Category: Blog

This month’s newsletter is about acne scars. August marks our one year anniversary for treating acne scars with the Fraxel laser. This laser has made the subject of “acne scars” interesting again. A discussion of acne scars should begin with the fact that they are very difficult to treat. Patients are often given unrealistic expectations. How well you will do depends on what type of acne scars you have, so let’s start by classifying the types of acne scars.

Scars vs. Blemishes:
It is preferable to reserve the term “scar” for something that is permanent unless treated. An acne “scar” is a change in the texture or contour of the skin left by an acne lesion. It is something that you can feel with your eyes closed. A “blemish” is simply a change in color of the skin and you cannot feel it with your eyes closed. Acne “blemishes” are red or brown discolorations of the skin. These generally fade over time without treatment and are not considered true scars. A topical bleaching cream can be used to speed up the fading of the brown discoloration. And a pulsed-dye laser or an IPL can do the same for the red discoloration.

Which acne scars do you have?
Read more…

Treatment of Acne Scars:
Acne scars are difficult to treat because the defect is usually located deep within the dermis. A treatment method can only be successful if it reaches a depth equal to or greater than the depth of the scar being targeted. Even the best acne treatment methods fail to achieve 100% improvement. There is no such thing as “perfection” in this area of dermatology, but moderate and in some cases excellent improvement can be achieved.

Treatment Options:
For thorough discussion of the available treatment options, including those that we do not offer click the following link: Microdermabrasion, Punch Excision, Focal Peeling, Subcision, Laser Resurfacing, and Fraxel Laser

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

This month’s newsletter is about Juvederm, a new wrinkle filler from the company that makes Botox. It will compete directly with Restylane, which is currently the most popular filler used in the United States.

What is Juvederm?

Juvederm (like Restylane) is a clear gel that is used to fill wrinkles. The gel is created in the laboratory (NOT from animals) and it is made of a natural substance called hyaluronic acid. Hyaluronic acid exists in your body. It lubricates your joints and is in your skin and eyes. The difference between the hyaluronic acid in Juvederm and that in your body is that Juvederm contains “cross-linked” hyaluronic acid. This makes it last longer. If natural hyaluronic acid was injected into a wrinkle, it would be absorbed by the body in a few weeks. Juvederm and Restylane last for 6 to 12 months.

Which lasts longer: Juvederm vs. Restylane?
This is the unanswered question. We know from experience that Restylane lasts an average of 7 or 8 months (and with some patients, a year or more). The makers of Juvederm “imply” that their product should last longer because it has a higher concentration of cross-linked hyaluronic acid (among other reasons), but no “head-to-head” studies have been performed.

Which is better: Juvederm vs. Restylane?

Another “unanswered” question. We were one of the first offices to have Juvederm available (because we participated in the JET trial – a pre-launch clinical study of Juvederm) so we can share our experience with you. We feel that Juvederm is easier to inject. It seems “smoother” than Restylane. Patients who have tried both Restylane and Juvederm have told us that Juvederm feels more natural. However, Restylane is an outstanding product and has a proven track record and a huge following. Only time will tell which one is “better”.

What about Juvederm vs. Botox?
Juvederm and Botox are different types of wrinkle treatments. Botox is a “relaxer”. Juvederm (like Restylane) is a filler. As a general rule we use Botox for wrinkles on the upper half of the face and “fillers” for wrinkles on the lower half of the face (especially around the mouth). The reason for this is that expression muscles cause the wrinkles on the upper half of the face (for example, a frown line when you frown or “crow’s feet” when you squint). Botox relaxes these muscles and the wrinkles fade.

Wrinkles form on the lower half of the face due to loss of volume. Fillers like Juvederm and Restylane replace this lost volume and fill in the line or wrinkle. So to summarize: Juvederm and Restylane are both hyaluronic acid fillers (from different companies) that compete with each other for the treatment of wrinkles on the lower face. Botox is a relaxer that is used for totally different wrinkles (on the upper half of the face.)

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

As dermatologists, one of the most expensive medications that we prescribe is Accutane. Over the last few years we realized that many of our “self- pay” patients have been buying this medication at a very wide range of prices: anywhere from $120 to $450 for a thirty day supply. So we decided to use Accutane as our “barometer” drug to compare prices at local pharmacies.

Our findings:
In general, the least expensive large pharmacies in our area are Walmart, Target, and Costco pharmacies. The most expensive are Walgreens and CVS. The best price we found for generic Accutane was at Target pharmacy on Hollywood Boulevard. Thirty pills of 40mg Sotret (a generic for Accutane) was $260 at Walgreen’s and only $118.99 at Target. A price difference of $141 for a one month supply! (and Accutane is a drug you usually take for 5 or 6 months).

Four dollar prescriptions?
In addition to lower prices on our “barometer” drug Accutane, Walmart and Target have a fairly extensive list of generic drugs that are offered for a mere $4 for thirty day supply. That is even less than most copays with insurance. Costco also has decent prices but does not have a $4 generic drug program. However, Costco’s website, www.Costco.com was the only website to include the useful feature of pricing information for many prescriptions.

What about factors other than price?

Customer service is poor at many of the larger pharmacy chains. Smaller “no-name” pharmacies often offer more personalized service. Also, as dermatologists, we like pharmacies that will “compound”. (“Compounding” is the art of mixing several active ingredients into one custom medication.) Do not try to fill a compound prescription at a large pharmacy chain. In Hollywood, we use Post Haste pharmacy to compound certain dermatology medications. And although they lose on price, Walgreens wins on convenience: the Stirling Road Walgreens in Hollywood is open 24 hours.

One discouraging fact:
Even at Target, the pharmacy that ultimately had the lowest price on generic Accutane by far, getting that price was not straight forward. I asked for the price of their cheapest generic for Accutane and they gave me a quote for two generics, the cheapest of which was $180 Only on further questioning about the specific generic brand Sotret, did the pharmacy tech give us that price for $118 Their explanation was that the first two prices were for what they had in stock, while Sotret had to be ordered (however, it could be there next-day if ordered.) So the question to ask at any pharmacy is: What is the cheapest version of this drug (and please check everywhere, even if it is not in stock and you have to order it)?

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

Occasionally in modern medicine, there are still actually “new” diseases. When a new disease is described, such as AIDS in the 1980’s, it is remarkable how quickly the medical community attacks the problem, learns the cause, and starts to develop treatments. What once took decades, now takes only a few years. For example, the first cases of AIDS were being described in 1981 and by 1987 successful trials of the drug AZT had begun.

A new disease in Dermatology:
In 2000 the first report was published describing a group of fifteen patients who had what seemed to be a new disease in dermatology. The disease consisted of a hardening of the skin of the hands and feet in patients who had end-stage renal disease and who were receiving dialysis. The hardening of the skin was progressive in many patients causing loss of mobility of the joints, leaving them in pain and often unable to walk or use their fingers and hands. The cause was not dialysis, because dialysis has been around for decades and this disease, called nephrogenic fibrosing dermopathy (NFD), was not seen until 2000.

In 2005 a registry was created to track patients with this new disease and more than 170 cases had been reported or published. But the cause was still unknown, and there were no effective treatments for this horribly debilitating condition that often ended in death.

A possible breakthrough:
Then in mid-2006, The Danish Health Authority notified the FDA of 25 reported cases of nephrogenic fibrosing dermopathy from two European medical centers. All of these cases occurred in patients with renal failure who underwent MRI and received a single dose of a gadolinium-containing contrast agent. (Contrast agent is a chemical injected into the vein of a patient before undergoing MRI. The contrast highlights certain structures in the body on an MRI scan allowing the radiologist to see organs and other structures more clearly.) All of the patients developed NFD within 3 months after receiving the contrast.

Worldwide, approximately 200 cases of NFD have now been reported. Efforts are underway to determine how many of these patients received gadolinium- containing contrast agents. There is still no cure and gadolinium-contrast is only an “association” and not yet a known “cause” of the disease. However, this case illustrates how the medical community of the world collaborates to tackle new diseases.

Just to be clear:
There are no reports of MRI contrast agent causing this disease in patients with normal kidney function.

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-751

Several months ago, three of our patients separately requested the Vitalize Peel by name. We had not heard of it but we were already doing a similar peel called a “Jessner’s Peel” from a different company. The problem with the Jessner’s Peel, which has been around for decades, is that the results were not consistent (some people peeled a lot, others very little.) So we tried the Vitalize Peel and discovered that it gives a great peel every time. Since switching to this brand of peel six months ago, it has become one of the most common procedures we do.

What does this procedure involve?
The peel takes about 10 to 15 minutes to perform in the office. The prep is very important. First you must wash your face to remove all make-up and dirt. Then the three-step peel is performed:
Step 1 – the nurse vigorously degreases your face with a gauze pad and the step-1 solution.
Step 2 – multiple coats of the first peeling agent are applied. The first peeling agent is a modified Jessner’s solution. For those of you not familiar with Jessner’s solution, it is a mixture of lactic acid, salicylic acid and resorcinol and we have been using this solution for years in dermatology.
Step 3 – one coat of the second peeling agent (retinoic acid) is applied.
There is a slight burn or tingle felt during the peel (and sometimes for a few hours afterward). For the next two days, your skin actually looks great, it is bright and glowing with no peeling, and then on day 3 —you start to peel! The peeling lasts for up to a week.

Why do people like it so much?
The results are predictable and there is no down- time. This is no “wrinkle-cure” but your skin does look noticeably better in a short period of time.

A reminder about peels:
Peels come in several strengths: superficial, medium, and deep. The deeper you go, the greater the results, but also the risk and downtime increase. Superficial peels just exfoliate you (like a salicylic acid peel for acne). A few cell layers flake off, but you don’t peel all that much. At the other extreme, a deep peel (like a phenol peel that you see on TV shows like Extreme Makeover) requires general anesthesia.

The Vitalize Peel is superficial to medium peel. It is the deepest of the superficial peels. It removes most of the epidermis, which we feel is the perfect depth. Why? Because, it is deep enough to give you visible results, but it does not hurt, it is very safe, and you do not need to miss any work.

What skin conditions does it help?
Acne – patients who need a stronger peel than the typical salicylic acid peels we routinely perform on our acne patients may consider the Vitalize peel.
Hyperpigmentation / Melasma – peeling is a part of the treatment (along with a bleaching cream and sun protection) for these conditions.
Anyone who wants a brighter more even skin tone. You will notice a difference after just one peel and you can get more dramatic results with a series of 3 to 6 peels.

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

This month is a short newsletter, but there is some BIG news:

Toe Nail Fungus just got Cheaper!
The patent for the very effective, but very expensive oral antifungal called Lamisil (generic name = terbinafine) just expired in June of 2007. Now that the drug is off patent, generics have started to appear. The cost difference is huge. A quick check at Costco.com pharmacy shows that 30 pills of the brand-name Lamisil cost $385 versus 30 pills of the generic at $21.

Are generics as good?
In most cases they are. To be approved by the FDA the generic drug must show that it has at least 80% of the effect that the name-brand drug has. Common sense also tells me that generic drugs are fine. For example, I always buy generic ibuprofen (Advil) and acetaminophen (Tyelenol) and it gets rid of my headache. Also, all of my patients on Accutane end up getting generics and their acne still goes away. To be fair, some drugs are more difficult to manufacture than others and sometimes 80% efficacy is not sufficient.

Pulse Therapy for Toenail Fungus:
Lamisil is typically prescribed as long course of continuous therapy: one pill a day for two months to treat finger nails; three months for toe nails. We treat nail fungus with a different approach called “pulse therapy”. Pulse therapy means that you take a one week “pulse” of the medicine every month or every two months. In other words you take Lamisil for seven days in a row (= one pulse) and then nothing for the rest of the month. There is data to support that pulse therapy is just as effective as “continuous therapy”, if not more so. The obvious appeal is that one can achieve the same results with less medicine. This means less potential for side effects and lower cost.

Read more about toe nail fungus and treatment

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

This month’s newsletter is about a drug called Propecia that we often use to treat male pattern baldness. New studies on this drug reveal that it may protect men against prostate cancer.

What does Propecia have to do with your prostate?
Propecia (generic name = finasteride) was originally a medicine used to treat BPH (benign prostate hypertrophy). BPH is a very common enlargement of the prostate that happens in older men and leads to urinary symptoms. Finasteride at a 5mg dose helps to relieve this condition by shrinking the prostate. Several years ago, some observant doctors noticed that their balding patients started growing hair while on finasteride. Tests were done to find the lowest dose necessary to grow hair, and the results showed that 1mg was just as good as 5mg, but with fewer side effects. So Propecia is a 1mg finasteride pill used to treat male pattern baldness, while Proscar is a 5mg finasteride pill used to treat BPH. All of the studies below refer to data in men using 5mg of finasteride.

Does finasteride protect men against prostate cancer?
The answer is “probably”. But for years the message was mixed: while finasteride use may reduce the overall risk of prostate cancer, it is associated with an increased risk of high-grade disease. Recently, the data on this subject was reanalyzed in a new study where the authors found no elevated risk of high- grade prostate cancer with finasteride use. I will present the information to you, but remember that all of the data is from tests done with the 5mg dose of finasteride, while Propecia is a 1mg dose of finasteride.

Lets start from the beginning:
In 2003 the results from the Prostate Cancer Prevention Trial (PCPT) demonstrated a 25% reduction in the prevalence of prostate cancer among patients treated with finasteride compared with patients treated with placebo. However, there was a 22% increase in high grade (i.e. “worse”) tumors. In other words, the men taking finasteride had a lower overall chance of getting prostate cancer, but the ones who got the cancer had a potentially worse kind. This was a confusing message for both doctors and patients: “take finasteride and you are less likely to get prostate cancer, but if you do ultimately get the cancer, it may be worse”.

In 2007 a re-analysis of the data:
In 2007 the data was looked at again. The scientists hypothesized that finasteride use does not cause high- grade prostate cancer, but rather shrinks prostate volume, making advanced disease easier to detect. In analyzing data from nearly 1000 men enrolled in PCPT, the researchers found that prostate volume was, in fact, reduced with finasteride use. The average volume in users of the drug was 25% lower than in subjects given placebo. After adjusting for prostate size, the authors found no elevated risk of high-grade prostate cancer with finasteride use.

Does this data tell us anything about Propecia which is 1mg of finasteride?
The real answer is, “we do not know”. Perhaps protecting men against prostate cancer is analogous to growing hair, where 1mg is just as effective as 5mg. Perhaps it is analogous to treating BPH, where 5mg is superior. What we do know is that the new data is reassuring and suggest that if there is any effect on prostate cancer in men taking Propecia, it is only a benefit and not a negative effect.

Read more about using Propecia for male pattern balding…

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

November 2007, Vol 1 Iss. 21

Attention Accutane Patients: We can now check your labs in the office. We have purchased a machine that can test both serum lipids and liver function with a small amount of blood from a fingerstick.

The good news:
This means that instead of two visits each month for Accutane (one to the lab for a blood test and one to our office), you only have to come to our office for one visit. No more waiting in line at Quest or Labcorp.

The bad news:
Your insurance won’t pay for it. We are not contracted with your insurance company for laboratory work. Most insurance companies have contracts with large labs such as Quest or Labcorp. We do a fingerstick (easier than a venous blood draw). We get the results in five minutes. The cost is $30 per test. Most accutane patients only require one test each month (a cholesterol panel).

Don’t forget:
You still need to be fasting when we check your cholesterol. Six to eight hours since your last meal is ideal (so try to come in the morning before breakfast). If you can only come in the afternoon and haven’t eaten in 3 or 4 hours, we can still do the test, however, if the results show that your cholesterol is elevated, then you will have to repeat the test after a real 6 to 8 hour fast.

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512

December 2007, Vol 1 Iss. 22

Many woman being treated for acne with antibiotics are concerned because they “heard somewhere” that antibiotics can decrease the effectiveness of the birth control pill (aka oral contraceptives). The effects of antibiotics on oral contraceptives may be overstated.

What we know:
Rifampin is an antibiotic that definitely decreases the effect of birth control, but we do not use this drug for acne.

The antibiotics that we use to treat acne are doxycycline, tetracycline, and minocycline. There is no data showing that these drugs decrease the effect of oral contraceptives’s. There is some data showing that these drugs do NOT effect oral contraceptives’s.

The data:
One study conducted on 356 patients showed a failure rate of 0.96% per year for women taking birth control pills vs. a 1.6% per year failure rate for women taking antibiotics with their birth control pills. This difference was not considered statistically significant.

reference: J Am Acad Dermatol. 1997 May;36(5 Pt 1):705-10.

Ask your gynecologist (I ask all the time):
I have spoken with several gynecologists on this subject and most of them say some version of the following “the acne antibiotics probably do not decrease the effectiveness of birth control pills, but if you want to be absolutely sure, then use a second form of birth control in addition to the pill, such as condoms”

Another important point:
Patients need to recognize that the expected oral contraceptive failure rate, regardless of antibiotic use, is at least 1% per year and it is not yet possible to predict in whom the birth control pill may fail.

Summary:
The antibiotics that we use to treat acne probably do not lower the effectiveness of your birth control pill. And if they do affect your birth control pill, it is only a small effect. However, if you want to be absolutely sure that you do not get pregnant, then use a second form of birth control in addition to the pill, such as condoms.

Read more about acne treatment

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com“>
phone: 954-987-7512

There is a group in Florida that is frequently being accused of crimes that they did not commit. The group I am referring to is spiders. Not a gang that calls themselves the “spiders”, but actual spiders. Almost once a week I have a patient accuse a spider of causing their skin problem because they, or a friend of theirs, or even a physician told them that they probably have a “spider bite”.

When physicians diagnose a spider bite they usually mean a “brown recluse” spider bite. When the brown recluse spider bites you, the reaction is a red necrotic lesion. But in reality no species of recluse spiders are native to Florida, (see the distribution map).

Listen to an expert:
An arachnologist at University of California, Riverside Department of Entomology further makes the point: In the case of necrotic wounds, “brown recluse spider bite” is a very common conclusion of medical personnel throughout North America including such ludicrously inhospitable places as Canada and Alaska where no brown recluses have ever been found.

In a 6-year database for the 3 Florida poison control centers, 124 brown recluse spider bites were diagnosed by medical personnel in that state (and these are only those that were reported). In comparison, in 100 years of arachnological information, only 11 recluse spiders have been found in Florida and only 2 of these finds were in homes. IN OTHER WORDS, EACH MONTH THE NUMBER OF RECLUSE SPIDER BITES DIAGNOSED IN FLORIDA IS GREATER THAN THE NUMBER OF RECLUSE SPIDERS EVER FOUND IN FLORIDA.

(click here for the original reference http://spiders.ucr.edu/necrotic.html)

If not a spider bite, then what is it?
My experience is that almost every time someone thinks that they have a spider bite, the patient actually has a furuncle. A furuncle is an infection of the hair follicle. Some people call it a “boil”. It is usually a red swollen nodule. Sometimes it is hot and tender, sometimes it is filled with pus. The culprit is not a spider, but actually Staph Aureus; a common bacteria that infects the skin. The treatment consists of draining it in the office and then using warm compresses at home (no antibiotics needed – usually).

Sincerely,
The Staff and Doctors at Minars Dermatology
email: tminars@hotmail.com
phone: 954-987-7512