Skin Sense - The Latest Developments in Skin Care

Dr. Rachel Herschenfeld
Dermatologist

What's on the horizon for skin care? Is there something better than Botox? What new injectables are taking the market by storm? Is there a new miracle skin cream? Dr. Rachel Herschenfeld, who writes the monthly column, Skin Sense, on washingtonpost.com, talks about the latest developments and what we can expect in the future.

The Harvard-educated dermatologist was online to answer questions, Thursday, Oct. 30, at 11 a.m. ET.

Herschenfeld's practice is based in Wellesley, Mass. After graduating from Harvard Medical School, she completed residencies in internal medicine and dermatology, then joined two other dermatologists to found Dermatology Partners, Inc., a successful general and cosmetic dermatology practice. Dr. Herschenfeld is board certified in dermatology, and is a Fellow of the American Academy of Dermatology. Her patients rely on her to diagnose and treat skin problems, to provide expert skin care advice and to perform cosmetic procedures including Botox, Restylane, collagen, Sculptra and laser treatments for many conditions.

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Rockville, Md.: I am a South Asian female(Indian) in my 50s who has a lot of dark patches (hormonal deposits and sun exposure) on my face that makes me very self-concious. I went to a dermatologist for consultation and was offered a $7500 package that included, chemical peel, some kind of dermabrasion, laser and she also threw in Botox for my neck! What is the best course ( considering I don't have $$ to drop)Initally it was recommended I use prescription trentonin ( spelling ??) cream , face wash etc. Thanks so much for reading this and for your response. Rani

Rachel Herschenfeld: It sounds like you may have melasma, which is very common in women with dark skin. Usually for this condition I recommend starting with fading creams and chemical peels. You should be able to get this type of treatment for less than $7500, so I would recommend seeking another opinion.

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Bethesda, Md.: I have tried Sculptra a few times, and it seems to make an improvement. How often and how frequently is it safe and advisable to have this injectable?

Rachel Herschenfeld: Sculptra is a great filler that stimulates collagen formation. Results usually last between 12 and 24 months. If you feel that you are noticing the effects wearing off after several months, it would be safe to have a touch-up treatment. If you are stil happy with your appearance, then wait a bit longer.

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Princeton, N.J.: I'm Chinese, and I just turned 40. I use cheap stuff - Mexoryl SX containing sunscreen against UVA/UVB, Eucerin or a similar cream for my kids as moisturizer, Retin-A at night to fight fine lines. Do you think I can do better with the more expensive creams? Some people say that you pay for new technology that really works, and I don't want to miss out, but don't want to waste my money either. Could you recommend any products?

Rachel Herschenfeld: Expensive does not mean better! Sunscreens that contain Mexoryl SX are using some of the best technology out there to protect your skin form harmful UV rays. Moisturizers don't have to cost a fortune to work. Many of the brands at CVS have very effective ingredients. One of my favorite moisturizers is Cerave cream, which you can find at many drug stores.

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Cedar Park, Tex.: What is the best solution for the fine lines forming around the mouth?

Rachel Herschenfeld: Lines forming around the mouth can be addressed in several ways. Fillers such as Restylane, Juvederm or Cosmoderm are very helpful, especially in combination with a little bit of Botox. Lasers have also become much more effective in treating this area, particularly fractional resurfacing devices such as Fraxel. It is worthwhile to seek a consultation from an experienced cosmetic dermatologist.

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Fairfax, Va.: Is laser hair removal permanent (I understand it can take several sessions). What are the most common side effects and how do you find a good practitioner? Thanks!

Rachel Herschenfeld: For most people laser hair removal can produce permanent reduction in the amount of hair, but it can't eliminate 100% of hair in most areas. Common side effects include redness and bumpiness after a treatment, which can last for a few hours. Sometimes the skin in a treated area will temporarily darken. I would advise you to seek treatment from a dermatologist who has experience treating patients for this problem.

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Maryland: Good morning, Dr. Herschenfeld, I had fraxel laser treatments last year (and I love how my skin looks now). My doctor had me use the Obagi presurgical line beforehand, and I've been using it since then. I'm starting to run out, and really can't afford to replace it. Is there a line of skin care that is comparable to this that is less expensive?

Rachel Herschenfeld: It's great to hear that you did well after Fraxel! You are smart to continue using products to maintain your improvement. The key ingredients in the Obagi products can be found elsewhere. Tretinoin is found in RetinA and Atralin and in generic form. Over the counter fading creams contain hydroquinone. I would recommend seeing a dermatologist to get a prescription for one of these alternatives, then pair it with an over the counter product.

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Washington, D.C.: I am in my mid 20s and have recently started using Retinol (.3 percent) on my face as preventative measures for any type of wrinkling and also to minimize acne scars. Is this too harsh for my skin? I used the .2 percent Retinol before and that didn't dry me out. Also, do you have any recommendations for a moisturizer for winter for acne-prone skin?

Rachel Herschenfeld: It is great to start an anti-aging regimen in your 20s. Retinol-containing products are ideal in that they can be found over the counter, and are usually less irritating than prescription strength products such as RetinA. So, keep using what you've got. You could also add a mild moisturizer containing some glycolic acid for the winter, which may actually help your akin. An example is AquaGlycolic. If that is too irritating try something like Cerave lotion.

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Cedar Park, Tex.: What is your opinion of Amlactin 12 percent moisturizer?

Rachel Herschenfeld: It's great product for dry, flaky skin! Just be careful since it can sting temporarily if you have a cut. It is also great for thinning out thick dry areas such as the heels or elbows.

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Washington, D.C.: Hello-- I am a 39-year-old woman with red hair. I once attempted to address spider veins in my legs with laser treatments, and it did not work at all. I recently attempted to make an appointment for laser hair removal and was told they "don't work on redheads."

I am now at an age where I would like to pursue some anti-aging treatments for my face (fine lines, uneven skin tone). Are there any procedures that work with fair-skinned redheads?? Thanks

Rachel Herschenfeld: People with fair skin can benefit from all sorts of laser treatments. If you have light hair, however, laser hair removal won't work very well. Examples of lasers that can do a great job in fair skinned people include: IPL, which is great for brown spots, Fraxel, which is very helpful for fine lines, and VBeam which can reduce redness. Other treatments that work equally well in fair skinned people and dark skinned people include Botox, fillers and Renova.

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Washington, D.C.: Hi, I've been looking for a resource that lists readily available products that do NOT contain parabens (even some baby products contain them!). Specifically, I'm having a hard time finding a lotion. Do any major manufacturers, like Curel, for instance provide any paraben-free products? Do you know of a Web resource to turn to? Thanks very much for your help!

Rachel Herschenfeld: Vanicream is a line of products that is designed to be paraben-free, and can be found at many drug stores. There is also a database that your doctor can search to print lists of products that specifically do not contain the ingredients you need to avoid. The American Contact Dermatitis Society has a website with a lot of this information.

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Washington, D.C.: I'm so glad you're doing this chat! I've always wondered how multiple layers of SPF work. For example, I use a tinted moisterizer that has an SPF of 20 and my powder has an SPF of 15. I'm sure together they don't equal 35 but how does that work? Should I wear something stronger underneath all that? And if so, what's a light one to wear that dries quickly, since I'm always running late in the morning and don't have five minutes to spare while my sunscreen dries. Thanks!!!

Rachel Herschenfeld: You're right- you can't just add up SPFs and assume that you have more protection. That is because what you see on the bottle may not be what you get on your skin if you don't apply enough of the product. There are no general rules since everyone puts these things on a little differently. I would recommend choosing a sunscreen that you like with and spf of 15 or higher, and putting it under your makeup every day. An example of one that dries quickly is Neutrogen Ultra Sheer. I also like the Neutrogena Healthy Defense Daily moisturizer.

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Reston, Va.: I have always had blocked pores that turn to blackheads on my chin. Can I get a good extraction at a salon/spa, or do you recommend going to a dermatologist's office?

Rachel Herschenfeld: I would recommend seeing an aesthetician in a dermatologist's office.

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Boston, Mass.: My (very fair, Irish) grandmother on my father's side's skin became extremely delicate toward the end of her life, to the point where she couldn't use a conventional band-aid on scrapes because that would damage her skin even more. The skin of my aunt and father is already starting to show some of these tendencies (they're both in their early-to-mid-60s). I'm in my mid-20s with their skin tone and currently moisturize and use sunscreen. Is there anything else I should be doing to protect myself? I will note that my Mom's side of the family is Eastern European and much hardier. Thank you!

Rachel Herschenfeld: Some skin changes with aging are due to genetic factors that we can't change, but the environment also plays a role. So, protect your skin by using sunscreen, avoiding sunburns, and using moisturizers if it gets dry. It sounds like you are doing the right thing.

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Rosacea: Hi, Dr. Herschenfeld, I have mild rosacea but I don't like the Finacea and Metrogel prescribed by the dermatologist. It's very drying! Are there other options? Also, how much of a factor is diet? Processed foods, etc.? Thanks!!!

Rachel Herschenfeld: There are other topical medications that can be precribed, including different topical antibiotics. There are also some medications that can be taken by mouth, and require a prescription. Diet can definitely contribute to the problem of redness and flushing with rosacea, so if you find that certain foods (like alcohol or spicy foods) make you redder, then avoid them.

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Dnn Loring, Va.: An important question for you: Joe Biden and Botox, yes or no in your professional opinion?

Rachel Herschenfeld: I think it was pretty obvious during the VP debate! All of us derms were buzzing about it.

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Arlington, Va.: Hiya, Dr. Herschenfeld. As a single 50-year-old man, my only hope for getting a second glance from the opposite gender is to get rid of these expanding bags under my eyes. Are there skin creams that could help, and if I decide to have an "eye job," how long could I expect to remain stunningly handsome and attractive?

Rachel Herschenfeld: Well, I wish I could tell you that there was a miracle cream out there, but there is not. It is hard to make specific recommendations without actually seeing you, but in most cases I recommend a consultation with a plastic surgeon for bags under the eyes. In some cases I can use fillers to improve the appearance in this area. If you opt for surgery, you should expect results to last for years, easily 5 or more. Fillers usually last between 6 and 18 months, depending on which one you choose.

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Washington, D.C.: My very fair-skinned husband has rosacea and takes Oracea (for rosacea!) to combat the redness. He doesn't think it helps very much; he still has the redness on his nose and forehead. He doesn't eat very much spicy food, and doesn't drink often or in large amounts. He does have an iced tea a day, on average. Any other suggestions?

Rachel Herschenfeld: It may be that some of the presistent redness is due to little blood vessels that often dilate in people with rosacea. In these casaes, laser treatments can be extremely helpful.

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Washington, D.C.: Hi,

I'm interested in laser hair removal and wanted to know your opinion on its safety. I am an Indian male and my skin tone is not dark, but not extremely fair either. About eight years ago someone who had laser hair removal said they got burns/scars from the treatment. However, I recently spoke with two dermatologists and an aesthetician who said the treatments are safe if a lower laser setting is used. I've done some web research and have not run across any blogs etc., where people have had scarring issues. What is your opinion? I'd like to have the procedure to get rid of unwanted hair, but am concerned about permanent burning/scarring.

Thanks

Rachel Herschenfeld: You should be very careful to choose a dermatologist who is familiar with using lasers to treat people with darker skin. Sometimes lower laser settings are appropriate, but in many cases it is a matter of choosing the proper laser device. There are actually several different kinds of lasers that can be used for hair removal, and some are much better for dark skinned people. In the hands of an experienced laser physician, your risk of scarring or pigment change in the skin is low. Also, it is always possible to be seen for a consultation and a test patch: just have a small area treated to see how your skin reacts before proceeding with a full treatment.

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Arlington, Va.: Do you have any recommendations for products to use on dry skin? I just moved from Florida where there is always humidity and the lack of it here is making my skin very dry and flaky, especially around the eyes. Thanks!

Rachel Herschenfeld: Moisturizers that contain cermaides, such as Cerave, are great for restoring moisture to very dry skin, even people with eczema. Moisturizers that contain lactic acid, such as AmLactin XL, are also great for dry skin because they help exfoliate the dead flaky skin surface. I wouldn't use AmLActin around the eyes, though, because it would sting.

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Washington, D.C.: I'm turning 26 this week and becoming paranoid about skin care and wrinkles down the road. I have very fair and rather dry skin. Currently I use Neutrogena oil-free moisturizer for my face and I cleanse with Dove gentle exfoliating face wash. Is there anything I should be adding to my routine? Or should I be changing it altogether? Thanks!

Rachel Herschenfeld: My first 3 words of advice: sunscreen, sunscreen, sunscreen every day on your face. Then consider using a product containing retinol, or get a prescription for Renova. And never, ever sunbathe! You don't need to live in a cave or wear a paper bag over your head, but you should avoid excessive sun exposure.

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Annandale, Va.: I have partial paralysis on one side of my face, the residual damage from Bell's Palsy. I am now in my 50s and things (neck, jowls, eyebrows) on that side of my face are sagging much more than on the other side.

I'm really not interested in plastic surgery. Can fillers help me, or anything else that a dermatologist can do?

By the way, am I wrong to imagine that Botox would in a way mimic some of the paralysis of Bell's Palsy?

Rachel Herschenfeld: It is possible that fillers could help to restore some symmetry to your face, and sometimes Botox can do so as well. You are right in thinking that Botox could mimic some of the effects of Bell's palsy, depending on where it is injected. That's why it is important to go to someone who knows what they are doing with this medication!

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Washington, D.C.: I'm approaching 40, but also pregnant. I know some treatments are off-limits (Retin-A), but are any OK during pregnancy?

Rachel Herschenfeld: I would definitely recommend that you avoid you RetinA. You can still use moisturizers, and sunscreen, and avoid too much sun exposure. I would also recommend that you check with your OB before using any anti-aging products. But for the most part, I recommend that people wait until they have their baby, and then restart their cosmetic treatments.

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Boston, Mass.: I swim 4-5 days a week for an hour or more which keeps me in shape but also dries me out. I use moisturizer, drink plenty of water and eat healthy, but I've heard that the goggles worn while swimming can damage the skin around the eye and cause premature wrinkles. Is there any truth in this?

I'm 30, and I welcome the changes as I age, but I certainly don't want to speed up the process!

Thanks!

Rachel Herschenfeld: Here's a tip you may not have heard: apply some moisturizer before you swim. It can help protect your skin from some of the harsh chemicals in the pool. Goggles should not cause wrinkling around you eyes. I have seen people who are allergic to some rubber ingredients get a rash around their eyes from swim goggles, but no permanent wrinkles.

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Washington, D.C.: Are there any vitamins you recommend for women to take internally to help the appearance of their skin?

Rachel Herschenfeld: There is medical evidence that taking a daily multivitamin is a healthy thing to do. However, there is no need for extra supplementation beyond this to keep your skin healthy.

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Re: Laser Hair Removal: You mentioned there are several different kinds of lasers that can be used. Do you have any suggested references so that I can read about these options. Also is it recommended that a dermatologist perform the laser hair removal? I've noticed that some dermatologists have aestheticians in their office who do it. Also are the laser hair removal clinics safe? Or is it best to stick with a dermatologist?

Rachel Herschenfeld: I always recommend having a dermatologist actually do your treatment. That is the standard in my office, and I think that it is safer and you are more likely to get the results that you want. I do not recommend clinics where non-physicians perform the procedure.

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Washington, D.C.: Hi Dr. Herchenfeld-

Can you recommend one or two brand-name, drug store or otherwise, products for those of us in our early thirties who are just starting to see small lines and want to prevent more? Thanks!

Rachel Herschenfeld: Try a retinol containing night cream from ROC or Vichy.

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Fairfax, Va.: Hi! I'm 50 and usually mistaken for someone in my mid-thirties. No treatments, but I always do the stuff doctors say, excellent nutrition, plenty of sleep, exercise, sunscreen, little alcohol, no smoking. I've noticed that most of my upscale associates spend a ton of money on pricey treatments and cosmetics and look either preserved or terrible anyway. They have terrible lifestyles. Do you do a physical evaluation of your patients first? Or do they come cash in hand and demand immediate results anyway? (And yes I know that there are definitely skin problems that don't respond to a healthy lifestyle alone. Thank goodness there are dermotologists!)

Rachel Herschenfeld: Sounds like you have great genes! And a healthy lifestyle. You are fortunate if you feel satisfied with your appearance. Many people aren't so lucky, even if they live a healthy lifestyle. To answer your questions: Yes, I always take a detailed medical history and examine my patient's skin before treating them. It is not unusual for me to find something in a person's history or exam that modifies my recommendations for treatment. No, my patients don't march into my office demanding treatment. Most of them sincerely want honest advice about what they can do to keep their skin healthy and looking good. I do my best to give them this advice.

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Alexandria, Va.: I have deep pores on and around my nose that fill with blackheads. I'm washing my face daily with a facial soap and a face scrub with salicylic acid. In addition, I use nose strips weekly to pull out some dirt and oil. But it only helps a small amount. Is there any more effective treatment to clean them out (for good?) and make the skin on my nose smooth and clear? Thanks.

Rachel Herschenfeld: There are other treatments that can help, but probably not eliminate, your blackhead problem. In particular, I would recommend trying RetinA or one of its relatives, such as Differin or Tazorac. These products help to unclog pores and diminish the appearance of blackheads.

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Washington, D,C.: I am 31 and have generally good, youthful-looking skin. Recently, however, I have noticed a deep line between my eyebrows that becomes more pronounced when I have inadequate sleep or am stressed out.

Do you think this is something appropriately treated with Botox or a similar treatment? Thanks.

Rachel Herschenfeld: It sounds like the classic frown line. This is excatly the indication for which the FDA approved the cosmetic use of Botox. It is worth obtaining a consultation to see if you are a good candidate.

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Spot, TY: Dr. Herschenfeld - As I've gotten older, my summer freckles no longer fade. They're turning into age or liver spots. Is there an OTC fade cream you can recommend? Or is there something my dermatologist can prescribe?

Rachel Herschenfeld: There are over the counter fading creams that contain hydroquinone, and other ingredients such as glycolic acid. There are also stronger fading creams that are available by prescription. These can work on some types of "liver spots", but not all of them, so it is worth a trip to your dermatologist to determine the best course of action. Some types of spots need more aggressive treatment, such as laser or treatment with peels or liquid nitrogen.

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Washington, D.C.: I'm not quite ready for Juvederm or Restylane for my naso-labial folds and wanted to try a topical treatment for now.

What do you think about Argeriline, and can I use it if I'm using a nighttime moisturizer with a light Retinol?

Rachel Herschenfeld: You can certainly use Argeriline, but it cannot fill lines, and it in no way replaces Restylane or Juvederm. In terms of topical anti-aging treatments, the best data is on the use of RetinA, and it works for fine lines and wrinkles, not on deep folds.

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Manassas, Va.: At 62 I have sensitive, dry facial skin.I like Clarins Restorative products, but at $105 for a day moisturizer I cannot afford it. Is there a less expensive, quality moisturizer?

Rachel Herschenfeld: I would try Vanicream, which is designed for sensitive skin, or Cerave, another great product for sensitive skin.

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Washington, D.C.: I'm having dandruff problems. I've tried Head and Shoulders, Selsun, and now tea tree shampoos. What's left to try if these are not working?

Rachel Herschenfeld: There are plenty of other over the counter products such as those containing salicylic acid (Neutrogena T-Sal, for example) or tar derivates (Neutrogena T-Gel, for example). Also, there are prescription products that can help dissolve the flaky scale or calm down the inflammation.

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Falls Church, Va.: I'm a 30-year old female and have noticed that the pores on either side of my nose are increasingly visible. My skin also seems dull lately, despite eating well and drinking lots of water. What do you recommend?

Rachel Herschenfeld: You may want to try exfoliating with a gentle scrub or glycolic acid containing cream (like AquaGlycolic). You may also benefit from microdermabrasion or chemical peels. These interventions may restore a smoother skin surface that doesn't look dull, but they won't help the pores very much. There really are not many treatments that can help pores. One thing to consider is Avage, which is related to RetinA and might help a little bit to shrink pore size. This product is available by prescription only.

A lot of information here.

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