumulation of a number of different genes that, when added together, give a heightened probability that you will develop an autoimmune disease. About a third of the risk of developing an autoimmune disease is inherited. That means the other 66% is environmental. Even if you inherit a genetic predisposition, the autoimmune disease will not occur unless there's an environmental trigger.

What are some conditions that are now considered autoimmune diseases?
Interestingly, back in the 1960s, many of us suspected that Type 1 diabetes might be an autoimmune disease, but we couldn't really find substantial evidence to support our suspicions. Later, it emerged that the autoimmune form of diabetes is the insulin-dependent form, sometimes called juvenile diabetes or Type 1, which affects about 10% of patients with diabetes. So that was a major surprise.

According to the current view, psoriasis is now considered an autoimmune disease involving an immune response that results in lesions in the skin. For example, they may have been exposed to an infection, and the infecting organism may have had an antigen - a substance that resembles a component of the skin. Whether psoriasis is caused by an internal or external stimulus, the upshot is that there is an immune response to something in the skin.
 
Another example is rheumatoid arthritis, a very common disease. Patients with rheumatoid arthritis have autoantibodies. We still don't know for certain whether the autoimmunity we see in the disease is actually causing the disease. That having been said, virtually all of us now accept rheumatoid arthritis as an autoimmune disease. Still, there's a little uncertainty in the back of our minds that there could be a virus, or something else, that's causing the disease, and that the autoimmunity is merely an accompaniment. 

Is it important to establish the ultimate cause of rheumatoid arthritis in order to treat it effectively?
At present, the ultimate cause is not a matter of overwhelming importance, because what we treat are its symptoms. The kinds of drugs we use today block the substances that are produced during an immune response, substances that are actually causing the pathology of the disease. These drugs work. It's not relevant whether the immune response that we're blocking is actually a true autoimmune response or whether it's a response to a hypothetical virus that we've never found.

Finding the actual cause of the autoimmune disease will probably become more of an issue in the future years. We hope to see a whole new generation of treatments based on a more advanced understanding of autoimmunity as an underlying disease process.

Once a patient has a full-blown autoimmune disease, what are today's preferred methods of treatment?
In some cases, we can treat an autoimmune disease by replacing a lost function. That's what we do when we give insulin for diabetes or thyroid hormone for Hashimoto's thyroiditis. When these symptomatic remedies fail, however, we must turn to immunosuppression in order to down-regulate the entire immune system. Obviously, this approach is hazardous, because it makes people susceptible to infection, plus most immunosuppressant drugs have severe side effects. They're a last resort. Most physicians give them with great reluctance.
 
How would you assess the pace of medical discovery in the field of autoimmunity? Is substantial progress being made?
We're getting closer and closer to the root cause of autoimmune disease. My vision is that someday we'll identify the substance that gets the harmful autoimmune disease process going. The goal is to make people unresponsive to their own excessive autoimmune response. We need to learn a lot more about how to identify these offending antigens in people and how to make people immunologically unresponsive. The fact that we can do it in animals shows that it's possible.

Looking at the labels of some of these products manufactured by chemists contain Propylene, glycol, isopropyl, and myristate as active ingredients and to get rid of these chemical smells manufacturers add fragrances made from petroleum, the same substance that makes your car run. 

You may be using a shampoo or cream that contains herbs, and the label reads  “natural.” but never beleive what is on the front label of any skin or hair care product.  By law all ingreidents must be listed in decending order on the back label of any product.  For example if the front reads: "Aloe Vera" and yet on the back "Aloe Vera" is closest to the bottom then the product contains very little Aloe Vera.  Above that will no doubt contain such chemicals as hexachlorophene, diazolidinyl, and polyquarterium-10 that will nullify the effectiveness of any botanical substance they may contain.

Skin Care the Natural Way
Our skin and hair can have different needs, that’s why you should use choose a preparation that matches yours but remember that your skin and hair are a reflection of your general health, if you smoke, consume alchol, have hormonal fluctuations, poor diet, and don’t exercise then these miracle creams will do nothing to repair such damage.

To maintain a radiant complexion and healthy hair, eat a balance diet, reduce stress, also rest and relax as much as possible, exercise.  This will ensure sufficient blood supply that will provides nutrients and oxygen to repair and generate new healthy skin tissue. 

Mature Skin Treatments
Why does skin wrinkle? As you grow older, your body produces fewer hormones that keep skin healthy, and supplies less oil, protein and natural moisturizing factors, which attract and hold water in the skin. This process also tends to make the skin drier.  As time goes by, collagen and elastin (fibers arranged in a mesh-like pattern) eventually lose their strength, leaving the skin without underlying support and causing it to wrinkle and sag. 

Antioxidants are also very important, they prevent the production of free radicals. These free radicals play an important role in all aspects of aging including hardening of the arteries, they are unstable, quickly multiplying molecules, which are increased by cigarette smoking and other pollutants. Many herbs and vitamins have antioxidant properties and are very powerful, stopping free radicals on their tracks. Some antioxidant herbs are gingko, witch hazel, and essential oil of rosemary, marjoram, and lavender. 
 

Cleanser For Dry Skin      2 oz aloe vera gel       1 tsp. Vegetable oil or jojoba oil or saint john’s wort      1 tsp. Glycerin       ½ tsp. Grapefruit seed extract       8 drops Sandalwood essential oil.       4 drops rosemary essential oil.  Mix ingredients and shake well before use. Apply with cotton balls and rinse with warm water.      Toner For Dry Skin Toners are used to improve, soothe and nourish the skin.  Men can use toners as aftershaves.       2 oz each aloe vera gel and orange-blossom water       1 tsp. wine vinegar.       6 drops rose geranium essential oil.       4 drops sandalwood essential oil.       1 drop chamomile essential oil.      800 UI vitamin E oil. (Puncture a gel capsule)  Mix ingredients and shake well before use.   Cream For Dry Skin      3/4 ounces beeswax, shaved. (do not use paraffin)       1 cup each vegetable oil and distilled water       800 UI vitamin E (from a liquid gel)       24 drops rose geranium essential oil.  Heat beeswax and oil in a pot until beeswax melts.  In a separate pot heat water until is warm to the touch. Remove the center part of your blender’s lid and pour the water in. Turn the blender on high speed and slowly but steadily add the oil and wax mixture. The whole concoction should begin to solidify keep adding oil until the mixture does not take any more. Using a spatula, place the cream in a wide mouthed container.  Facial Steam For Dry Skin      3 cups of water       1 drop each rose geranium, rosemary, fennel,       peppermint essential oils.  Boil water, turn off heat and add essential oils. Place a towel over your head and over the pot, close your eyes and let the steam warm your face. After 15 minutes splash your face with cool water.  Facial Scrub For Dry Skin      2 tbsp. Oatmeal.       1 tbsp Cornmeal      1 tsp. each: chamomile, lavender, elder flowers.       6 drops lavender essential oil.  Grind all dry ingredients in an electric coffee grinder, add essential oil and mix thoroughly. To use, place a small amount of the mixture on the palm of your hand and moisten with a few drops of water to create a paste, wet your face and apply scrub gently. Rinse with warm water.  Did You Know: Yogurt, placed on the face helps bring water from the deeper layers of the skin to the surface, thus moisturizing your skin for the rest of the day.    Honey Cleansing Scrub      1 tbsp. Honey       2 tbsps Finley Ground Almonds      1/2 tsp of Lemon Juice Rub gently on to face. Rinse off with warm water     Tomato Mask For Acne      Remove skin and seeds and mash 1/4 of a tomato      2 tsps. plain yougurt      1 tsp. mash cucuumber      2 tso, aloe gel      3 tsp. Oatmean powder      2 mint leaves (crushed) Mix ingridents together in a bowl, apply to face and leave on for about 10 minutes rinse with warm water. Finish with an oil free misturizer Herbal After Bath Oil      4 tbsp. almond oil       3 tbsp. of each: sunflower and olive oils       2 tbsp. of each wheat germoil and sesame oil       1 tbsp. each apricot, avocado oil and essential oil                 of basil.  Shake all ingredients together in a bottle and use. Flora After Bath Cologne      3 cups of water      1 large cup of geranium, jasmine, and roses petals       1 large cup pure alcohol vodka       6 tbsp. dried ground orange and lemon peel       2 tbsp. dried crushed mint leaves      1/4 tsp. ground cloves Mix Alcohol and petals in a jar seal tightly and leave for a week. Boil Water and put peels, herbs and cloves in jar and leave 24 hours. Strain alcohol and infusion and combine. Store in a Glass jar and shake well. Rose and Basil Perfume      2 cups each: rose water and white wine vinegar.      1 tbsp. dried basil       1 tsp. crushed cloves       1 shredded bay leaf.  Mix all ingredients and bring to a boil. Simmer for a few minutes, as liquid reduces add water. Cover and leave for 24 hours. Strain and bottle, store for 4 weeks before using. Great for perfuming baths, blankets and rooms.       Solution For Dry Elbows and Knees Start by using a good body scrub to exfoliate in the shower.  Next mash-up pineapple in the blender and rub in on your elbow and knees. Leave it on for about 15 minutes so the natural enzymes can do their work.  Shower it off and follow up with a thick lotion.   Dry Skin Body Treatment Heat almond oil in a Pyrex dish until warm; slather all over your body. Standing outside the shower, turn on the spray until the  water is hot, closing the shower curtain or door till Steam forms.  Now, enter the shower and stand under the steam. (not the hot water!) For 10 minutes. Feel the oil slip into your skin.  Next, stand under the warm -- not hot - water for 10 minutes.  Then wash is usual.   Foaming Vanilla Honey Bath 1 cup sweet almond oil (light olive or sesame oil may be substituted) 1/2 cup honey 1/2 cup liquid soap (plain or flower scented) 1 tablespoon vanilla extract Mix all the ingredients together and pour about 1/2 cup under running water into tub. Relax and enjoy! Put the remainder in a canning jar for later use and refrigerate for upto 30 days. Homemade Milk and Sea Salt Bath 1 cup of instant dried skim milk 3/4 cup of either fine or coarse sea salt 20-25 drops of fragrance oil if desired or 15-20 drop of essential oils. Place the dried milk and sea salt into large bowl.  Mix well.  Scoop out about 1/2 cup or so and place into small bowl.  Sprinkle your fragrance or essentials oils over the top of this mixture and stir well.  Add this back into the main bowl and thoroughly mix.  Store your milk bath in a glass jar with a tight fitting lid. Now just scoop out about 1/3 cup and dissolve under running bath water.  This recipe makes for about 6 baths. Homemade Fragrant Milk Baths 2 cups dry milk powder 1 cup cornstarch 1/8 teaspoon fragrance oil of you choice Blend together all ingredients in blender Add 1/2 cup of mixture to hot bath water Mix all the ingredient together and pour about 1/2 cup under running water into tub.

Cleanser For Oily Skin      2 ounces witch hazel       1 tsp each vinegar and glycerin       ½ tsp. grapefruit seed extract.       6 drops lemon essential oil.       2 drops cypress essential oil.    Mix all ingredients and shake well before use. Apply with cotton balls and rinse with warm water.      Facial Steam For Oily Skin      3 cups of water       1 drop each: chamomile, lemongrass, lavender,       rosemary essential oils Boil water, turn off heat and add essential oils. Place a towel over your head and over the pot, close your eyes and let the steam warm your face. After 15 minutes splash your face with cool water.  Did You Know: Strawberries, their leaves, Basil, eucalyptus, cedarwood, sage, lemon, and ylang-ylang all reduce the production of oil. Toner For Oily Skin      2 ounces witch hazel       1 tbsp. aloe vera gel      5 drops cedarwood essential oil      3 drops lemon essential oil      1 drop ylang-ylang essential oil  Mix ingredients and shake well before using.      Conditioning & Rejuvenating Night Cream      2 tbsps each: cocoa butter and emulsifying wax       1 tbsp each: bees wax and apricot oil      1 tbsp primerose oil       2 tbsp. sesame oil       1 capsule each of Vitamin A, E, and D.       8 drops rose geranium essential oil.  Melt the cocoa butter and waxes in a bowl. Then beat in the oils.  Remove from heat and beat until cool, then add essential oil. Beat until cold. Store in a clean jar.     Age Spot Remover      1 tsp. grated horseradish root       ½ tsp of each lemon juice and vinegar       3 drops rosemary essential oil  Mix ingredients and keep away from eyes.  Toner for Mature Skin      2 oz each: aloe vera gel & orange blossom water.       1 tsp. vinegar       6 drops rose geranium essential oil.       4 drops each: frankincense and carrot seed       essential oil.       800 IU vitamin E oil  Mix ingredients and apply. Blemish Remover      1/4 cup of water       1 tsp. Epson salts       4 drops lavender essential oil       Small cloth.  Mix water and salts, once the salts has dissolved, add lavender. Soak a cotton cloth and compress on affected area. when cloth cools soak it again and repeat several times.  Herbal Face Mask      1 handful of fresh basil leaves.       1/2 avocado.       1 tsp each lemon juice and clear honey.  Place basil leaves in a blender a pulverize. Mash the avocado flesh. Mix all the ingredients together until they are smooth. Apply on clean face and leave it for one hour and rinse off with warm water.      Healing Hand Cream      3 tbsp. anhydrous lanolin.       2 tbsp each: almond oil and glycerin.       8 drops rose geranium essential oil.  Melt Lanolin in a bowl. Beat in the almond oil and glycerin. Remove from heat and continue beating. until the mixture cools, then add essential oil. Lavender Deodorant      2 cups of purified water      3 drops lavender essential oil       1 tbsp. sugar.  Shake the ingredients together, bottle and store for 2 weeks. Place in a spray bottle or atomizer, shake well before using. Homemade Intensive Conditioner Mix 1/4 cup of olive oil with 1 egg and apply to hair.  Use more olive oil is your hair in very long.  Cover your head with aluminum foil, then cover with a towel that has been soaked in hot water and rung out.  Leave on for 30 minutes or overnight for deep conditioning very dry hair, then shampoo as usual.   Blemished Skin Body Treatment This treatment is great for broken out backs Add enough water to crushed almonds or cornmeal to make a paste.  stand in the shower and apply your meal paste all over your body massaging it vigorously -- first with your hand, then with a loofah, or Body Buf Puf The skin will look clear following your shower. Paraffin Wax Treatment For Hands and Feet Deep conditioning treatment to soften and smooth your feet and hands. 3 blocks paraffin wax 3 oz. vegetable oil 20 drops of essential oil a few drops of olive il plastic sandwich bags Melt the paraffin, oil, and the scented oil in a double boiler.  be sure to use a double boiler for safety purposes.  Very carefully pour the wax into a greased foot tub and wait until a skin was a formed on the top of the wax.  At this point the temperature should be about right for submerging your hands and feet. Be sure to test a little on your wrist first to make sure its cool enough.  Thoroughly wash your hands and feet and pat dry with a soft cotton towel. Smooth on the olive oil and be sure to cover every inch of your hands, fingers, feet toes.  Dip each hand or foot into the way repeatedly until you have several layers of wax build up. Have someone help you put on the sandwich bags onto each hand or foot and then relax for about 30 minutes.  For added benefit, place a bath towel over your hands or feet while you wait. Now to remove the way, simply peel it away.  Start at the wrist or ankle area and pull it down.  It should come in large sections.  Follow with hand and foot massage.     Honey Milk Bath 1 cup honey 2 cups milk 1 cup salt 1/4 cup baking soda 1/2 cup baby il Fragrance oil of your choice Combine honey, milk, salt and baking soda in a bowl.  Fill your tub and pout the mixture in.  Add the baby oil and a few drops of the fragrance.