There is NO reason to re-excise a moderately-atypical nevus

To those who are patients and those who follow my posts, you know that I am adamant that there has been an over-treatment of these atypical nevi for decades. In short, the data just does not support the removal of these lesions–PERIOD!

Another study was just completed at Emory University (Atlanta) and Atlanta Veterans Administration Medical Center. Here are their conclusions:

Re-excisions are not needed when clinically excised moderately dysplastic nevi have positive histologic margins, based on results of a retrospective study of 438 patients who were treated at nine academic medical centers in the United States. Not a single patient in the study developed melanoma at the excision site after an average follow-up of 6.9 years, and at least 3 years in all cases.     [SOURCE: Kim CC et al. IID 2018, Abstract 571.]

So when your Dermatologist or the Dermatopathologist (on their pathology report) states that your moderately atypical nevus should be removed, ask Why!



Most Cosmetics Do Not Work

Study Suggests Most Claims Reported on a Beauty Product Are Not Considered Truthful.

CBS News (7/29) reports on its website that “a new study found fewer than one out of five” beauty product “claims was considered truthful by a panel of readers – and ads that used scientific language to describe the benefits were even less persuasive.” The study that was cited was published in the Journal of Global Fashion Marketing: Bridging Fashion and Marketing.

This comes as no surprise as most companies do not perform studies on their products to prove that they actually work. Others “perform” poorly constructed studies, that would never be published in a peer-reviewed medical journal, using photographs as “evidence” of effect. Photographs alone prove nothing unless they are standardized (same exact lighting, same exact positioning, etc) so when one looks at photographic claims, one should be wary–is the lighting the same, is the person smiling in one picture and not in another.  I never base proof on photographs alone, unless used in a well-performed trial.

Many companies will put the same “active ingredient” in their product and use the claims from other products. Well, while that may sound fine, it is not. While an active ingredient may be essential to achieving a desired result, it is the other ingredients that allow it to penetrate the skin and work. These other ingredients differ, thus changing the result. The active ingredient itself may be different–not as pure or a different percentage. In short, there are many variables.

Therefore, one should be very skeptical regarding claims that are made. Additionally, the same holds true for many products that are sold in Spas, Plastic Surgeon’s offices, and Dermatologist’s offices. Many of the products that I have found on the shelves in these offices were not tested, but based their claims on studies performed on other products from other companies.

Eyelid Dermatitis in Women: Home Remedies

Eyelid dermatitis in women is fairly common.  In many cases, the initial cause is irritation incurred during the removal of make-up. Mechanical friction, often with a wash cloth or other cleaning product, removes some critical components of the outer layer of the skin that protects the skin. After this occurs, things that normally would not irritate the skin when the normal barrier is intact, may irritate the skin. This results in redness, occasional white scale, and itching and/or burning.

What to do when this occurs?

  1. First is one must not use eye makeup until the rash resolves completely.
  2. If there is no personal or family history of glaucoma (above normal pressure in the eyes), then hydrocortisone 1% ointment (and I stress ointment–not cream) should do the trick.  Apply it up to 4 times a day for the first couple of days, then twice a day for 3-7 days decreasing to once a day as it improves. Then apply every other day for 2 applications. When one is using the medication once a day or less, they should apply Vaseline petroleum jelly to the eyelids, where affected, at bedtime. This is a great, safe moisturizer. Only use a tiny amount.

In general, the rash should resolve within 10 days. If not, one should seek the help of a Dermatologist. Other possible causes would include allergy to nail polish, eye drops, and cosmetics. In my practice, allergy is far less common than irritation.

After the rash has resolved, one can start to use one eye make-up product for 2 weeks. If there is no rash, then add the next one in. The most important part–how one removes their make-up. Use your fingers (best) or the softest possible product. Be gentle–no aggressive wiping or rubbing. Use oils or products like Albolene (a greasy make-up remover that moisturizes and removes at the same time).

New drugs for Psoriasis looking GREAT!

TYK2 inhibitor is being developed by Bristol-Myers Squibb and the early Phase II trial results have been great. Why? Here is the scientific talk: the TYK2 inhibitor has been shown to be 100 times more selective in inhibiting IL-23 , IL-12, and interferon-alpha than JAK 1/3 inhibitors and 3,000 times more selective than JAK 2 inhibitors. What do you have to know: IL-23 is the primary cytokine responsible for developing psoriatic lesions and this new mediation works very well and blocking it.

It will be a while before this medication will be available as further studies are needed for both efficacy and, more importantly, safety. At least there will be another medication that may be the answer for patients with moderate to severe psoriasis. Oh, and of course what will the price tag be for this new drug? Who knows, but as history as shown us with the other new psoriasis drugs, we expect that it will be a lot.

Risankizumab also known as BI-655066 is a humanized monoclonal antibody targeting interleukin 23A (IL-23A). This drug is also in Phase II trials and has had great success.

It is exciting to see even more effective treatments for psoriasis on the horizon.

Hydrochlorothiazide (HCTZ) use is associated with increased risk of Basal Cell and Squamous Cell Carcinoma

A recent study published in the Journal of the American Academy of Dermatology has shown that taking hydrochlorothiazide (HCTZ) is associated with an increased risk of basal cell carcinoma and an even higher risk of squamous cell carcinoma. The risk was dose dependent (the higher the cumulative dose, the higher the risk).

An increased risk was not seen with other anti-hypertensive agents or diuretics.

High costs cited as major reason patients do not adhere to their treatments

Has anybody seen the changes in the cost of medications lately? In case you have not noticed, they have soared completely out of control. For example, a bottle of 100 doxycycline capsules used to cost about $4. Today that same bottle is well over $100.  Patients are faced with high copayments for their medications, which is leading to problems of affordability.

Physicians need to play their part too. All to often I see physicians prescribing expensive medications when a suitable generic alternative is available at a fraction of the cost.

Here are my simple recommendations:

Over-the-counter topical medications:

  • Differin Gel 1% — In 2017 this went over the counter. It is great for unclogging pores. There is no reason to get tretinoin (Retin A) or any other topical retinoid before using this for several months. The average cost is $18
  • Benzoyl Peroxide 2.5% – 5% gel–this is great at killing the bacteria that causes acne. in fact, there is nothing better.  This medication will bleach clothes and sheets so be careful. The average cost is about $5-10.
  • Benzoyl Peroxide 10% wash–this works well for acne on the back, chest, and shoulders. Use this once or twice day to these areas in the shower. Use towels that you do not like as they will get discolored.
  • Salicylic Acid–there are many preparations for this which helps to unclog the pores. It does not work nearly as well as Differin, but it can be used in addition to it.
  • Glycolic Acid–there are many preparation for this which also helps to unclog the pores. Some preparation combine this with salicylic acid. The two together work very well, but still not as well as Differin gel.

Always ask  your doctor if one of these above options will be suitable, as they will be FAR cheaper than prescription medications.

Those with deep seated cysts will require oral medications, which are available by prescription only.

Always request generic medications. You can always price them out on and get coupons with that site. For medications that are not covered, try to find one that is covered. In most cases, this insurance carrier is telling you that there is a cheaper alternative that can be prescribed. If you are paying for the medication or have a high copay for it, shop around.

I have a skin problem: Who should I see?

Without question, it is ALWAYS best to see a well-trained, board-certified Dermatologist if one has any skin problems (rashes or growths).  Although many PCPs and Urgent care centers can handle COMMON problems (i.e. Shingles, poison ivy and minor burns), but what happens when both you and the doctor does not know what is the diagnosis? In many of these cases, patients are treated with Lotrisone (clotrimazole/betamethasone cream), which I call the “I have no idea what you have so I will give you this” medication.

In short, this medication is RARELY ever used by Dermatologists for a couple of reasons. It is a combination of a VERY STRONG topical steroid with an old anti-fungal agent. If one really had a fungal infection, topical steroids actually stimulate the growth of fungi. For this reason, it is uncommon to use a very strong steroid with an anti-fungal drug. Additionally, the use of strong topical steroids can thin the skin if used for more than 2 weeks, especially if used in the armpits, groin, face, or neck. I see patients regularly who are prescribed this medication only to be left with thin skin or stretch marks that will not go away. Dermatologists do occasionally use topical steroids with anti-fungal creams, although usually they prescribe them both separately, which costs less and is safer.

In summary, if you have an acute problem, such as an infection, Shingles, a burn, or Poison Ivy, your PCP and/or local Urgent Care Center will likely be able to treat you effectively. For these acute problems, you do not want to delay treatment.

If you have a “rash” or “growth” and do not know the cause, your best bet is to find a good Dermatologist. In my experience, it is far less costly to pay more for a visit with a Specialist than to be ineffectively treated with medications that can be costly. For example, a 15g tube (tiny) of generic Lotrisone can cost $131 compared with a 85g tube of another steroid that costs $12.

Most importantly, Emergency Rooms are for just that–life threatening emergencies. Nearly all skin conditions are NOT life-threatening, and unless one has reason to suspect otherwise (many blisters, sheets of skin coming off, or suspected serious infection), one should not seek advice for skin conditions in an Emergency Room Setting. There are times when one might be prompted to go to the Emergency Room. An example of such would be a diabetic who thinks that he/she has cellulitis who calls his/her PCP for advice and is then directed to go to the Emergency Room for evaluation.

Infections after a Pedicure

Patients often ask about the risk of getting infections after a Pedicure. In most cases, they are asking about getting a toenail fungal infection, which is rare in this circumstance. Bacterial infections have occurred after getting a Pedicure, although is uncommon. Those who are immuno-compromised or have diabetes and/or poor circulation are more at risk to getting infections.

The American Academy of Dermatology recommends that people not shave their lower legs for at least 24 hours before receiving a pedicure, because cuts from shaving could put people at risk of infection.