11 April 2016 Inside Cosmetic Surgery Today on WebTalkRadio.net. Interview with Dr Barry Lycka & Dr Neelam Vashi

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1 11 April 2016 Inside Cosmetic Surgery Today on WebTalkRadio.net Interview with Dr Barry Lycka & Dr Neelam Vashi Dr Barry Lycka cosmetic dermatologist from Edmonton, Alberta is talking today with Dr Neelam Vashi board certified Dermatologist from Boston, Massachusetts. This is your number one internet radio show on cosmetic surgery, in the world! We get over 8000 downloads per week, because this show is designed for those who want the newest and best information about cosmetic surgery, and of course we have the best expert doctors as our guests, answering your questions. If you have any topics you would like us to feature, please Dr Lycka on We are talking today with a popular repeat guest on our show, Dr Neelam Vashi. She is an expert on skin disorders on skin of color, such as hyperpigmentation & hyperpigmented lesions dark patches on the skin and dark spots on the skin. Welcome, Dr Vashi! What sort of lesions on the skin should someone consider serious when they are looking at their skin? Dr Vashi has lots of consultations for dark patches and spots on the skin and of course, the most serious of these is melanoma. They can actually also be light colored and we call them amelanotic melanoma. When we are looking at something that is worrisome, we use the ABCDE rules to help us. If you see a dark spot on the skin that is ASYMETRICAL (that is the A) Irregular BORDERS (B) Different COLORS (C) Big DIAMETER (D) EVOLVING / changing (E) Then that is something to be more concerned with. So if a person has a brown spot and they think it is a melanoma, what are the telltale signs that they should look for? Well look for those ABCDE s and also if they are problematic, such as bleeding, itchy, that would also be of concern, but of course a lot of times lesions can be non-dangerous spots. If you see something that is the ugly duckling and just doesn t look like the rest that can be helpful. Going through the ABCDE s in more detail IF a spot is not symmetrical, that is more concerning. IF a spot has irregular borders that is more concerning. IF a spot has color variation, has many different colors in it, that is more concerning. IF a spot has a size that is bigger than the end of a pencil, that is more concerning. And the last if it is changing over time, then again, that is more concerning. Yes. Asymmetry is when one side of a mole doesn t look like the other side, and it is growing a bit out of synch. Most moles that are benign are pretty symmetrical not completely. If the border is getting jagged edges (like the coastline of Maine) then we get more worried about it that jaggedness is a sign that there is some sort of growth going on. For Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Neelam Vashi, 11apr16 1

2 color, when Dr Lycka was in the USA they used to say beware of the colors of the American flag if a mole is red, white and blue, then there is definitely something going on there. Shades of brown are a bit of a problem, especially dark brown and light brown, that s when we also start getting worried because that means that there is some sort of growth going on that isn t completely normal. A diameter bigger than the end of a pencil is certainly one of the signs we look at but it is not the only sign because lots of things are bigger than that without having a major concern. And finally evolving as Dr Vashi said, if something is changing we need to be thinking about it and taking notice. If a mole doesn t look the same as it did a month ago vs a year ago then something is going on. And Dr Lycka is sorry to say that the number of melanomas that are being seen are going up and up and up! It is a scary thing because it is a type of cancer that is diagnosable and treatable if we catch them early we can do a lot with them, and have the best chance of curing them. Dr Vashi likes to use E for Evolving, but a lot of physicians will use E for Enlarging. But it s the same kind of idea something is changing. There are a lot of benign moles out there moles that don t worry us. What are the common ones that people SHOULDN T be too scared about? Since we have been talking about melanoma, its worth saying that the biggest lesion that patients are concerned about that fits a lot of those criteria are these non-dangerous growths called seborrheic keratosis. They often occur on the face, and also on the back and chest, underneath the breast. These are non-dangerous growths of the top layers of the skin and they can have different colors, look bigger, and can even be picked off sometimes and bleed, which lead them to look like the disturbing signs from melanoma, but they are actually non-dangerous lesions. For qualified doctors such as Dr Vashi & Dr Lycka, they are not a major concern, and usually they can be spotted a mile off. The good news is that Dr Lycka loves seeing patients when they have these because firstly he can reassure them that they are not going to die, and secondly that they are a sign that they are getting more mature and their skin is getting a bit older, so they are really wisdom spots rather than anything else, and they have earned the right to have them! What about Freckles what does that mean? Well freckles are non-dangerous spots on the skin as well. They are very common in our lighter skinned patients. Older patients will get similar spots called lentigines. When we are comparing these flat brown spots on the face, freckles usually occur on the top of the cheek, they are small 1 3 mm and they fade over time, especially with using sun protection. There is some genetic cause but also an indication that there has been sun exposure. They don t have any propensity to undergo any malignant changes. Lentigines are in a similar family to the freckles and we see those in our older population and they are bigger than freckles 3mm to 2cm in size. They increase with advancing age and for the most part they are non-dangerous, BUT in our older population (in 70s) some of these can become malignant and then the ABCDE s criteria can be used. So we have talked about some moles that we would be concerned about, melanomas and we have talked about moles that can mimic melanomas and moles that are pretty benign but that cause a lot of anxiety for people. What can we do if people just don t like the look of these non-dangerous freckles, seborrheic keratosis & lentigines? Dr Vashi does a lot of consultations in her clinic for these types of spots. And another spot that is in this family is called dermatosis papulosa nigra and that occurs more in our African American and Afro Caribbean patients. They are essentially smaller and darker seborrheic keratosis. She also gets a lot of consultations for lentigines and freckles where people want their skin tone evening out and a cosmetic procedure to remove them. For the lentigines Dr Vashi uses laser treatment, that works the best, especially in our lighter skinned patients when the risk of adverse effects is lower. There are special lasers which output wavelengths of energy and remove these lesions over a series of 2 treatments. What is your favorite laser for working on these? Dr Lycka asks this question because not all lasers are the same and not all doctors treat these the same and Dr Lycka has seen some tremendous scars caused by other doctors For lentigines Dr Vashi uses Q-switched lasers, which pulse energy in a very short time. Side effects and problems are seen when a proper q-switched laser has not been used on certain types of skin tones. The wavelength range from low Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Neelam Vashi, 11apr16 2

3 to high when we are taking off spots in darker skinned patients we should use a higher wavelength because it penetrates deeper into the skin and then protects the top of the skin. The right type and amount of laser has to be used to get the right results. A laser interacts with the skin it isn t just magic that makes a lesion vanish! It has to interact with the components of the skin. Each laser has particular things that are very important to a doctor that knows how to use it. These criteria are very important when choosing a doctor who you want to remove these spots for you. If they are using the wrong laser there will be scarring, and that is not what we want. Another machine that doctors use is an IPL (intense pulsed light) or BBL (broad band light) which are also wavelengths of light that when used properly with the proper cooling can also do some good things for the skin. Do you find that they work in your hands, Dr Vashi? In Dr Vashi s experience when she sees lentigines on aged skin she will use her q-switch laser, but when she sees lentigines combined with pink spots then yes she will use her IPL treatment and also use that for freckles as well it can help with both of those lesions. There is another set of lesions that are more diffuse they are certainly of concern in people of color and this is called post-inflammatory hyperpigmentation. There is also Melasma. These 2 lesions are quite different, they act in different ways, and yet many people don t know how to treat these problems and many people are frustrated because they have been trying to treat these lesions and all they are doing is making them worse! Post-inflammatory hyperpigmentation and melisma are the top 2 reasons for consultations for Dr Vashi. Melasma has another term for it the mask of pregnancy, because it is associated with pregnancy and women s hormonal therapies and about 90% of cases are in women. What we see in the skin are these patches of hyperpigmentation (darker areas) generally in the central face, middle of the forehead and the cheeks. These lesions often make people of color very anxious. They like to have uniform colored skin so when there are differences in color it becomes a problem. Do you see that too Dr Vashi? Yes, and in Boston Dr Vashi is doing a study at the moment questioning patients who are coming in, to see how much it does bother them and the preliminary data is showing that it is incredibly bothersome, and they really want an even skin tone. Dr Vashi is doing different types of treatments to help patients bring back that even skin tone. And this is the difficult thing. Dr Vashi & Dr Lycka attended a conference in 2015 held by a world authority on hyperpigmentation Dr Zein Obagi. He has some certain ideas on how to help these problems. Certainly there are other doctors out there who have ideas too. Have you found treatments that work in your hands? Yes. The first thing that Dr Vashi always counsels is good sun protection, even in the winter months as sun exposure does make these lesions worse. Then her first go to will be topical treatments and the gold standard is hydroquinone. It is essentially a bleaching agent, that comes in different percentages. It can t be used for an extended period of time. There are also other agents that Dr Vashi uses. Some of the proprietary treatments such as the Obagi ZO products (in Dr Lycka s hands) seem to help the hydroquinone reach into the skin better. They improve the efficacy of them. That is important because the skin acts as a great barrier to products. One of the most common problems that people do is that they think the 2% hydroquinone isn t working so they go to the 4%, and then keep going with it when the biggest problem is that it isn t even entering the skin, and is actually causing the skin to become resistant to it. So using agents to help get these products into the skin to act on the pigment cells (the melanocytes) is very important. Yes, penetration is the answer so Dr Vashi uses triple combination creams for example combining a bleaching agent (hydroquinone) with a retinoid (which also in of itself helps with treating darkened patches) but it helps with penetration into the skin. And then also combined with a topical steroid to decrease any inflammation or irritation that those other products can cause. Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Neelam Vashi, 11apr16 3

4 It is not just one treatment. Things do have to be used in combination. The biggest disappointment is that some doctors over-use lasers to treat these conditions. They do help sometimes but in many cases it can make things worse. Lasers should not be the first line of treatment for anything like this. Exactly so the first line treatment for Dr Vashi is topical treatments. Then the second is a lot of chemical peels, and they work very well for patients. Nothing is 100% of course but Dr Vashi finds that adding chemical peels to topical treatments works quite well. Dr Lycka just wants to mention that the word peeling sounds like all the skin is going to peel off like a salamander, and that more pain, more gain! But in reality it is really the opposite of that. They have to be done gently, in a series, in a way that doesn t cause irritation or inflammation because that will cause the skin to get worse. Dr Vashi tells her patients don t worry about the name chemical peel, and don t expect that your skin will be flaking off. She goes slow with them and does typically superficial peels, because yes if we cause too much irritation or too much peeling to the skin then we may start off treating melasma but then what we cause is post-inflammatory hyperpigmentation. So the key message for people who do have these conditions is that they have to be prepared to go through treatments over a longer period of time. It s not something we can wave a magic wand over and it will be gone tomorrow. It is a process that you have to follow, where we normalize the skin and get it healthier, and back to the way it was. It includes prevention, active treatments and it also means home care programs too. Without all these interventions, the chances of success are very small. Yes, Dr Vashi tells patients with melasma that we don t have a cure for it and it will come and go, and we can make it better but it is a lifelong treatment, with prevention and with strict sun protection. Tinted makeup can also help mask these lesions. Absolutely because while this is all getting better a person doesn t have to look bad. They can actually hide it a bit. That is important too because there are a lot of things out there to hide it and make it look pretty good. Dr Vashi really advocates the use of those tinted sunscreens because not only do they help with the condition and mask the dark spots, but also she has found that visible light can make melisma worse and the tinted sunscreens have something in them called iron oxide which protects against visible light. It s important to not just block certain types of light you almost have to block all the types of light. These melanocytes are under the control of a lot of different wavelengths of light. Another thing that most people don t realize is that birth control pills are also a thing that can cause hyperpigmentation in a lot of women. The melanocytes are the pigment cells. Dr Vashi does advocate on the oral contraceptives, birth control options, advocating a low estrogen oral contraceptive, or alternatively a copper IUD which doesn t have hormones in it. Once people are aware of their options, it really helps with controlling these problems. And Dr Lycka would also like to warn people to not just use everything over the counter. Being your own doctor is not the best thing in a situation like this. There are a lot of issues in treating yourself with these pigmentary agents that you will not be aware of, and you can actually make your situation and problems even worse. Yes, that is very true including the most dreaded side effects of hydroquinone which is exogenous ochronosis. Although we don t know exactly what is happening when this occurs, it has mostly been associated with high concentration of hydroquinone being used for extended amounts of time. Sometimes products are adulterated with other components like resorcinol which is another form of skin lightening agent. But when this happens there are dark spots which occur within the existing dark spots and it is incredibly hard to treat once that side effect has happened. Dr Lycka knows that once that starts it is very hard to reverse. In fact, Dr Lycka doesn t know of a great treatment for ochronosis once it is fully established. Dr Vashi actually has several patients with it and all have been caused by using products from overseas. So they have not been using US products under the care of a physician. It is incredibly hard to treat. We have to use some of the very, very short lasers (the pico second lasers) as they can break up the pigment a bit. Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Neelam Vashi, 11apr16 4

5 Dr Vashi we really have to thank you for your knowledge and the time you have spent sharing with us today. You will have enlightened a lot of people. Thank you so much for having me as your guest! Contact details for Dr Neelam Vashi & Dr Barry Lycka: Dr Neelam Vashi Affiliated with Boston University Cosmetic Center Telephone: (617) cosmetic.clinic@bmc.org Dr Barry Lycka Telephone: Edmonton: (780) Inside Cosmetic Surgery Today interview Dr Barry Lycka and Dr Neelam Vashi, 11apr16 5

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