Therapeutic Challenges and Practical Approaches to Routine Skin Care
Heidi A. Waldorf, MD

Skin-Care Advice

Slide 1. Therapeutic Challenges and Practical Approaches to Routine Skin Care


Slide 2. I think an important point to remember is that we are trained to treat disease. People come in, they have a disease, and we treat it. But by definition, every patient in a dermatologist's office has a skin care question. Skin care is not a dirty word. It's not what the cosmetician is doing. We need to re-establish that dermatologists are the doctors to go to for skin care questions.


Slide 3. Where are our patients going? They're picking things up on the street. Magazines such as Allure advertise skin care shortcuts at home. There is Botox (botulinum toxin type A), collagen, and skin peels, wash your hair with whipped cream, and hundreds more offbeat uses for even more brand name products. Then of course, there is The New York Times Sunday style section. I recommend that you make sure that you're picking up these magazines and newspapers yourself, reading what your patients are reading, but then we have to know better.


Slide 4. What is skin care? The purpose of skin care is to reduce dysfunction and enhance healthy function. This same scenario is involved whether the patient has a skin disorder or not, because wherever you live -- whether it's sunny, windy, or cold -- you're going to have some things that are going to add to skin dysfunction.


Slide 5. I want to discuss routine remedial skin-care advice in my practice. I practice in the northeast United States, in New York. We have "New York itch," our own personal variety, and we also have a lot of sunny weather and people who run to beaches in the summertime. Every patient who comes to my office hears certain things. I'm a broken record. One hundred percent of the patient population, no matter their color skin, hears that they have to practice vigilant sun protection.

I talk about dry skin care to about 75% of my patient population from October through March. These are not necessarily people who have come in complaining of dry skin. These are people coming in for other things. I stress no cigarette smoking, again, to 100% of the patient population. I also stress no scrubbing or picking the skin. I see a lot of acne excoriee and neurodermatitis. I try to stress that gentle is best, and for acne patients, I recommend noncomedogenic products. You'd be amazed at the number of acne patients who use hair products that are very thick and comedogenic and get on their foreheads, for example, during use.


Skin-Care Choices

Slide 6. As a dermatologist, you need to understand what's out there. We understand topical antibiotics, topical retinoids, and anti-inflammatory agents. But to a patient, these are the categories: soaps and cleansers; toners, astringents, and clarifiers; moisturizers; eye creams; sunblocks; exfoliants and scrubs; and masks. Patients come in with a bag containing a 12-step program, including several items in every one of those categories that they have been sold and believe they must use.


Slide 7. This basket rule is a great way to think about managing your patients. Basket A is things that are non-negotiable. Basket B is things on which you can compromise. Basket C is things that are not important and that you can let go. As I go through the products, have in mind which of these baskets you're putting your choices in.


Slide 8. Let's start with soaps and cleansers. The goal is to remove makeup, oil, and dirt, and prepare for topical agents. That's what we see as the goal. What does the patient want? They want squeaky-clean skin. They have been told that they need a deep clean. I would put this in the category of, for me in New York, basket A. People cannot get that squeaky clean. They cannot dry out their skin; otherwise, for two thirds of the year they're not going to tolerate the retinoids. They're not going to tolerate benzoyl peroxide. We won't be able to do for them what we need to do, and they won't have good results. So I can give them other choices.

The choice to convince them of is using non-drying, non-soap replenishing cleanser. Replenishing is currently the buzzword for a cleanser that not only does not strip the skin, but also leaves moisture on the skin. I think it's important to make sure that you know what's out there. Walk through your local pharmacy, and get to know the different products. Because one product that may say it's for sensitive skin, may in fact still have a detergent in it that strips the skin.

The other thing to keep in mind is that very often the products that we are recommending are lotions, a cleansing lotion or a cleansing bar that is very moisturizing to the patient. The patient will say, "It makes me feel slick." One way to get around that is to use a product that's foaming. For example, in Dove's new line they have a liquid cleanser that's more in line with some of the other products -- Nu Soap, Cetaphil, Aquanil -- that we know about. A number of the products now are foaming products, and some patients find that the action of the foaming makes their skin feel cleaner.

Another thing is a cloth. A number of companies now make cloths and patients can use one cloth a day to wash their face. Some of these cloths are replenishing and have emollients that are laid on the skin. There is something very satisfying to some patients about seeing their makeup on that piece of cloth, and there's a limit to how much they can scrub with it. That's a positive.


Slide 9. Next, we have toners, astringents, and clarifiers. I'm not a believer in these personally. I don't see a need. The goal is to remove oil or soap film. But we want to leave some emollients on the skin. We do not want the skin to be stripped. In the days of alkaline detergent cleansers perhaps this was necessary, but at this point it'll remove what little sebum is left. The patient likes it because they feel fresh, and they have this myth that if their face is tight, it's clean. We need to try to convince them that tight is not a positive. If you put retinoid on and your skin is tight to begin with, you're going to get red, itchy, and inflamed skin. That's not going to work. If the patient insists on something in this category, you can use an alcohol-free formulation. That doesn't really make much sense in terms of what a toner is supposed to do because a toner often has a high concentration of alcohol in order to get the leftover oil off, but there are a lot of companies that make what they call soothing, humectant toners; if the patient insists upon a toner, I'll have them use one of those

The other thing you can do is find some other medicine that gives them the same feeling. If you're having a patient use a topical antioxidant, perhaps have them use a spray or gel form. Use a topical with the feel of a toner to accomplish some other goal.


Additional Skin-Care Choices

Slide 10. The next group is facial moisturizers and body moisturizers. The goal is to maintain the barrier. We need to replenish moisture. Anti-aging also may be thrown in.

It's self evident to us that if your skin is dry, you moisturize it; this is not always obvious to the patient. My patients frequently say, "I'm dry because I don't drink enough water." I ask them about the color of their urine. I tell them that if their urine is light, they're drinking plenty of water. They are dry because they're taking long, hot, steaming showers, and they're using a detergent cleanser to strip every piece of moisture from their skin. Then they leave the shower, rub themselves down with their towel, and put nothing on their skin. That's why they're dry.

You have the category of patients with acne who are convinced that moisturizers cause acne and they think, "People with acne really can't use anything. I have to keep my skin very dry." They get into a cycle where they can't use their acne medicines because their skin is dry.

What are our choices? You can use a lotion, a cream, or an ointment. Have in mind, whether you're dispensing products or you're sending people to the pharmacy, that just about every company that makes a lotion also makes a cream. If the patient doesn't like the feel of one, have them try another. In our office we have samples of various products. Oil-free moisturizers exist, they're plentiful, and they're noncomedogenic.

If somebody isn't dry, they don't need a moisturizer. Some patients just don't need it.


Slide 11. Eye creams. This is a basket C for me. Basically, for eye creams the goal is the same as that of a facial moisturizer. The reality is that patients are convinced that the skin around the eyes always requires different products than the rest of the face. They are willing to buy tiny containers of very expensive product for just around their eyes. I try to convince them that they can use what they're using on their face around their eyes, in most cases

We only use a second product if the tolerability of the concentration of the active ingredients of their facial moisturizer is too irritating.

There also are patients with acne who don't use a moisturizer and may not need it on the rest of their face. But they do need it around their eyes or, particularly with a lot of my patients, the jawline and the neck. These are details that the patient appreciates


Slide 12. Sunblocks fall into basket A; patients must have adequate ultraviolet A (UVA) and ultraviolet B (UVB) protection to prevent burn or tan. The reality is that women say, "It's in my makeup," or "I always protect my face." I stress 2 things: 1) we see more skin cancers on women's arms and legs, more bad skin cancers, melanomas; and 2) they're going to end up with a very youthful face on a very old body. You have to show them how to apply it. Have your nurse or assistant stress that they have to get the sunblock onto the side of their face.

Patients are also concerned that sunscreen will cause acne. All the same companies that have advances in moisturizing now have daytime moisturizers with an appropriate sun protection factor (SPF) and an appropriate UVA protecting ingredient. There are a lot of them that are in various elegant bases.

The other thing to remember is the teaspoon, or shot glass, rule of how much to put on. The teaspoon rule is that you need a half a teaspoon of sunblock for the head, half for the neck, and a half for each arm. You need a teaspoon for the front of the trunk, the back of the trunk, and each leg. Put that together, it's a shot glass. People are not using enough. So make sure they are using enough. My patients ask, "How do I know if it's expired?" And always tell them by the end of the summer, at the end of a vacation, they shouldn't have anything left. They should be using it all.

If a patient does not need a moisturizer in the morning, they can get a sunblock that's a spray or a gel.


Slide 13. Exfoliants and scrubs encourage stratum corneum desquamation. A scrub is basically a mechanical exfoliant. I find I have a lot of difficulty with these scrubs because, in general, patients overuse them. A lot of my acne excoriee patients, for example, use them. They think that they're encouraging new cells to come out; the skin feels smooth, looks shiny, and it glows.

How do we handle this? I explain to them that their alpha-hydroxy acid (AHA) or butylated hydroxyanisole (BHA), the retinoid, is an exfoliant and that's doing more than anything else. Patients understand exfoliants. If you let them know that this medicine they're using for their acne or for their sun damage is exfoliating their skin, they're happy.

There also are products out there, such as Dove Cleansing Pillows, which are not as abrasive as a Buff Puff. They can use that and they're not going to hurt themselves. There are also various lotions that have beads that burst, as opposed to apricot pits that are going to scrub away.

Finally, microdermabrasion; I have found a lot of my acne excoriee patients are satisfied with controlled sessions of microdermabrasion to get that exfoliated feel.


Slide 14. Masks are a delivery system. The nice thing about them is you can now incorporate short-contact therapy of various products and give the sense of a mask. But explain to the patient that a mask is something that's only going to be helpful while it's on.


Choosing Between Skin-Care Choices to Cleanse, Treat, and Protect the Skin

Slide 15. When patients comes back and they're no better, specifically ask them if they have used what you prescribed, because you assume they've used it, and very often they stopped after 2 weeks because they felt it was too greasy or too light. Make sure you ask why they stopped using it.


Slide 16. The choices depend on age, gender, and the patient's skin characteristics -- do they have sensitive skin? do they feel they have sebaceous skin? -- and their lifestyle. Are they indoors, outdoors, day, night? Another factor is race, in terms of how things will look on your skin. For example, if you take a micronized zinc or titanium sunblock and put it on someone who's skin is olive toned or darker, it may give a very ashy or filmy appearance that they're not going to like. Most patients can get their UVA protection with Parsol (avobenzone), for example.


Slide 17. This is a sheet we have in our office. It gives the order. We have morning, we have evening, we check off products or fill lines in, we say what product they're using, and we number it in order. At the bottom we have instructions for how they should use their retinoids, such as not waxing while they're actively using it, etc.

The basic regimen is separated into cleansing, treating, and protecting. You use a cleanser, you put treatment on -- whether it's anti-aging, whether it's acne -- and then you put on your protection, your sunblock, your occlusive. For example, Vaseline in my area is very popular to put over a retinoid, so then overnight with the dry heat in the house, they're not losing all their moisture.


Common Skin-Care Treatment Challenges

Slide 18. I want to go through common therapeutic challenges.


Slide 19. The big problem with the preteen is that they are often noncompliant. I have a little pop-out book about acne. I show the patient what normal skin is, what a comedone is, and how a pimple forms. I'll say, "We're going to give you this retinoid that's going to make your skin cells feel slippery. That's why you're going to think you're getting some more pimples in the beginning. See all the bacteria. That's what this antibiotic is helping."

When the patient comes back, let him or her tell you what he's using, when and how, and figure out the patient's schedule. Does the patient have sports after school? Does he fall asleep over his homework? Make a realistic regimen. You've got to assume that a preteen or teenager will not necessarily be compliant.


Slide 20. Another type of patient is the picker. Again, explain the pathophysiology to them. I tell the patient every time they pop the pimple they're imploding it and spreading all the bad stuff, which they understand, and I make sure there's something satisfying in their regimen. Is there something minimally abrasive they can use? Are they having microdermabrasion? Is there a topical that they can put on that will hide and give them the sense of drying something up?


Slide 21. Then there is the patient who is fried and dried. We have snowbirds. They go down south. They don't use the retinoids. I explain to them that all the people who are sun damaged in the southern United States are using these things. I reassure them that the desquamation is good, and we start very slowly. We moisturize nightly and I tell them not to discontinue when they're outdoors. They should just increase their sunblock.


Slide 22. Finally, there is the patient who is oily outdoors, and this doesn't have to be a moisturizing issue. There are liquids, there are gels, there are sprays, and there are foams. A man with hairy arms should not be given a cream sunblock. Give him something that's going to go in. There also are various things you can mix your sunblocks with that will surround the oil so it doesn't feel as greasy on. Don't take no for an answer.


Conclusion

Slide 23. In summary, for fundamental skin care there are everyday skin care routines for cleansing and care that you want to go through with every patient. You want to adjust to their lifestyle as well as their routines. Make sure everything fits in.











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