Exfol

REJUVENATING YOUR SKIN - "WINNING COMBINATIONS" RETIN-A, FRUIT ACIDS, SALICYLIC ACID

INTRODUCTION: When Retin-A, fruit acids and salicylic acid are used together at home, combined with in-office exfoliation programs, the skin can literally shed years of wear and tear. Those who persevere while the skin adapts to the use of these agents can expect a more youthful, clearer looking skin as sallowness and age spots slowly disappear, skin texture improves, fine wrinkles and pore size seem to be diminished and clearer, more youthful, rosier complexion emerges. RETIN-A AND FRUIT ACIDS: Although almost 90% of all patients can tolerate Retin_A and fruit acids, it is important to understand that almost everyone at least initially develops some dryness, irritation or flaking of the skin. A few individuals also have a tendency to tingle or burn when first applying fruit acids. This is an entirely natural phenomenon which is not detrimental to the skin and will subside with the passage of time as the skin gradually accommodates to individual treatment programs. FRUIT ACIDS: Fruit acids enhance the effect of Retin_A and bleaching agents. We often prescribe Retin_A compounded with a soothing cream or bleach to be combined with fruit acids and sunscreens in individualized programs. As your skin becomes accustomed to the use of these products, we gradually increase their strength as well as the concentration and duration of application of the in-office exfoliating peels (fruit acids, mild T.C.A.). SUCCESSFUL CHOICES AND STRATEGIES: Home and in-office treatment programs offer you two options: The fast track, in which you experience more redness, scaling, irritation and general fuss, but you improve much more quickly; or the slow track, in which there are very few hassles but results occur much more slowly. When first beginning: 1. Determine your skin type; dry, oily or combined and select appropriate products. 2. Avoid anything which irritates your skin. Do not use scrubs, strong soaps, buff puffs, loofah pads or other abrasives. Do not scrub your face hard with a washcloth. Avoid sunburns, blustery winds and cold weather which irritate the skin. When problems occur stop using Retin_A and fruit acids for a few days. Substitute soap free cleansers for ordinary soap and apply Westcort cream or other prescription medication to hasten the healing process. 3. When things are back to normal begin again but add a favorite moisturizer to the fruit acids to dilute them and make them more tolerable. You can, for example, mix them in equal parts on the surface of your skin and rub them in together. ALLERGIES: About 2% of the population will never be able to tolerate Retin_A or glycol acid. This situation is more common in those with a history of eczema, atopic dermatitis or multiple skin allergies. Such patients will be plagued by a great deal of persistent redness, tenderness, itching or swelling. DEPILATORIES AND WAXES: Stop using Retin_A or glycol acids at least 4-5 days before using a depilatory to avoid excessive irritation. If you intend to undergo waxing for facial hair, discontinue Retin_A or glycol acids for a full month beforehand to avoid the risk of severe irritation or scaring. SUNLIGHT: The use of sunscreens is important; a No. 15 or better is fine. Some of the better facial make-up products have low strength sunscreens which work almost as well as the higher number SPF sunscreens because of their combination with opaque make-up. Just remember there are 2 kinds of sunscreens; greasy ones that stay on well in the water and provide excellent protection but may make you break out if your skin is oily. the other group of alcoholic or gel type sunscreens, which are not waterproof, tend to dry out the skin but work well for those who have problems with acne or oiliness. We have included a summary of sunscreens later in this handout which you may find useful. You should also remember that there are other sources of ultraviolet light including halogen lamps and there are certain drugs which will sensitize you to sunlight. NEW BLOOD VESSELS (TELANGIECTASIA) Some patients are particularly prone to the development of fine, red vessels on their faces. Retin_A can worsen this, although fruit acids won't. Accordingly, use only fruit acids and eliminate Retin_A when treating areas where small blood vessels are located. ACNE: Mild breakouts of acne are common when first initiating glycol acid or Retin_A treatment. You can also develop pimples following in-office peels. This condition probably results from the unplugging of pores and is easily treated using prescription, topical antibiotics (Cleocin, Erymax) which you apply to your skin. Many acne patients cannot use any products, including fruit acids which are incorporated into greasy ointments or heavy lotions in areas where they break out. As a general rule, oily skin tolerates alcoholic based products such as astringents whereas, dry skin is most appropriately treated with less drying agents such as lotions, creams and ointments. IN-OFFICE FRUIT ACID PEELS AND T.C.A. PEELS: You can speed up the process of clarifying your skin by using increasingly stronger, office applied, solutions of fruit acids (Glycolic, pyruvic and lactic) which are often combined with T.C.A. (trichloroacetic acid) for increased potency. Results are quicker as the solutions become stronger or are left on longer. However, increased scaling and redness will occur and you will definitely look less presentable after treatment. For those who tan easily, caution must be used because deeper peels plus sun exposure often lead to temporary pigmentation (brown discoloration). FAST TRACK/SLOW TRACK - AGAIN: The choice is yours. Repeated low concentration peels work slowly but you won't need to take time off while you heal. On the other hand, results are much quicker when higher concentrations are used. Two or three in-office peels of any type can produce, in a couple of months, the sort of improvement that might take you a year applying products at home. POST TREATMENT TIPS: After your in-office peel, keep a little diary which notes where you peeled, how soon it started and how long it lasted. This lets us know where we should use higher and lower concentrations in various regions of your face. If you have a great deal of pain or burning or blisters, call us or come in. If you have a history of repeated cold sores on your face, let us know. Sometimes deeper peels can precipitate fever blisters. We can head this off by giving you medications in advance. PICKING AND PIGMENTATION: People who develop brown streaks after burns or scratches occasionally develop the same problem following even light peels done in the office or vigorous application of home applied products. Pigmentation is a rare event following the use of home applied Retin_A or glycolic acids but much more common when medium strength T.C.A. (15% or stronger) or long duration (over 4 minutes) glycolic peels on the face. Patients at even greater risk for pigmentation are those who insist on not wearing a sunscreen, deliberately sitting out in the sun, or picking at crusts. Picking can also produce scarring. Pickers should avoid chemical peels or be willing to swear off picking during the healing process. QUESTIONS AND ANSWERS FOR USING ALPHA HYDROXY ACIDS AND RETIN-A Q1. After I applied glycolic acid/Retin_A the treated areas became: a) Tender b) Red c) Scaly or crusted d) Broke out in pimples What should I do? Answer: A), B), & C) - Stop using Retin_A or glycolic acid when your skin first becomes irritated. Use Westcort cream several times a day and use Cetaphil, Aquanil or Therapeutic Dermatoligic Non-Drying Cleansing Lotion (available here) for cleansing. Call Us. D) - When you "break-out" with pimples it is caused by the rapid unplugging of your pores which causes a temporary flare-up of acne. This is treated with prescription medication; topical antibiotics as such as Cleocin or Erythromycin. We can prescribe this to your pharmacist by phone or you can come in and get a sample without charge. Tricks of the trade: 1. Do not use the products as often. 2. Do not leave them on as long. 3. Instead of using them overnight, gradually increase application time from a few minutes to a few hours before washing them off. With time, you may develop much more tolerance and be able to leave these products on without problems. 4. Dilute or weaken these compounds and mix them with your moisturizer. Some authorities also advise wetting the skin before applying these products to dilute them. 5. Remember not to use anything that irritates your skin. This includes abrasive cleansers, scrubs, depilatories, facial waxing and hard scrubbing with a washcloth. The good news is that if you try hard and get through this period of discomfort, scaling, and so forth, your skin may truly adapt and continually benefit. Your goal is to try to use these agents at least twice daily but you may only be able to do this for only a portion of the time. The most successful patients behave learned when to start and when to briefly stop and take a "breather". Use your regular moisturizer, Westcort and mild cleanser. You will find that weather, humidity, sun exposure and wind will affect your tolerance for these products. COPING WITH SENSITIVE SKIN 3 PROGRAMS PROGRAM #1: Apply glycolic acid or Retin_A once or twice daily every three days. If you cannot tolerate this try program #2. PROGRAM #2: Mix 1 part of glycolic acid with 3 parts of your ordinary moisturizer, again, try using it every three or four days. As tolerance develops use it more often. PROGRAM #3: If the last two programs resulted in continuous irritation, begin applying these compounds only for two minutes to about an hour before you wash them off. Q2: There are so many kinds of fruit acid preparations. Which one should I use and where? ANSWER: An enormous number of glycolic and lactic acid containing products are flooding the market. Most available products fall into 2 groups: Lower strength glycolic acid based preparations between 1.2% and 5%, marketed by cosmetic firms through drug and department stores; and higher strength modalities usually between 8% and 30%, distributed by smaller pharmaceutical companies through dermatology and plastic surgery practices or at salons for use by estheticians. Our experience suggests that preparations between 2% and 3% may help a little bit but their progress is agonizingly slow in improving the quality of your skin. We know for a fact that products over about 8% can produce better looking skin sometimes in as little as 2 to 3 months of regular applications particularly when combined with in-office peels. Individuals with severe sun damage, particularly those over 40 years of age and those who have very oily skin can expect excellent results using concentrations between 15% and 20% on their faces and almost everyone can use 155 to 30% products on their arms, hands and legs. For many, however, tolerance must be developed over a period of time. Buffering: Chemists use buffers to partially neutralize acid and thus, reduce irritation. Although the ladies magazines and the manufacturers make a big deal out of buffering, the fact is that buffered products are less sensitizing but often act much more slowly, taking months rather than weeks to work. Buffering is a trade off and is in no way as wonderful an advantage as is proposed by the slick advertising which accompanies certain lines of products. BACK TO BASES Sometimes the effect of what a preparation (Retin-A, glycolic acid) is mixed into is more important than the strength indicated on the bottle. TYPES OF PRODUCTS LIQUID ASTRINGENTS: These, the most drying of preparations, are used to clean oily areas, particularly useful for those with acne. these dry the skin and can be very irritating to those who already have dry skin but they sometimes act almost miraculously for the treatment of acne or oily skin. GELS: Gels can carry compounds such as lightening agents more deeply into the skin and , accordingly, are often combined with bleaches such as Hydroquinone to promote better penetration and enhance its effect. Gels are often used on thicker, harder to penetrate skin such as the sides of the face, the upper lip, crow's feet, hands, arms and legs. LOTIONS: Lotions are less drying than gels and are tolerated almost anywhere. They are often applied over glycolic acid gels or Retin-A to soothe the skin. CREAMS: Creams, which usually contain between 2% and 10% glycolic acid, are often used for drier delicate areas. Eye creams are specifically formulated for use on the lower lids. Creams are more beneficial for people with dry skin and often during the winter, patients who can use astringents or gels during the summer, will switch to creams until humidity increases again. OINTMENTS: "Vaseline-like" ointments are used for truly thick calluses and thickened patches of skin on the feet or hands. Elderly patients and those with truly dry skin will benefit from the use of these ointments. Applied over gels and other agents, ointments can literally seal in (occlude) and enhance other types of preparations. All of these preparations require some time and experimentation to work out an individual program. One patient who was quite successful would use a gel grist, allowing it to dry, then applying either a lotion or a cream based preparation over it. After a few days or weeks using this technique, she would stop using the gels in the areas which were dry and simply apply the lotions or creams there. She still continued to use both preparations on the areas that did not dry out too much using both of the products. Q3: I have heard that Retin-A works well combined with glycolic acids. How should I sue these products? ANSWER: You can use any combination of Retin-A and glycolic acid almost any way you want. You can do this by 1) first layering on the Retin-A and then a gel, cream or lotion preparation of glycolic acid at the same time or you can 2) apply different combinations on different days or 3) you can mix equal parts of Retin-A and any other product and put them on at the same time. Retin-A is most effective on the wrinkles at the sides of the eyes (crow's feet" and the lower lid as well as the upper lip. The usual program is to apply Retin-A cream (we usually start with the lower concentrations first and work up), allow the cream to dry, then apply glycolic acid preparation (usually the crams or lotion) over the Retin-A. Usually, the Retin-A is applied one night under the glycolic acid preparation and the next night glycolic acid is used alone. Some patients have done very well mixing Retin-A and glycolic acid preparations together and it does save time. Q4: Can I use makeup or sunscreen over Retin-A or glycolic acid? ANSWER: Yes. For some patients, the cream base works well in combination with makeup. For others, I hear complaints that it becomes too tacky. Experiment to find which one of the glycolic acids or Retin-A you can use under makeup or sunscreen. Q5: Is there an advantage to using glycolic acid or Retin-A twice a day? ANSWER: The best results we ever obtained have occurred when individuals do use these products, either one or the other, or both, twice a day. For some patients simply adding Retin-A to glycolic acid in equal parts is quite effective, used twice a day. Others will mix their glycolic acid or Retin-A with equal parts and sunscreen and apply it in the morning. Each person has to set up her own individual program. FORMULATIONS We routinely use five combinations of Retin-A combined with varying amounts of soothing hydrocortisone and hydroquinone (a bleach) which are formulated by our pharmacist specifically for your use. We can vary concentrations as needed. These compounds have the advantage of combining various products especially for you.

COMPOUNDING RETIN-A
COMPOUND #1 HYDROQUINONE 2% HYDROCORTISONE 0.5% ASCORBIC ACID 2.5% RETIN-A CREAM 0.025%	COMPOUND #4 HYDROQUINONE 5% HYDROCORTISONE 0.5% ASCORBIC ACID 2.5% RETIN-A CREAM 0.10%
COMPOUND #2 HYDROQUINONE 2% HYDROCORTISONE 0.5% ASCORBIC ACID 2.5% RETIN-A CREAM 0.05%	COMPOUND #5 HYDROQUINONE 2% HYDROCORTISONE 0.5% ASCORBIC ACID 2.5% RETIN-A CREAM 0.01%
COMPOUND #3 HYDROQUINONE 5% HYDROCORTISONE 0.5% ASCORBIC ACID 2.5% RETIN-A CREAM 0.05%

RETIN-A STRENGTH
0.01% GEL (Green tube)
0.025% GEL (Orange)
0.025% CREAM (Gray)
0.5% CREAM (Blue)
0.1% CREAM (Red)
0.05% LIQUID

PRESCRIPTION LEVEL GLYCOLIC ACID PREPARATIONS/SALICYLIC ACID

When glycolic acid preparations are formulated between 20% and 40% for some sensitive individuals, it's like a "peel in a can". They are often combined with salicylic acid in strengths between 2.5% and 10%. These must be used on an individual basis and are usually only applied for a few minutes before being washed off.

HOME APPLICATION OF SALICYLIC ACID
Salicylic acid, the same material used in aspirin, has some amazing properties on the skin. It will literally dissolve scale. If you have ever used Dr. Sholl's pads on your feet you will get an idea of just how much scale it can dissolve. Accordingly, in tough areas like the feet, we use high concentrations of salicylic acid. In other areas (face, arms and hands), we lower the concentration.
Used along with Retin-A or AHAs, salicylic acid provides just the right amount of extra punch for people who have severely sun damaged skin. It is inexpensive, non-toxic and non-prescription and we can vary the strength all the way from 5% to 40%. Ordinarily, we use salicylic acid in the tough areas (arms, hands, legs) where the extra ability to dissolve thickened, age related scaling is necessary. However, there are those for whom it works beautifully on the face. Using it is an individual matter and a variety of different concentrations will be made available to you, both pre-mixed or available as an individual.