Sandy Martin, MD (retired)

You've made a decision to remove your tattoo and from the looks of the photograph you've submitted, you are nicely on your way to accomplishing it.  I really can't perceive any abnormal reddening or anything suggesting any sort of a problem.  I think you are going to do well and suggest that you make sure you keep the area out of the sun and use a high SPF broad spectrum sunscreen daily.  Zinc oxide or titanium dioxide would be excellent broad spectrum ingredients to seek in your product.

     Accutane is not a miracle drug that will cure every case of acne against which it is used. As a disclaimer, let me say that I rarely, if ever, prescribe it, for fear of potential side effects.  I am worried about the risk of inflammatory bowel disease, teratogenicity, and psychiatric manifestations, to name a few. That being said, there is no question that side effects aside (if it would be reasonable to put side effects aside!), there is no other medication for severe cystic acne like isotretinoin.

 

     The majority of patients' skin will clear nicely with this treatment when they take the standard 1-2 mg/kg x 4-6 months, and most will not need a second course.  Some will not clear, and some will benefit from a second course.  Some patients even receive a third course. And regrettably, some will not clear very much at all.  There also is a category of patient who thinks they failed a course simply because they have a pimple or two.  That should not be considered a failure, but rather unreasonable expectation.

 

     So, the very act of deciding to take a drug like Accutane should not be taken lightly.  This is the reason the complex IPLEDGE system was devised. However, it is available to be prescribed (not Accutane per se, that brand has been removed from the market), and each of us in charge of our own health destiny.  Just don't take it without hearing about the risks and accepting the risks in full should they happen to you. Realize that risks are just that...potentialities.  So just because everyone who you know to have taken Accutane did so without problem, does not mean that you will get away without problem.  Read the product inserts and decide with full understanding after a good, frank discussion with your board certified dermatologist whether you can accept the risks.  If you can, the likelihood is that your skin will improve.

Thank you for trying to take a photograph.  It's amazing how many patients come in with pictures of their skin problems and the pictures are tremendously helpful.  Unfortunately, in your case, at least as I see the photo, it is not helpful to me.  The picture is blurry and from it I have no way of telling whether this is a skin cancer, basal cell carcinoma or otherwise.

 

That leads to some general responses to your questions.  Different physicians have different experience with diagnosing skin cancer.  Some have seen countless numbers and others less so.  It is not surprising that two or more physicians have different responses on how you should proceed.  With that as a caveat, I can only add my own general protocol to the mix.  I have seen numerous skin cancers appear to get bigger and smaller over time, so the fact that a lesion appears to be "improving" is not adequate for me to proclaim it benign.  If I look at a lesion and it fits the picture of a basal cell or squamous cell carcinoma (or other tumor), I think one has no choice but to biopsy it.  Now, mind you, if it looks like a pimple or cyst or benign wart, we may proceed accordingly.  But if its suspicious, and particularly if it is suspicious and persists after a month or so, then I would opt for a skin biopsy.

 

Skin biopsies, in general are easy to do.  Depending on the location, they usually leave only a small scar and the scar is worth the reassurance that a cancer doesn't lurk beneath the surface. The only other thing I would like to add is that in your case you have two different physicians who express different degrees of concern plus your lesion has bled and persisted for quite a while. The only way you can really know who is correct  and what you have is by a small skin biopsy.

 

I hope this give you at least one dermatologist's general approach to skin lesions.  Good Luck!

I have performed a fair amount of Botox injections for axillary hyperhidrosis. Most patients find the treatment easy to tolerate and moderately to amazingly effective. The amount of time of relief varies from person to person but can be as little as 3 or 4 months to as much as one year. The amount of BOTOX I use varies from 50 units to 100 units per armpit and I typically give about 20 (painless or nearly so :)) injections. I will usually do a starch iodine test at least once on a patient to determine the extent of area to inject.

Thank you for the photographs.  They are very helpful.  The first thing that came to my mind was what is called the En Coup de Sabre type of Scleroderma.  This is a linear type of scleroderma that one sees on the forehead or scalp.  This condition is not related to Botox or to underlying muscle atrophy but rather is a condition that may be associated with certain serologic changes.

The cause is unknown, but I would suggest you discuss this with a dermatologist who I suspect may want to take a skin biopsy.