Update on Cosmetic Dermatology

Posted By SHL Librarian

Presented by S. Tyler Hollmig, MD
Clinical Associate Professor of Dermatology
September 21, 2017

A man looks in the mirror and sees a network of tiny red veins has spread over his nose. A woman sees brown splotches on her cheek.

Either one may notice the skin has begun to sag around their eyes and mouth, leaving wrinkles and bags.

“We kind of go from a grape to a raisin as we get older,” said S. Tyler Hollmig, MD, at a recent presentation to the Stanford Health Library. At first subtle, these changes accumulate as we age.

“Even small changes in the human face…really impact us all. We all see it,” said Dr. Hollmig, director of laser and aesthetic dermatology at Stanford University Medical Center. Many of these skin changes can be reduced or even removed, with the right dermatology procedure.

It’s important to be realistic about goals and limitations, Dr. Hollmig said. “There’s a lot of snake oil out there,” he said. “At the same time, small things can make a big difference.”

Dermatology procedures are tailored for each individual person who comes to the Stanford cosmetic dermatology clinic, Dr. Hollmig said. The clinic offers procedures that are “evidence-based”—meaning that they have been shown in studies to be safe and effective.

The treatment depends on the nature of the skin change—whether it’s a ruddy face, brown sun spots, a scar from an injury, or wrinkles that have multiplied with age.

Dr. Hollmig grouped the most common skin changes he sees into 3 categories.

Red skin due to damaged blood vessels

Skin can look red and irritated for a variety of reasons. Often the underlying cause is small blood vessels that have grown close to the surface of the skin, called vascular lesions.

  • Rosacea: This is the term for redness that can leave the face looking ruddy or flushed. The redness comes from small blood vessels that have spread close to the surface of the skin over a large area of the race.
  • Spider veins: These are tiny red branching networks of blood vessels, also called telangiectasia.  Again, they are caused by small blood vessels that have grown close to the surface of the skin (vascular lesions).
  • Scars: Red skin can also be the result of scars from injuries to the skin, including acne. After an injury, the body brings blood vessels to the harmed area to provide nutrition to help heal it. After it’s healed, the blood vessels stick around. That can leave the area looking red.
  • Cherry angiomas: This is another cause of red skin caused by small red bumps that are actually little groups of small blood vessels. “You start developing them when you are about 30 years old,” Dr. Hollmig said.
  • Stretch marks: These are the skin marks common in pregnancy that usually start out red but later fade to white.
  • Port wine stains: These can appear at birth, caused by groups of blood vessels growing close to the skin surface.
  • Poikiloderma: A reddish chicken-skin look on the neck that can be caused by sun damage. Sometimes poikiloderma appears dark from spider veins that accompany it, and sometimes it appears unusually light.

Treatment target for red skin: Hemoglobin

For all these red skin conditions, treatment has the same target: hemoglobin. That’s the protein in red blood cells carried in blood vessels.

Dermatologists can use a laser beam to “hit” hemoglobin by heating it up, which reduces or removes redness in the skin.

The laser beam used for this procedure produces light at a specific wavelength that targets hemoglobin. The laser heats up hemoglobin, but it doesn’t heat up the surrounding skin.

“It’s almost like a heat-seeking missile just hitting hemoglobin but not burning the skin,” Dr. Hollmig said.

The wavelength of the laser can be adjusted, depending on the size of the blood vessels and other factors, to selectively hit the target without causing too much damage. That’s where the skill of the dermatologist is important.

“There’s a fine line between no improvement or no response, a perfect response, and then burning or blistering or scarring someone,” Dr. Hollmig said. Doctors have to be “very vigilant in understanding how aggressive to be.”

To go slowly and safely, many of these treatments take multiple sessions, Dr. Hollmig said. There are side effects with every laser treatment. There can be redness, swelling, and sometimes bruising, which take time to heal.

That’s why it’s always important to discuss realistic goals and expectations before the treatment. “If I discuss these things beforehand with patients, my experience is they understand and are grateful and become partners,” Dr. Hollmig said.

Red skin from vascular lesions is one of the skin conditions treated most easily and effectively with laser therapy. “It’s not rocket science. But this technology really works,” Dr. Hollmig said. One firefighter given treatment for dark red cheeks went “from a pretty tough-looking hombre to a pretty happy guy, with just a few treatments.”

Similarly, red skin caused by scars can be improved with laser treatment. Whether the scars are caused by acne, a bicycle accident or surgery, laser therapy can reduce or even remove them, Dr. Hollmig said.

Some women get red skin scars from radiation treatment for breast cancer. Lasers can be used to minimize or even banish them.

Lasers can also remove the surgical tattoos used for the radiation treatment. “You end up with a tattoo on your breast for the rest of your life,” Dr. Hollmig said.  “We can make those go away with one shot. That’s really liberating for many women, and rewarding for me.”

Brown skin: Sun damage

One of the most common conditions that brings patients to a dermatologist are the brown spots—sometimes called liver spots or lentigines—that are caused by sun damage. They often occur on the face or hands, which both get a lot of exposure to the sun.

“The backs of the hands are really telling,” Dr. Hollmig said. “The reason why they show our age is because UVA light penetrates window glass and the side windows of our car. And that causes sun spots.”

Treatment target for brown skin: Melanin

For a dermatologist, many types of brown spots are relatively easy targets for laser therapy—if the brown spot is surrounded by a blank canvas of white skin. The laser can see its target and hit it, Dr. Hollmig said.

Within the brown spot, the lasers target melanin, the pigment that colors skin and is made by cells called melanocytes. The lasers used for this select only the melanin in the brown spot, sparing other surrounding lighter skin.

For patients who have overall darker skin, including some Asians, laser treatment for brown spots can be more tricky. If the brown spot blends in with background skin color, there’s a higher risk the laser will be too aggressive.

“We have to take it very, very slow,” Dr. Hollmig said.

Another kind of brown skin is called “the mask of pregnancy,” or melasma. While it is also linked to sun exposure, it may also be linked to hormones that change in pregnant women.

“Melasma is about the hardest thing to treat in aesthetic dermatology,” Dr. Hollmig said. He is often able to help women with melasma, although this can be challenging, particularly for women with darker skin types.”

Wrinkles: Father Time undefeated

Everybody gets wrinkles as they age, some more than others. The causes are multiple and overlapping.

“As we get older, we lose volume. We lose muscle, we lose bone mass,” Dr. Hollmig said. At the same time, the skin becomes less elastic as collagen declines. “That causes wrinkles.”

All this is aided and abetted by bad health habits like smoking and excessive drinking plus environmental culprits like sun damage.

Treatment target: Collagen

Treatment to reduce wrinkles is not as simple as for other skin conditions. “We don’t have as pure a target for wrinkles as we do for red spots with hemoglobin, or brown spots with melanin,” Dr. Hollmig said.

The goal for treatment, using lasers, is to stimulate cells to grow more collagen. That helps to fill in the “dents” in wrinkled skin.

This can help refill the skin where it’s lost a lot of the deeper layer, the dermal layer of skin, Dr. Hollmig said. Lasers are used to target water, heating it up, which has been shown to kick off collagen growth. “The goal is to make our skin actually turn back the clock to when we’re 20 or 25 years old, and really grow some collagen,” he said.

Treating wrinkles with lasers often involves trade-offs between improving the wrinkles and requiring longer healing time with more pain.

“I hate to say, ‘No pain, no gain,’ but there is some relationship between what a patient’s willing to go through, and how aggressive we can be in treating wrinkles,” Dr. Hollmig said. “We talk about down time, too.”

The laser beams used for today’s dermatology procedures are dramatically safer than the chemical peels used in the 1950s and 1960s when cosmetic dermatology was starting on the West Coast.

“With a chemical peel, you’re trying basically to just destroy the skin with a chemical,” Dr. Hollmig said. “These [1950s] dermatologists would mix up all sorts of amazing things in their office, put it on the skin, and then watch it burn the skin off, and then wipe it off. And then great things would happen, usually, except when they didn’t, and then there’d be scarring, or other problems.”

“We’ve really gone away from chemical peels now. “Lasers allow us to be very specific in targeting certain things.”

The first lasers were much stronger than most of the ones used now. Today’s lasers can be “fractionated,” which means they “basically drill just teeny, tiny holes into the skin, almost like aerating a golf course green or a lawn,” Dr. Hollmig said. Those tiny holes can penetrate very deeply, stimulate water, and stimulate collagen growth.

By making just tiny holes, there’s a lot of skin around it, which can reseal the holes quickly and heal nicely. “So the down time is significantly less, the pain is less, the risk of infection is much less because that skin barrier is intact,” Dr. Hollmig said.

There are trade-offs in this treatment, too. More aggressive therapy requires more time to heal. For some people, it can take as long as 6 months to achieve full treatment benefits.

The bottom line at Stanford is that doctors work with patients to choose the treatment that’s best for them. Doctors offer procedures that they know, from studies, will work.

“We really try to be honest with our patients, about goals, about risks, about ‘Is this worth it or not?’” Dr. Hollmig said. “I probably spend half my day talking patients out of treatments.”
He added, “The most important thing you can do for your skin is wear sunscreen.”

For more information:

Stanford Health Library can do the searching for you. Send us your medical questions.

S. Tyler Hollmig, MD

Stanford Cosmetic and Laser Dermatology