Eliminating Discolorations, Shrinking Pores, & Fading Flushing
Article by Nelson L. Novick, MD
New York Dermatologic Surgeon
No doubt you already know a great deal about ways of getting rid of wrinkles, straightening jowls, removing moles, and fixing scars. However, a healthy and youthful appearance hinges on more than the absence of furrows, sagging, and unsightly lumps and bumps. Your skin is like a fabric or a canvass upon which everything sits. If I handed you a hot iron, and asked you to press a frayed, threadbare, and badly wrinkled shirt, you would likely be able to eliminate all the creases, but in the end you would still have a tattered garment, unfit for wearing. So, too, with your skin. In order to be fully restored and revitalized, you must also pay attention to the background fabric, to improve its luster, tone, and texture.
There are unfortunately quite a number of common imperfections that can mar the background fabric of our skin and detract from our appearance. These include sallow complexion, roughened or leathery skin, dark circles under the eyes, persistent facial flush, “liver spots”, freckles, melasma, post-inflammatory hyperpigmentation and dilated pores.
A dull and sallow (sickly yellow) tone can result from long-term photodamage, stress, lack of sleep, ill-health or improper skin care routines. Likewise, coarse, dry, alligator skin has its roots in chronic overexposure to ultraviolet light, chronologic aging, and the overuse of hot water and harsh cleansers. Dark circles under the eyes have been linked both to sun damage-related thinning of the lower lid that increases the visibility of the dark, bluish vessels beneath and to ultraviolet light-induced deposition of melanin within the region. The presence of a persisent, embarassing facial flush is most often an ethnic/familial trait or a manifestation of rosacea.
“Liver spots,” more correctly known as solar lentigines, have nothing whatever to do with the liver. They are small, flat or slightly raised brownish discolorations commonly seen on the face and hands of fair-skinned people who have had a great deal of lifetime tanning. They impart a mottled and uneven look that accentuates whatever lines and wrinkles are present. Another common discoloration, garden variety freckles or ephelides, may seem charming when there are only a few of them scattered over the cheeks and nose. But, when they merge together and become densely packed, they can be quite unattractive.
Then we have melasma, a common, inherited condition of blotchy brown pigmentation that typically affects the cheeks and forhead. Melasma is thought to be provoked by estrogens, birth control pills, the hormones of pregnancy, and sunlight. And finally, there is postinflammatory hyperpigmentation (PIH). Lesions of PIH are those annoying, dark blemishes, the bane of all teenagers, that can persist long after the healing of any intense or prolonged episode of inflammatory skin condition, such as acne or rosacea.
Traditional medium and deep chemical peels using phenol and high concentrations (50% or greater) of trichloracetic acid (TCA) have fallen in popularity in the past couple of decades. Although they are extremely effective for treating chronic sundamage, wrinkles, and pigmentary and surface irregularities, they typically require extended recuperative and recovery periods.
Fortunately, milder chemexfoliation agents, such as low potency TCA, Jessner’s solution, and maximal concentrations of glycolic acid and salicylic acid are available that can achieve many of the same effects without the long downtime. To distinguish these treatments from a chemical peel, the application of these substances is sometimes referred to as skin freshening, skin renewal, or skin rejuvenation. And because they can be performed in a matter of minutes, they have been described as “lunch-hour peels.”
TCA in concentrations of 10%-15% and Jessner’s solution, a preparation composed of lactic acid (an alpha hydroxy acid, see below), salicylic acid, and resorcinol in relatively low concentrations, has a long, proven safety and efficacy record.. A series of six or more peels can be helpful for brightening the skin, adding luster, smoothing roughened areas, and fading dark spots and larger discolored patches.
In my practice, I rely more heavily upon what I have nicknamed “Fruit Washes” and “Beta Washes” for improving brilliance, luster and tone; achieving smoother texture; softening fine wrinkles; minimizing superficial laxity; evening out pigmentary irregularities; and diminishing pore size. Both kinds of peels may be used safely and effectively for the face, neck, chest, and hands.
Fruit Washes are solutions of glycolic acid in its maximum 70% concentration. Glycolic acid is one of several alpha-hydroxy acids (AHAs), a group of naturally occurring substances often referred to as “fruit acids” because they are found in various fruits and other foods. In nature, glycolic acid is a component of sugar cane juice.
Topical anesthesia is seldom necessary before a Fruit Wash, although it may be occasionally needed to numb specific sites, especially the delicate areas under the eyes or around the mouth. Mild stinging, itching and burning are common shortly after application, but are eliminated by plain water or bicarbonate compresses applied after about two minutes. This is followed by a pleasing blush, and most people are delighted by an almost immediate overall improved glow or radiance. For best effect, a series of six to twelve treatments spaced at one to two week intervals is often necessary followed by periodic maintenance treatments as needed. Fees range $100-$150 per session.
Beta Washes contain salicylic acid, a beta-hydroxy acid, in a maximal 30% potency. Salicylic acid has been used safely as a peeling agent for more than sixty years. Prior to treatment, the skin must be thoroughly cleansed and degreased. Here, too, topical anesthesia is rarely required. After application, most people experience an intense stinging and burning sensation, which stops spontaneously in about three minutes without any need for neutralization.
Beta Washes possess several distinct advantages. For one thing, since the skin turns a powdery white as the solution dries, it is easier to be sure of an even and complete application without any skipped areas. Moreover, because it is lipid soluble, a Beta Wash can more easily penetrate follicles to unplug and tighten pores and improve acne prone skin. And, finally, it is especially safe because the peel stops by itself limiting the depth of penetration.
As a rule, Beta Washes more rapidly achieve some of the effects of multiple fruit washes, particularly for smoothing fine lines, lightening darkened skin, and hastening the resolution of active acne. A series of two to four treatments at two to four week intervals is typically required followed by periodic maintenance as necessary. Fees range from $350-$750 per session. The accompanying figures demonstrate melasma of the cheek before and following four Beta Wash sessions spaced at two week intervals.
Immediately after treatment, most people note an incredible smoothness and softness to their skin. However, it usually takes a few days for the surface to completely return to normal. A faint reddish-white appearance and slight puffiness is not unusual for a day or two. And during the next few days of healing, renewal, and repair, the skin may also feel a bit taut. Not infrequently, there will be a mild, sunburn-like flaking of the topmost layer. No particular aftercare is generally necessary, however, and regular makeup can be applied right away.
A variety of ablative and non-ablative lasers have also been used for the treatment of the above conditions. In my opinion, they tend to be more expensive, and none have been shown to be consistently more effective than the peeling methods described. By contrast, electrosurgery, the application of electric current, and radiosurgery, the use of radiowaves, are each useful and relatively inexpensive methods for treating liver spots when they are few in number. Fees typically range from $100-$300 for up to six lesions.
While most people are gratified with the improvement they see in the tightness of their pores after several Beta Washes, others with more dilated pores can profit from the use of trichloracetic acid 100% instilled directly down the shaft of the pore. The resulting irritation of the lining of the follicle leads to its permanent shrinkage with complete healing. This technique known by the acronym CROSS (Chemical Recsonstruction of Skin Skars) was developed for the treatment ice pick scars from acne. Depending upon the number of sites treated, fees may range between $150-$500 per session.
Finally, I find that individuals complaining of a persistent flush to the cheeks (not “broken” blood vessels) can be most effectively treated by a combination of small amounts of Botox injected superficially in a gridlike pattern over each flushed area accompanied by a series of intense pulsed light ( IPL) therapy sessions. The Botox helps to “calm” the overreactive neurons believed to contribute to blood vessel dilation, and the IPL targets and heats the hemoglobin in the minute blood vessels causing them to shrink. Fees for the Botox (usually only one session needed) typically run $400-$600, and for the IPL $350/session for a series of four to six treatments spaced at two week intervals.