Your SPF 50 isn’t protecting you (as much as you think)

Many of my patients are dismayed when I tell them that their high SPF sunscreen is not protecting them very well. I am a proponent of sunscreen, but real life use of sunscreen doesn’t give you the protection level on the bottle and this is why:

1. We don’t apply enough. In order to get the protection on the bottle, a person must use a whole teaspoon on their face. For covering the body (such as when in a bathing suit) an entire ounce needs to be used. Nobody uses this much because it would require multiple layers of sunscreen in order to avoid having sunscreen dripping off your skin.

2. We don’t reapply with enough frequency. Sunscreen needs to be reapplied every 2 hours and after swimming or sweating. In real world terms this would mean going through a bottle of your tinted moisturizer every 1-2 weeks and a whole bottle of sunscreen every day (per person) when on a beach vacation.

3. We use old sunscreen. How many of you have sunscreen bottles from 2010? Sunscreen breaks down and is not effective when it is old. Your sunscreen should be replaced every year. However, if you are using enough, your bottle should run out well before the year is up. If your sunscreen is separated, clumpy, smelly or just old- get a new bottle.

4. Sunscreen is not 100 percent protective. Even if you are applying enough sunscreen and reapplying, sunscreen still lets a percentage of UV light through.  This small amount of UV light is enough to stimulate dark spots in people who are sensitive. If you have melasma, sunscreen is not enough to keep your face clear.

Sunscreen is a great tool to protect against skin cancer and photo-aging. However, we cannot depend on it to protect us 100 percent. When you put on sunscreen in the morning assume you are getting about half the SPF on the bottle. If your bottle says SPF 30, then your effective SPF at the moment you put it on is SPF 15. This number decreases as the day goes on, so at the end of the day (when you are sitting on the deck at happy hour) you likely have very minimal (or no) sun protection.

As we go into spring and summer, keep wearing sunscreen, but remember to reapply and consider other sun protective measures such as hats, clothing and shade. You’ll see me under the umbrella with my big hat and long sleeve shirt.


Don’t wait until it’s too late (for Botox)

I consider myself primarily a medical dermatologist, but I am trained in cosmetics and offer some services to my patients for convenience. I often get questions about Botox, and sometimes I have to disappoint people by telling them that Botox will likely not be able to smoothen their lines.

Why is this? Botulinum toxin binds to receptors on the targeted muscle and relaxes the muscle, so it temporarily (3-6 months) cannot move. Botox will only remove lines that are present when you are moving your face. If you look in the mirror and see lines when your face is not moving- then these lines will either take time to go away (after several treatments over many months) or they will never go away.

I don’t push people to undergo cosmetic procedures that they don’t want or need, but I have come to appreciate the preventive nature of Botox. If you start having Botox treatments before you have lines that you can see, then you may never develop the deep lines in your forehead and between the eyes (until you stop the treatments). So if you are thinking about Botox- don’t wait until it’s too late. It is a very safe, quick and relatively painless procedure when performed by a knowledgable injector.


Why is my hair falling out?!?

Hair loss, a distressing issue for patients and doctors.
Diagnosing and treating hair loss can be very challenging. Often there is not one cause and the treatment options are limited. However, hair loss should be reported to your doctor to ensure that it isn’t a sign of a serious condition and some hair loss can be easily treated. In this article I will review the most common causes of hair loss and briefly discuss treatment. This article should not be used to replace a visit to your doctor because every case of hair loss is unique.

  • Alopecia areata.┬áThis is a type of hair loss that cause patches of hair to fall out, leaving a completely bald spot. It usually happens in small areas but can affect any hair follicle including facial hair, eyebrows and eyelashes. This is an easy diagnosis for most doctors. It is caused by your immune system attacking the hair follicles. We don’t know why this occurs. In most cases it is not associated with any other autoimmune conditions, but in a few cases it can be associated with diabetes or a thyroid problem. In the majority of cases it will resolve without treatment in 12 months. Certain locations can be treated with topical steroids or steroid injections but these treatments just suppress the inflammation and allow the hair to grow back. They need to be repeated every 4-8 weeks or the hair will fall out again. On a personal note, I experienced alopecia areata of my eyelashes on one eye in college. It was not treatable with the steroids but they grew back and hasn’t recurred (yet).
  • Male Pattern Hair Loss. Another easy one to diagnose. Most men will experience hair loss. It is hereditary but comes from both mom and dad (contrary to the myth that it is through the mom) and most men will look most like their father. I feel a little bad for my son. Male pattern hair loss is treated with finasteride (also called Propecia) and minoxidil (also called Rogaine). Hair transplants can also be used where hair from the back of the head is moved to the front. Finasteride works by blocking the hormone (a type of testosterone) responsible for hair loss- it is preventative. Minoxidil (Rogaine) works by stimulating hair growth. They work best when used together. They are not curative and if they are stopped the natural trajectory of hair loss will continue.
  • Telogen Effluvium. This is a generalized sudden loss of scalp hair. Usually people notice lots of hair in the drain or on the floor and hair seems overall thinner. This can be caused by a long list of conditions. The most common are: childbirth, surgery or illness, weight loss or weight gain, nutritional deficiency, life stress and medications. Often there are multiple factors playing a role. Telogen effluvium occurs 3-4 months after the inciting event. It can continue for 3-4 months after the body “stressor” has ended. Often people never regain the fullness they had, though the shedding usually stops. A doctor may test your iron reserves (called ferritin) and thyroid levels to ensure this is not playing a role. I have experienced telogen effluvium, it can be stressful.
  • Female Pattern Hair Loss. This is the most difficult to diagnose and treat, and probably the most common cause of hair loss that I see. Similar to men, most women experience hair loss as they age. The hair gets less full and the texture of the hair changes with age. This change can be very distressing if it starts at a young age (the definition of young is subjective). It can start in the twenties for some women. Sometimes there is a telogen effluvium event that unmasks female pattern hair loss earlier than it would otherwise be noticeable. In most cases it presents during peri-menopause or menopause and in the majority of cases all hormones are normal. In some cases there are elevated testosterone, but most often not. Female pattern hair loss is challenging to treat and usually not completely reversible. Rogaine, spironolactone (a blood pressure pill that can block the hormones contributing to hair loss) and finasteride can be used with variable success. Finasteride is not used by all doctors as it is not FDA approved in women. I see quite a few women for this condition.
  • Other types of hair loss. This category is the least common (in my practice) but potentially the most serious. Autoimmune conditions such as lupus and lichen planus can present with hair loss. Psoriasis and eczema can cause hair loss. Infections such as ringworm and syphilis can cause hair loss. These conditions obviously need treatment and are beyond the scope of this discussion- but just reinforces that hair loss should be reported to your doctor.

I hope this article has been helpful in discussing this very large topic. Again, see your doctor if you are having hair loss and make sure to mention it early in the visit- it is often the last topic mentioned in a visit in my office, which makes complete evaluation difficult.


What is going on with my skin?!?

There are days/weeks/months that this phrase goes through my head. Even as a dermatologist I have bad (sometimes very bad) skin days. Often it is due to trying out a new product (occupational hazard), but sometimes I cannot figure out what caused the decompensation in my skin.

So what should you do if you wake up with a terrible breakout or rash? Here are the rules that I try to follow- though sometimes I break them.

1. Minimize products. Stop all but the most basic skin care products. Especially stop new products- they might be the cause. I try to stick with a gentle cleanser (such as cetaphil or cerave) and then use only a gentle moisturizer (again cetaphil or cerave are good choices). Use only the amountof makeup needed to be presentable. Stop all anti aging (such as retin A) products.

2. Try very hard to avoid treating the breakout with new products. In general, topical acne products are irritating and can make an acute breakout look and feel worse. Try to avoid cortisone creams unless you know the rash is eczema. Cortisone will make rosacea and ringworm worse. If this is an allergic reaction the new product may have the same allergen (which could be common to many products).

3. Try not to pick. It can cause scarring.

4. Avoid harsh environments if possible. Sun, sweat, snow will likely make things worse. Your skin is out of balance and these conditions make your skin work harder to maintain balance.

5. Don’t get a facial or go to the department store/drugstore. See number 2 above. This will likely make things worse and you’ll be out a few (hundred?) bucks as well.

6. Be gentle with your body. Get adequate sleep, eat healthy, drink water (not alcohol). The skin is the largest organ of the body and will reflect how you are caring for yourself.

7. Lastly, if the skin madness lasts longer than a week, call your dermatologist. We can usually help.

I hope this post helps you through the next bad skin day!