50 Shades of Red


April is Rosacea Awareness Month, which is fitting since the spring can be considered “rosacea season” due to the weather changes causing many to flare this time of year. Rosacea is more common than you may realize and can often be misdiagnosed as Acne.

What is Rosacea?

  • Rosacea is a fairly chronic inflammatory disorder of the hair and oil (pilosebaceous unit) glands on the face that is coupled with increased capillary reactivity which leads to flushing and superficial blood vessels.
  • It most commonly affects adult women with fair skin and Celtic origins.

What does Rosacea look like?

  • The rash usually involves the face symmetrically. Early on flushing is characteristic along with prominent blood vessels causing the characteristic “red face”.
  • Papules and pustules can develop and it can look similar to acne, but the biggest difference with acne is that there are no comedones (black heads and white heads) present.
  • Late stages of Rosacea can cause deep red bumps and nodules underneath the skin and can lead to disfigurement of the nose, forehead, eyelids, ears and chin. Men more commonly  have this type.
  • The eyes can also be involved. You may notice dry, red eyes and a gritty sensation and it rarely can lead to more serious problems such as; corneal ulcers.

What triggers Rosacea flares?

  • Increase in skin temperature in response to heat stimuli
    • Exercise, sun exposure, hot baths, hot or spicy foods/liquids
  • Alcohol and caffeine
  • Emotional stress
  • Change in environment (cold, hot, humidity, wind etc..)
  • Medications
  • Facial creams or oils, Topical steroids

Is there a treatment for Rosacea?

  • Unfortunately the exact cause of Rosacea is unknown and there is no cure, but it can be controlled. Recurrences are very common and it usually waxes and wanes, but it can also spontaneously resolve over a few years.
  • Avoiding triggers is key!
  • Topical make-ups in a green tinted base help to camouflage the redness. Make sure to use gentle products that are fragrance free.
  • Topical treatments include; Metronidazole cream, Soolantra cream, Sodium Sulfacetamide, topical antibiotics.
  • Oral medications are usually more effective than topical treatments and tetracycline antibiotics are the mainstay of therapy.
  • Isotretinoin has been used for severe cases.
  • Laser therapy is very effective for treating the redness and any facial disfigurement.

Melanoma does not always play fair

Most melanomas I see look funky and problematic before a biopsy is ever done. However, recently I had another scary case that took me by surprise and served as a reminder that melanoma does not always play by the rules.  I had a patient come in to see me concerned about a new spot on their back. At a quick glance I thought it may be simply an inflamed flesh colored mole or possibly a Basal Cell type of skin cancer. The picture below is not a picture of my patient, but it is very similar to the spot.


If you are not too familiar with skin cancers, in general, Basal Cell and Squamous Cell skin cancers are more common and generally less aggressive. They can become a big problem locally, but they do not commonly kill you. Melanoma, by comparison, is much more serious and more likely to be fatal.

Now back to the patient. During the exam I noticed two other areas that were much more atypical looking, but thankfully we still performed a biopsy on that initial pink spot. I ended up doing three biopsies on this patient and all biopsies came back as skin cancer, but the one that looked “not s0 concerning” came back as a melanoma metastasis that was very deep. I was quite surprised.  As always, the worst part was having to tell the patient that not only do they have melanoma, but a very serious one that was already at an advanced stage.

The ABCDE’s of Melanoma are a helpful tool when looking at your own spots.  Like I said earlier, most melanomas follow these rules and look abnormal. The more uniform a spot is, the better. The more variety in color and pattern in the lesion, the more likely it needs to be checked.


However, as the story above illustrates, melanoma does not always play fair. And our patient had an amelanotic variant, which means it didn’t have a brown or black color from melanin in the skin.  Amelanotic melanaoma, in my opinion, is the scariest melanoma because it lacks pigment, making it look more like a basal cell carcinoma, acne, or even like nothing at all.  Luckily, these are not too common.

Now, not every mole is a perfect brown round circle.  In fact, most of them are not and yet most of them are still benign. This is where something called the “ugly duckling” rule comes in to play. The ugly duckling sign refers to how similar the moles look to each other. If you have a mole that looks a little funny, but happens to look pretty similar to other spots then that is usually a good sign. If you have a mole that does not follow the rules and you can not find another spot on your body that appears similar, then it is an ugly duckling and deserves further evaluation.

The key is early detection for all types of skin cancers, and when it is all said and done any new or changing spot should be evaluated by a dermatologist.  No one will fault you for coming in for a spot that was benign. I always tell my patient’s that it is better to be safe than sorry. If you never have had your skin checked, now is as good a time as any. Also, if you go get your skin checked then you might as well really get it checked. That means don’t be afraid to get naked and show your skin, and make sure that whoever is doing your exam checks everywhere because some types of Melanoma occur where the sun does not shine.

Lindsey Smart Smith  PA-C

References: American Academy of Dermatology, Spot Skin Cancer

Science and not blowing the lid on the cancer and sunscreen “myth”

Is sun screen really effective in counteracting damage from overexposure to the sun? Dermatologists agree that sunscreen is a necessary preventative measure for sun damage to the skin and even skin cancer.

Every now and again an article will appear in print or on the Internet discussing the dangers of sunscreen or claiming that the sun and skin cancer link has been debunked. I recently re-read an article online that stated, “Scientists blew the lid on the cancer and the sunscreen myth”.  Reading it made me grin, as these articles always do, because….no we didn’t.

These articles are mostly click-bait, sensationalized journalism that distorts science and fact to support an eye-catching headline. I respect the innovation and manipulation, as well as the need to simply increase the size of the audience. But the amount of ridiculousness in this article is hilarious, so I couldn’t help but respond.

The foundation of this article and others like it is a Swedish study published in 2014 and it’s an interesting study.

Lets review the facts of this study.

29,518 Swedish women from ages 25 to 64 answered a survey with a variety of questions principally aimed at how frequently they sunbathed. For 20 years the women were followed and national databases were checked to see who died and who developed melanoma.

The survey study found that all-cause mortality (death for any reason) was inversely related to sun exposure habits.  Meaning that over the 20-year period, twice as many women from the lowest sun exposure group died as compared to the highest sun exposure group.

The study has no idea as to what the participants died of and does not comment on significant baseline health habits of these groups, though their data showed the non-sunbathers group to have a higher rate of non-exercisers and obesity. The study also does not measure vitamin-D at any point, nor does the study have anything to do with sunscreen. In fact, the words sunscreen or sunblock are not found in the study at all. Not even as commentary.

That’s it. Those are the facts. Notwithstanding, the association is truly fascinating and has value on its own. But any statement that expounds upon the aforementioned finding is conjecture, and while conjecture is an important part of discovery it should be taken, as they say, with a grain of salt.

The authors of the study surmise that perhaps low vitamin D is to blame for the noted trend of increased death among the non-sunbather group. It is certainly a possibility. Vitamin D is an essential vitamin and sun exposure is a significant source of vitamin D production and important in Vitamin D levels. In order to come to this conclusion the authors of the study make a few assumptions.

First, that the women’s sun exposure habits did not change over a 20-year period. Second, that the consequences of an unhealthy lifestyle, obesity and lack of exercise, that appeared to be more prevalent in the non-sunbather group, did not affect their results. Third, that Vitamin D levels were chronically low in the women who self-reported to have low sun exposure, and that the other group’s levels were not.

Now, the issues with the first two assumptions are relatively clear. But the problem with the third assumption may not be as clear, so lets talk vitamin D.

Dermatologists and other medical practitioners agree that vitamin D is an essential part of a healthy lifestyle, but how much is too much?

I don’t think any physician would challenge the importance of Vitamin D. It is essential for a number of physiologic processes and organ systems. It appears to be protective in several conditions including more aggressive forms of melanoma, and a growing number of studies support the idea that low levels of vitamin D are linked to an increased risk of heart disease. This vitamin is something you need and want in your body.

But remember that vitamin D is not obtained by sunlight alone. And there is a limit on the amount our skin can produce.  As such the vitamin is also, in many instances,  an essential part of our diet.

Only a modest amount of sun exposure is required to make sufficient amounts of the vitamin, several minutes at midday in the summer months are sufficient for many Caucasians. And after reaching the production limit, further exposure may actually destroy the vitamin.

Furthermore, UV exposure is unlikely to produce enough vitamin D in people with very dark skin. People with darker skin types produce less of the vitamin in response to the same amount of sunlight. Also, the elderly have a reduced ability to synthesize vitamin D from sunlight, and during the winter, sunlight is insufficient to produce vitamin D in people living above 42 north latitude, which includes Boston and northern California.  Sweden, where the study was conducted, is well north of this. Which means that regardless of how frequently a study participant sunbathes, vitamin D may need to come from the diet as well for a significant part of the year.

The authors of the online article are more shameless in their assumptions. They assert, “Researchers concluded that the conventional dogma, which advises avoiding the sun at all costs and slathering on sunscreen to minimize sun exposure, is doing more harm than actual good.” This is a lie on two accounts, the definition of dermatologic dogma and about the researcher’s thoughts on sunscreen.

The current dermatologic dogma is focused on sun protection, not sun avoidance. No reasonable dermatologist would advocate for complete sun avoidance unless you are a vampire, have a photosensitive disorder, or have undergone a recent procedure that warrants temporary but strict sun protection for an optimal outcome. And sunscreen, as mentioned above, is not part of the referenced study.

The article also paraphrases a well-known dermatologist who effectively said, “There’s no proof that increased exposure to the sun increases the risk of melanoma.” True, but this is only part of the story.

Does the sun cause skin cancer. Yes. Unequivocally yes. Ultraviolet (UV) radiation from the sun causes mutations in the DNA of skin cells that are very closely linked to certain types of skin cancer. What often gets overlooked is the fact there are different types of skin cancer. Squamous cell carcinoma and basal cell carcinoma are highly associated with the amount of sun exposure and sun damage over a person’s lifetime. Melanoma is a different beast and while there is no evidence to suggest a causal relationship between simple sun exposure and melanoma, there does seem to be an association of some kind.

The article then goes on to reference a second Swedish study published in 2000 titled “Sunscreen use and malignant melanoma”. They misrepresent the authors by saying that the study “concluded that higher rates of melanoma occurred in those who used sunscreen versus those who did not.”

While this is technically true it is seriously misleading. The authors of the study actually concluded, “sunscreen use, by permitting more time sunbathing, is associated with melanoma occurrence.” This statement/theory on the researchers part was further supported by the fact that the association between more frequent sunscreen use and melanoma was stronger in men, and people using sunscreens with SPF of 10 or lower. Meaning that the people using more sunscreen where hypothesized as getting more sun exposure and using the sunscreen ineffectively.

Regardless of the facts and your interpretation thereof, skin cancer is not the only untoward effect of excessive sun exposure. Sun damage also results in wrinkles, loss of collagen, uneven pigmentation, and premature aging.  And many people find these reasons for sun protection to be more compelling.

Overall, there are clear benefits from prudent exposure to the healing rays of the sun, physically and emotionally. But protection and moderation is, at this time, what the medical community painstakingly tries to suggest.
The best approach to sun exposure, as recommended by cosmetic dermatologists, is moderation and spf protection.

If you’re simply thinking I’m biased because I’m a dermatologist, you’re probably right.  I suppose that in the end, more UV radiation is ultimately good for business.  If we really do need to get more sun, and subsequently increase the incidence of sun related skin conditions, in order to better our chances of living longer, then I’ve got plenty of job security to look forward to.

The Cosmeceutical

What skin creams will be best for keeping away signs of wrinkles and aging? Cosmetic dermatologists warn that not all skin creams are created equal and to investigate and research fully the claims of your skin care routine before committing time and money to a product.Cosmeceutical is the term currently used among dermatologists to refer to the area between cosmetics and pharmaceuticals. The FDA defines cosmetics as articles intended to be topically applied for cleansing, beautifying, promoting attractiveness without affecting structure or function. Whereas pharmaceuticals are defined as compounds designed to be used as medicinal drugs. As you can imagine the requirements and FDA regulations place on the manufacturing and marketing of new drugs is dramatically different than the regulations placed on makeup.

The cosmetic industry is a vibrant and growing market, and this is a bit of an understatement.   Revenue from the cosmetic and skin care industry is over $ 50 billion annually in the US alone, and nearly a third of that is defined as facial skin care. The US is not unique in its cosmetic inclinations. In fact, global industry sales reach close to $200 billion annually with the largest consumer being Asia.   In short, the skin care market continues to grow on an impressive international scale.

As this occurs, the sophistication of raw materials, compounds, and formulations used in this arena increases. In conjunction, a greater appreciation of the top layer of the skin, called the stratum corneum, has been achieved through the use and basic study of these non-invasive bioengineered creams.

Research clearly demonstrates that non-prescription topical agents can dramatically influence the stratum corneum, and that these agents can indeed penetrate the stratum corneum and influence skin function. Thus cosmetics and skin care products are assuming an increasingly important role in clinical dermatology.

One of the foundational dermatologic texts defines a cosmeceutical as “a scientifically designed, useful product intended for external application to the human body that has desirable aesthetic effects and meets rigid chemical, physical and medical standards.”  But it also readily recognizes that “there is no regulatory description that acknowledges the current scientific sophistication of these formulations”. Which means that cosmecuetical products currently do not need to rigorously demonstrate that they are what they say they are, or do what they say they’ll do. And consequently, in many physicians’ minds walk a fine line between evidenced based medicine and snake oil.

What this means for you? You need to get your product from a trusted source and beware of online fraudulence. Also take the products claims with a grain of salt and a healthy degree of skepticism. You can think of the industry oversight as being similar to that of vitamins and supplements. A company’s claims about the product do not have to be rigorously substantiated through scientific study. They only have to prove safety, not efficacy, and not even content sometimes. You may want to seek real, sound, evidenced based medical advice. And even more importantly, beware of online fraudulence.Cosmetic dermatologist advice on skin care products

Counterfeiting and theft are real issues with medical grade skin care products. A quick Google search will show you high-end cosmetic skin care products for only a fraction of the cost. Products like SkinCeuticals, Biopelle, EltaMD, SkinMedica, TNS, and Neocutis found online are perhaps the most suspect, as these skin care lines are principally sold in medical clinics and spa settings, any online distribution should be seriously scrutinized. But the fraudulence is not limited to these brands. Even impure Botox is cheaply purchased online.

Shipments are stolen and sold to consumers, products are counterfeited with different creams and sold in identical packaging, or expired products can be repackaged or sold that won’t give you the full benefit you expect.

Keeping that in mind, there are plenty of great companies making cosmeceuticals out there that are high in quality with good scientific evidence to back their efficacy in helping to rejuvenate and maintain skin tone and texture.