Tips & Wisdom
Actinic Keratoses (AK) Treatment
Psoriasis Treatments: Biologics
Basal Cell Carcinoma (BCC) Treatment
Stelara Treatment for Psoriasis
Tips for using Topical Retinoids
Rosacea Treatment Review
Bleach Bath for Eczema
Acne Medications: OTC vs Prescription
Early treatment of actinic keratoses (AKs) is generally simple, fast and effective in eliminating these growths, and preventing skin cancer.
There a many ways to treat AKs. The most common approach is with cryotherapy with liquid nitrogen (freezing). Essentially this a controlled, localized frost-bite injury that is very quick and effective in eliminating AKs.
Other treatments may include electrocautery and curettage (scraping with a special instrument), photodynamic treatment (applying a special chemical mixed with light activation), or various topical prescription medications that you can apply at home.
There are number of very good medications that may be used for AK treatment. These are often best used for "field" treatment of an area with many AKs, marked sun damage, or for those with a history of skin cancers.
I tell my patient it is a way to try to "wipe the blackboard clean" of the precancerous lesions we may not even see yet.
Medications presently available for the treatment of AKs include 5-Fluorouricil (5-FU), imiquimod (Aldara®, Zyclara®), and diclofenac (Solaraze®). These agents may also be used for discrete AKs, and the newest agent, ingenol mebutate (Picato®), is specifically for small, localized areas.
The most important part of prevention is good sun protection. Slip on shirt (or other sun-protective clothing), slap on a hat, and slop on the sunscreen.
I tell my patients to go out, be active and do the things they enjoy-- just don't strive to get a tan, and by all means avoid burning. REMEMBER also, that just because you have sunscreen on, it isn't a license to receive excess sun exposure--- just as wearing a seat belt doesn't mean it's okay to drive drunk or recklessly.Learn More
Biologics are the most recent advances in the treatment of psoriasis, though they have been in use in the U.S. for nearly 14 years. Biologics were initially considered 2nd line agents, but can now be considered 1st line therapy for severe, diffuse or resistant cases of psoriasis.
These drugs include such tongue-twisting names as infliximab, etanercept, adalimumab, and ustekinumab.
Biologics are often easy to use and offer dosing regimens that range from twice a week to once every 3 months. They also appear to be very safe, with minimal lab monitoring, and low side-effect profile.
Biologics should be considered when someone has psoriasis that is limiting their daily life in terms of function or psychosocially. Some examples of this include the following:
When psoriasis covers large areas of the body so that applying a topical medication to all of the affected areas is impractical. In such cases, using a "whole body" therapy, such as biologics, might be considered.
When psoriasis is especially severe, even if the affected area is limited. Examples include severe/resistant hand psoriasis in a surgeon or pianist, facial psoriasis in an actress or newscaster, or foot psoriasis in an athlete.
Psoriasis that requires "whole body" therapy, but has failed other, non-biologic treatments, such as UV phototherapy, methotrexate, and acitretin to name a few.
Each case of psoriasis has unique characteristics and each individual has a unique health history and lifestyle. These variables may make one medication a better fit for a particular patient than another.
In general, make sure you consult with a board-certified dermatologist who is experienced with treatment of complicated psoriasis.
In general, I tend to prescribe etanercept (Enbrel®) and adalimumab (Humira®) as my first agents -- both have a long track record of safety with excellent effectiveness, and are quite similar in their mode of action.
Ustekinumab (Stelara®) is the newer kid on the block, and for this reason, I generally reserve it if someones fails or does not respond sufficiently to my first options. Because Stelara® works by a different mechanism of action, there are some patients in which it may be my first line agent. Infliximab (Remicade®), while probably the most potent, also has a higher side-effect profile and requires an IV infusion, so I reserve this for my most resistant patients.Learn More
Topical therapies, such as imiquimod and 5-fluorouracil (5-FU), may be prescribed for the treatment of certain types of basal cell carcinomas (BCCs).
Ingenol mebutate (Picato® Gel), another topical medication, may also be prescribed for the treatment of BCC. Although this use is "off-label" (meaning the medication was first approved by the FDA for a different medical condition) it may become a leading topical agent in BCC treatment.
Some recent studies have shown very good efficacy using both the pulsed-dye laser and the long-pulsed Alexandrite laser.
Most recently, vismodegib (Erivedge®) became the first systemic agent approved for metastatic or advanced cases of basal cell carcinoma. The approval of this new medication marks a truly exciting time in the field of skin cancer therapy.
The goal of these BCC treatment options is to provide a simpler treatment course, produce less scarring, or provide an effective treatment option for those patients that cannot tolerate or do not desire surgery.
Referral to a Mohs surgeon is generally reserved for high-risk locations (such as the eye, mouth, ears or nose), cosmetically sensitive areas, or for high-risk lesions.
Recurrent skin cancers, especially large lesions, or certain more aggressive sub-types, such as morpheaphorm or sclerosing BCC, are often candidates for Mohs surgery as well.Learn More
The age of biologics has made a tremendous impact on the care of psoriasis. These medicines have opened up a new world of safe and effective treatments for our worst psoriasis sufferers. They are often my first choice for "whole body" and/or lifestyle affecting psoriasis, where topical therapies just can't do the job or aren't practical.
Stelara® is a nice addition to our current treatment options. It offers a novel mechanism of action, so patients that have perhaps failed other biologics in the past, have hope with this drug. It also offers less frequent dosing than our other options, essentially every 12 weeks after the initial induction phase.
Our primary concern with Stelara® right now is the lack of long term safety data, relative to the other biologic and non-biologic therapies. Safety, before efficacy, needs to be our first goal.
Currently, I am comfortable with Stelara® as a 2nd line biologic agent for patients that have failed one of my first options, or as a first line option if their medical history suggests Stelara® would be safer.Learn More
Topical retinoids (Differin®, Epiduo®, Retin-A®, Tazorac®, .... etc) are a must in most all acne treatment regimens.
They are part of the foundation for most acne treatment. All acne lesions start as a clogged pore (comedone), and effective acne therapy requires the removal of this clogged orifice (comedolysis). Retinoids continue to be our most effective topical medicines for this. Additionally, they have anti-inflammatory properties that further help to decrease the red pimples and pustules of acne.
The first 1-2 months of starting any retinoid will be an adjustment period for your skin. Most people's skin will get dry, red, and mildly irritated. For some people, this can be quite severe. I tell my patients to follow these steps:
At night, after brushing your teeth, wash your face and pat dry. Sunlight may breakdown retinoids, so they are best to apply at night. I find medicine spreads easier and is less irritating on moist skin.
While your face is still moist, apply a small "finger tip" amount of medicine in small dots around the face, then spread over the whole face to a thin film. Be careful to avoid the sensitive skin under the eyes, next to the nose, and the in corners of the mouth.
After rubbing the medicine in well, apply a moisturizer of your choice. Reapply the moisturizer in the morning, along with a daily sunscreen.
If you find your skin becoming very irritated, hold the medicine for a few days, then start applying it only 2-3 times per week. Increase application by 1 day per week every few weeks as tolerated. For patients with sensitive skin, I often start them at this 2-3 times per week regimen.
For some very sensitive skin, we may use short contact therapy. This means applying the medicine for 15 minutes before washing it off, and slowly increasing over time as tolerated.
Remember -- this is medicine, not magic. Acne may initially get a little worse in the first 2-4 weeks of treatment. Continued improvement may occur for up to 4-6 months! So be patient and persistent!
Many people may become dry, red or peeling during the first 1-2 months until they fully adjust to the retinoid. This is a sign of the medicine working effectively. Be sure to moisturize regularly with a ceramide containing moisturizer (such as Cerave®, Cetaphil Restoraderm and Aveeno® Eczema Therapy.Learn More
Although there have been concerns raised about a range of possible side effects, isotretinoin continues to be prescribed for acne because of its unique benefits. Isotretinoin is by far our most effective therapy for acne, and has the potential to cure someone’s acne. It is a very safe medicine when properly prescribed, and virtually every patient I have treated with isotretinoin is thrilled with the results and lack of significant side effects.
Generally, isotretinoin has been thought of as a “last resort” treatment or for severe-nodular cystic acne. However, I prescribe isotretinoin in a wide variety of cases:
- for the persistent or resistant acne that is not responding well to standard treatments
- for the patient that is beginning to develop or at risk of developing acne scars
- for the patient with moderate but extensive acne at a young age with a family history of severe or scarring acne
- and often for the adult patient who has persistent moderate acne and is tired of all the creams and pills and wants a “cure”.
These are some of the most common reasons I use for starting isotretinoin, but I address each person individually regarding their acne and situation, and often present isotretinoin as one, excellent option. Learn More
Many people with rosacea may first experience the facial redness of rosacea subtype 1 called "Erythrotelangiectatic rosacea".
The causes the face to become red, flush easily from various stimuli such as alcohol, caffeine or temperature changes. Sun protection is key to prevent long term progression of this stage, which may progress. Coverup makeups can be used to hide the redness, and the newer mineral makeups seem to work well and are non-irritating.
Pulsed Dye Laser (PDL) or intense pulsed light (IPL) are the best treatment options for rosacea subtype 1. These lasers and light sources target the blood vessels that are the cause of this condition. Generally 3-4 treatments are sufficient for excellent results.
Most of the medications prescribed for rosacea treat the pimples and bumps of rosacea that occur with subtype 2, called "papulopustular rosacea". Topical medications (metronidazole and azelaic acid) and oral medicines, such as doxcycycline (Oracea) and minocycline, are very effective in decreasing the red pimples and bumps.
Long-term use of rosacea medications is the rule, and flares tend to recur as rosacea medications are weaned. Pulsed dye laser treatment may improve rosacea subtype 2 symptoms and decrease the frequency of flares.
The swollen nose of "Rhinophyma", seen with subytpe 3, generally only occurs with men and less commonly than a few generations ago.
Treatment of rhinophyma can be with ablative lasers such as the CO2 laser, or with an electrocautery unit. Many patients find improvement in their sleep and less snoring, as well as a improved cosmetic appearance, with treatment.Learn More
I prefer the term ‘swimming pool baths’ for dilute bleach baths since this is essentially what they are–the same level of chlorine (bleach) that you find in your own backyard or neighborhood pool. We in Pediatric Dermatology have been using this therapy for years with our patients with atopic dermatitis / eczema. This is a very good adjunctive treatment for many children with eczema, especially those with frequent skin infections.
It is well accepted that the naturally occurring bacteria on our skin may trigger or flare bouts of eczema, and patients with eczema are at a higher risk of skin infection due to their compromised skin barrier function. The use of this safe, readily available therapy can improve patients atopic dermatitis by decreasing the severity and frequency of flares and secondary infections. While most children with atopic dermatitis are generally mild enough that swimming pool baths are not necessary, anybody with moderate/severe or poorly controlled eczema should consider adding this to their routine. Be sure to consult with a Board Certified Dermatologist, ideally one with an interest in eczema, to maximize all the components of you or your child’s skin care regimen.”Learn More
Over the counter (OTC) acne medicines are a good first choice in mild acne, and can be fairly effective. Most all of these contain one of three ingredients, and despite what advertising and television stars may tell you, they work about the same. These ingredients are:
- benzoyl peroxide (an excellent germ killer, but can be irritating)
- salicylic acid (a chemical exfoliant), and
- sulfur (the least commonly used of the 3 because of its unpleasant smell.
For moderate to severe acne, or acne that is persistent/resistant to OTC treatment, seek the help of a board-certified Dermatologist. We are the experts in the evaluation and management for diseases of the skin, hair and nails, and have access to a large arsenal of weapons to attack your acne. Prescription therapy for acne is vastly more potent than any of the OTC options.
A good dermatologist first should initially examine your acne closely to make sure that you do, in fact, have acne! There are a number of conditions that may mimic acne, many of which may not be easily identified by your general physician.
Secondly, it is important to assess for conditions, medicines or exposures that may effect your acne. Examples could include hormonal conditions, steroid exposure, or prescription medicines such as lithium. Knowing and evaluating for these problems will impact not only your acne care, but also your general health.
Third, is developing an individualized plan for your acne. Again, this is where expertise is so critical- Dermatologist simply have more "arrows in our quiver" to treat your acne.
Acne treatments generally fall into 6 categories:
- Comedolytics (whitehead/blackhead removers)
- topical antibiotics
- oral antibiotics
- systemic retinoids (like Accutane® (Isotretinoin)
- hormonal therapies
- physical modalities.
As acne has 4 root causes (increased oil, sticky pores, overgrowth of germs, and inflammation), most acne requires a combination of treatments for maximum results.
Comedolytics remove the clogged up pores (comedone= whitehead/blackheads) that are initial formation of all acne bumps. The most effective are the retinoids, such as Retin-A®, Differin®, and Tazorac®.
Topical antibiotics kill the germs associated with acne, that result in inflammation. Prescription therapies offer more options and increased effectiveness over their OTC counterparts.
Oral antibiotics not only assist in germ killing, but also decrease the inflammatory response in acne. There are many options, often with subtle differences and differing side effects. Your dermatologist will be able to choose the appropriate one for your personalized care.
Other, more advanced and powerful treatments, are generally solely used by dermatologists. These include systemic retinoids (isotretinoin/accutane), hormonal therapy, and physical modalities (acne surgery, chemical peels, laser or light based therapies).
Be sure to aggressively pursue appropriate treatment for acne. Acne scarring is extremely difficult to improve and the social impact of severe acne should not be ignored. With all the options available today, your acne your be well controlled."Learn More
Dr. Jeffrey Poole, MD is a board-certified New Orleans dermatologist providing care to patients at Poole Dermatology.
Dr. Poole also serves as Assistant Clinical Professor of Dermatology at both the LSU and Tulane Schools of Medicine, acting as their Pediatric and Adolescent specialist, and remains a board-certified Pediatrician.
Dr. Poole is also a founder and co-director of the Vascular Anomalies Center – Children’s Hospital New Orleans, an area of his specialty where he has great interest and expertise.
Dr. Poole is a published medical author, and has given numerous talks on a wide range of topics at regional and local society meetings. Teaching medical students and residents continues to be one of his strong areas of interest.
Dr. Poole has privileges at East Jefferson General Hospital, the Medical Center of Louisiana, and Children’s Hospital of New Orleans.Dr. Jeffrey Poole is a member of several esteemed medical professional organizations. Local organizations include the Greater New Orleans Pediatric Society and the Louisiana Dermatologic Society, for which he previously served as President.
Education & Training
Dr. Jeffrey Poole received his undergraduate education from the University of Virginia. He earned his medical degree (MD) from Tulane University School of Medicine, while on a full scholarship from the United States Air Force.
Following medical school, Dr. Poole completed an internship and residency in Pediatrics at Keesler AFB Regional Medical Center. His tour of duty included being stationed at Charleston AFB, South Carolina, where he was Chief of Pediatrics for 2 years. Dr. Poole then performed a residency in Dermatology at the LSU School of Medicine in New Orleans, during which he was selected to be Chief Resident. He has attained the highest level of accreditation in his specialty, being board-certified by the American Board of Dermatology.
111 Veterans Boulevard, Suite 406,
Metairie, Louisiana, 70005