Acne is an inflammatory condition of oil glands. It occurs commonly in teenagers, but is not limited to that age group, particularly in women. Acne typically presents first as comedones ( blackheads and whiteheads), and may become more red and inflamed with papules, pustules ( known as ‘zits’), and deeper, painful cysts. Treatment options range from over-the-counter cleansers and leave-on products, to prescription strength topical creams, gels, lotions and washes, oral medications, and light treatments.
Mohs Micrographic Surgery is a specialized, highly effective technique used to remove skin cancer tumors that grow in critical areas such as around the nose, lips, eyes and ears, or for tumors which are poorly demarcated, recurrent, or very large.
How Mohs surgery is different from other treatments
Mohs surgery differs from other surgical treatments in that it permits the immediate and complete microscopic examination of the removed cancerous tissue, so that all the “roots” and extensions of the cancer can be eliminated. Mohs surgery removes only the cancerous tissue, while normal tissue is spared.
Special Qualifications of a Mohs Surgeon
Physicians performing Mohs surgery have specialized skills in dermatology, dermatologic surgery, dermopathology and Mohs surgery. Dr. Baughman has completed basic and advanced training in Mohs surgery, and Alamo Oaks Dermatology is a fully equipped Mohs surgical facility.
The Mohs Surgical Procedure
Typically, Dr. Baughman performs Mohs surgery as an outpatient procedure in our office. A local anesthetic is used, and the procedure is done in stages.
- The visible cancer is removed, along with a thin layer of additional tissue. The tissue specimen is processed by an on-site lab technician who first freezes the tissue, then prepares slides of stained tissue. The removal of the specimen from the patient takes only 15 minutes, and the tissue preparation and slide interpretation requires at least 1 hour. Dr. Baughman uses a Mohs map to maintain the location and orientation of the tissue specimen with the Mohs technician.
- Dr. Baughman examines the slides and is able to determine if the cancer is completely removed, or where cancer cells are still located.
- The steps described above are repeated as many times as is necessary until the cancer cells are completely removed. A Level is the term used each time tissue is removed. Most skin cancers clear in two levels, but occasionally more are required to clear the cancer.
- When microscopic examination reveals that there is no remaining tumor, Dr. Baughman surgically repairs the hole left in the skin. This opening, or “defect”, is closed, either with adjacent skin moved and sutured in place – a skin flap, or skin from elsewhere on the body – a skin graft. The reconstruction is painstaking, and may take up to an hour to complete. In exceptional cases, Dr. Baughman may coordinate the reconstruction of the defect with a colleague – a Mohs surgeon, or Plastic Surgeon. She wants the best possible outcome for her patients.
Is Mohs surgery covered by insurance?
Most insurance policies cover the costs of Mohs surgery and the reconstruction of the surgical area.
Where can I find more information about Mohs surgery?
You can find detailed information about the procedure, including a video from the American Society for Mohs Surgery at: www.mohssurgery.org
Overview of Rosacea / Perioral Dermatitis
Rosacea (row-ZAY-shuh) is a common condition seen in people with fair skin types. It may appear as bright pink or red cheeks, easy flushing, with a gradual reddening of the complexion. Bumps (papules) and pustules form on the nose, central cheeks, forhead and chin. Men are more likely to develop dilated blood vessels (telangiectasias) around their nose which may become lumpy and enlarged (rhynophyma). Ocular rosacea effects the eyelid margins which can feel dry, irritated, and as if something is rubbing on the eye. Rosacea usually begins between 30 – 50 years of age, but can occur in children, and older.
Help! My esthetician said I have rosacea. How did I get it? How can I get rid of it? I just have a few red bumps on my cheeks, but what if it gets worse? Someone told me rosacea causes noses to grow, becoming bulbous and lumpy. Am I going to look like Bill Clinton? Aargh!
First of all, relax, take a deep breath, and read on. Rosacea (row-ZAY-shuh) is a common condition seen in people with fair skin types. It may appear as bright pink or red cheeks, easy flushing, with a gradual reddening of the complexion. Bumps (papules) and pustules form on the nose, central cheeks, forhead and chin. Men are more likely to develop dilated blood vessels (telangiectasias) around their nose which may become lumpy and enlarged (rhynophyma). Ocular rosacea effects the eyelid margins which can feel dry, irritated, and as if something is rubbing on the eye. Rosacea usually begins between 30 – 50 years of age, but can occur in children, and older.
Women are more likely to get rosacea than men. Assisted by vivid descriptions from Chaucer and Shakespeare, a bleary-eyed, self-indulgent drunk, with a red face and swollen nose, is the image erroneously linked with the disease. This is a mistaken connection. Most people with rosacea are neither alcoholics, nor wealthy hedonists, but have fair, Celtic skin and blush easily.
When a person blushes, the network of small blood vessels on the cheeks enlarge, filling with blood. The cheeks feel warm, and appear bright pink. Emotional responses such as embarrassment, shame, anger, and guilt can trigger blushing. Very cold or hot weather, vigorous exercise, sunburn, or wind burn will also cause cheeks to redden. People with rosacea might once have blushed more easily than others, and over time the blushing lasted longer resulting in permanent pink or red cheeks. Dilated blood vessels begin to form around the nostrils, on the mid-cheeks and chin. Chronic sun damage directly contributes to the blood vessels. The person may notice stinging and burning cheeks, or may feel a fullness and warmth in the cheeks. This is the earliest and most subtle subtype of rosacea called VASCULAR (ERYTHEMATOTELANGIECTATIC) ROSACEA.
The other three common forms are PAPULOPUSTULAR, OCULAR, AND RHINOPHYMA TYPE. INFLAMMATORY (PAPULOPUSTULAR) ROSACEA- might be confused with acne, because both can have red raised bumps and pustules on the mid face. One significant difference is that blackheads and whiteheads do not occur with rosacea, but are common with acne.
BULBOUS NOSE (RHYNOPHYMATOUS) ROSACEA- This occurs when the oil glands become inflamed and
enlarge. The surrounding tissue swells and grows. Prominent men with this form of rosacea include W.C. Fields, Rembrandt, and financier JP Morgan.
OCULAR ROSACEA occurs at the eyelid margins. A person may have itchy, irritated eyes, or feel like something is stuck in their eye.
Once rosacea has developed, many things can trigger a flare- hot-tempurature beverages, spicy food, drinking alcohol, laughing robustly, and fluctuations in hot/cold temperatures. The stigma of being labeled a tippler because of red cheeks is embarrassing and wrong. A better idea is that a person with rosacea is someone who responds enthusiastically to life.
If you want to avoid these altogether, reserve them for special occasions, learn to enjoy permanent bright pink cheeks, or proceed to treatment. With treatment, consider the risk/ benefit profile, starting with the medication with the best efficacy and safety. Topical treatment with metronidazole cream 1%, or metronidazole gel 0.75% has been shown to be both effective and safe. Be patient, a good response might take up to two months initially. A decrease in red bumps, and background redness will be noticed, but dilated blood vessels usually do not respond. People with normal to oily skin prefer the gel, and those with dry skin prefer the cream, with once or twice daily application having similar results. If a person notices itching or dryness from the gel, switching to the cream is advised.
Azelaic acid gel 15%, or cream 20% is another topical product used for rosacea. For some people this is more effective than metronidazole, but others find azeleic acid causes more discomfort and stinging. Simply keeping the skin barrier intact and healthy results in less inflammation, and regular application of an effective moisturizer also helps with background redness.
Oral medications include tetracycline, doxycline, and minocycline, and erythomycin. The tetracyclines are used for their anti inflammatory effect, not for their antibiotic effect. Once improvement is seen, as early as one month, the dosage can be reduced to the minimum needed. Side effects include abdominal upset, nausea, vomiting, headache, dizzyness, increased sun sensitivity, yeast infections in women, medication interactions,and more.
Many of these effects are dose related. In some cases, a micro dose of a tetracycline is effective at reducing inflammation, minimizing potential side effects. Telangiectasias are permanently dilated capillaries and are virtually unresponsive to any treatments discussed so far. They require a physical treatment with a vascular laser, or IPL intense pulsed light. Camoflage make-up is a short term fix.
Flushing usually isn’t controlled with these treatments however and sometimes clonidine, a medication to treat high blood pressure, is prescribed in low doses. Side effects include dry mouth, dizzyness, and low blood pressure. Laser, or IPL can also help with flushing.
Ocular rosacea often improves with treatment for papulopustular rosacea. Rhynophyma can be smoothed with a minimally invasive surgical procedure, giving spectacular results.
Rosacea treatment can be simple and straightforward, but can also be a bit challenging. An individualized treatment plan is usually very successful for improvement. We won’t be satisfied, till you aren’t satisfied.
Warts are caused by a viral infection of the skin. Warts are very common, particularly in children, with 20% of children developing at least one wart.
Warts are benign, minimally contagious, and usually clear up over a period of several months to years. Sometimes they persist, even with treatment.
Treatment is recommended if the warts are spreading, painful (on the sole of the foot or fingertips), or embarrassing. Warts can be treated at home or in the medical office. Home treatment includes topical wart preparations or home freezing kits, and may require three or more months of regular treatment.
Office treatments also require multiple treatments and include cryosurgery ( liquid nitrogen spray), topical in – office or prescription products, or even injectable bleomycin, or candida antigen for persistent warts. Office treatments may be more painful than home treatments, and are usually more effective.
Dr. Baughman advises a combination ‘home and office’ approach with monthly visits until warts are clear.