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Take Responsibility for Your Own...
The 19 year old sophomore sat on the exam table looking at the floor. A college student with obvious charm and kindness, she appeared withdrawn and shy. Covering her face were pustules , redness, and several cysts. Her mother was in tears fearing her child could not continue college because of depression concerning her appearance. They had been to a “doctor”, at a dermatologist’s office for the past 6 weeks and after taking several ineffective oral antibiotics and 6 different topical medications; having spent hundreds of dollars this family could ill afford to lose; after having hopes for a resolution dashed by failure to respond; her “doctor” recommended Acutane – a drug known to cause depression in students. This is to ignore also the potential for injury to eyes, liver, and cholesterol. A drug that causes depression is being recommended for a depressed college student. I looked at the different medicines and out of curiosity, if nothing else, gazed at the prescribing doctor’s name on the bottle. The doctor was a name unfamiliar to me with the suffix “PA” after her name. “PA: Physician Assistant”. The child was not being treated by a doctor but by a “doctor” i.e. “PA”. The doctor was a dermatologist who saw the patient once and referred her to his employee “doctor” with a diploma as a “PA” and this “doctor” with 2 years of education diagnosing everything from brain tumors to acne was going to give a depressed student a drug that might induce depression! A 65 year old female patient had progressive shortness of breath and acute anxiety. She and her husband went to a University affiliated hospital emergency room where the doctor noted no evidence of heart disease and omitted a chest Xray or scan. He sent her home for a cardiac stress test. Her primary care physician, noting the absence of cardiac symptoms ordered a chest scan and found a pulmonary embolism. The patient survived and will never trust an emergency room doctor again. A patient saw an advertisement for a new form of ultrasound to reduce fat in her abdomen. She called our office and told the receptionist, “Don’t give me smartlipo or slim lipo, or cool lipo. I don’t want Velashape or Zeltique or Zerona. I just want the new ultrasound so if you don’t have it I will go somewhere else.” The patient never considered the value of examination or diagnosis. Noted physician experts in plastic surgery and dermatology have published their opinion that the often promoted “stem cell face lift” is at this time hyperbole and does not exist as a separate procedure. Nevertheless, judging from its popularity in the lay and medical press, many patients seek this “new break-through”. From seeking help for disease to addressing cosmetic concerns, many patients fail to follow minimal procedures for assuring responsible care for themselves and their loved ones. As examples: • Interview physicians when there is time. • Look at before and after results • Check physician credentials at least using Google and hospital references • Seek second opinions when care does not appear effective or when an elective medical/surgical path is recommended • Use resources like Mayo Clinic and John’s Hopkins websites • Maintain objectivity It is nice to remember 50 years ago when a physician sat at your side and held your hand. Today we have much better diagnostic and therapeutic aides with which to intervene; but… they will only be available for those who take responsibility for their own care.
By Edward Lack on 2011.06.23
U.S. vs. Europe: Health Care
As I have tried to make abundantly clear the United States is the only country in the industrialized world that does not provide universal health care for its citizens. We have preferred crisis management to preventive medicine and we use emergency rooms of hospitals as triage units and primary care offices for the poor. In my judgment the reason for the lack of consensus on the need for universal coverage is the self centered attitude of patients. They want what they want and they want it now! Anecdotally this is nowhere more evident than the selfish and immature attitude of senior citizens. Two vignettes, please. I asked 10 female senior citizens a hypothetical question. Your husband needs a liver or he will die. A 4 year old child needs a liver or he will die. Only one liver is available. To whom will you reward the liver? In all cases the women chose to give the liver to a husband in his waning years rather than a child with the potential for a full life ahead of him. A male senior citizen came to my office complaining of a benign growth on his face which he requested be removed. I told him I would comply but that since removal was not medically necessary the procedure would be considered cosmetic and he would have to pay for his care out of his own pocket. He responded with some anger saying that several years ago he had a similar growth and the dermatologist down the block charged Medicare. I explained that the doctor probably falsified the diagnosis to justify the procedure and questioned if his physician would lie to the government was he comfortable that the physician would not lie to him. He was not assuaged. So we are in a deadlock where voters want everything for themselves and do not want to pay for it. At least they do not want to pay so that someone else can get care. Another problem: State after state has voted down itemizing basic health care; that is, listing diagnoses that would be covered for all Americans. The presumed worry is what if my diagnosis is not on the list? This is the same sentiment that prevents tort reform in medicine. What if I have a medical injury? I want to collect the big bonanza too! The conundrum: Technologically health care in the U.S. is superior to any in the world. The last vignette: My wife’s was back in Sweden a few years ago and had a physical check-up. I advised her to request a routine colonoscopy. The doctor denied the request advising that the Swedish health care system only provides colonoscopy for patients who are bleeding. My wife had her colonoscopy paid for by our health insurance in the United States. Three years ago my wife’s best friend moved from Sweden to France. This year her French physician insisted she receive a routine colonoscopy. Her friend was found to have colon cancer! We believe successful surgery followed. Conclusion: The health care system in the United States is technologically superior for those who can afford the system and know how to access care. The health care system in the United States in inequitable and even if you can afford it most patients have no idea how to evaluate care. The social care system in Europe is often inferior and inadequate given the knowledge we possess today. One would think it would be possible to merge the advantages of each. Health care in the United States is schizophrenic; we have the best quality and poor distribution. Those of us on Medicare don’t have to worry. The politicians are too scared of us to change the system.
By Edward Lack on 2011.06.07
Fat Returns After Liposuction ......
A study appeared in a journal titled “Obesity” which was reported by a group from the University of Colorado. In a nutshell the study used sophisticated techniques to prove a doubtful if not unsubstantiated conclusion. More than 100 years ago Mark Twain wrote (quotations are used despite my paraphrasing) “There are three kinds of lies in the world. There are lies. There are worse lies. And then there are statistics.” I read the article and noted a number of background and design errors in the study and I would have forgotten about it except that a reporter called me for an interview regarding the study. The reporter told me that the article had been picked up and circulated by the press and was being taken seriously in the lay literature (magazines and newspapers). Now it is one thing for educated investigators to report their findings and argue their conclusions; it is quite another to publish these findings in the lay press where inadequacies and inconsistencies are taken for truths by unsophisticated readers. So... here goes: my analysis of the data. First, the study was done on patients with “small volume liposuction”; a group which has previously been shown to have little metabolic changes after liposuction. Second, studies in which metabolic changes have been demonstrated are numerous in the diabetes literature and demonstrate at the least changes in insulin resistance and blood sugar. Much more important is the authors’ conclusion that there is a homeostasis in the human body which compels the body to hold a fixed amount of fat so if you take some away it naturally comes back. How many of us have lost weight on a diet. How many of us have gained it back? How many of us complained that we went off our diet and the fat came back. Do any of us think this happened by serendipity? How many overweight patients do you know that gained weight after losing it and were not eating more. Lastly, fat is deposited according to hormone receptors that are present on adipocytes (fat cells).. Females in pubertal years deposit fat on hips, thighs, and buttocks; in reproductive years on hips and abdomen; in pre-menopausal years on arms , shoulders, breasts. You don’t have to believe me. Ask anyone who has been there. So when these investigators found increased fat in the abdomen a year after liposuction, I am not sure what they were thinking. Twenty years ago cosmetic surgeons felt that women increased breast size after liposuction and you would not believe how many men came to my office in support of their wives having a liposuction procedure. Five years later we found it was not true and in my practice only 15% of female patients developed larger breasts. Yet the myth goes on. Now women who gain weight after liposuction will blame the liposuction and the self sustaining prophesy will continue. Fat returns after low volume liposuction ? … NOT!
By Edward Lack on 2011.05.26
Stem Cell Facelift Continues to...
The Stem Cell hype just won't go away. I don't know if this is Western culture or United States culture, but the continuous promotion of tenuous concepts for commercial gain is downright boring if not pathetic. While relatively few physicians spend their time evangelizing specious concepts for their own gain, a few individuals tweak the monetary imaginations enough to produce headlines and patient queries. How many times must we say, "The emperor is wearing no clothes?" How many times do we have to listen to the cacophony (notice the root word phony in cacophony) of a Donald Trump or a Sara Palin before rational people call them to task and stop the insanity? No one questions that stem cells exist. No one questions that they are pleuri-potential cells capable of regenerating virtually every cell in the body. No one questions the usefulness they might have in fighting disease like heart injuries, spinal cord injuries, perhaps even cancer. However, the time is not now. Stem cells are a subject of research and development, and entrepreneurs who claim to make machines that remove stem cells from tissue have no more idea of how to use them in a way that satisfies the rigors of evidence based medicine than I do of applying quantum physics. It may be fun to read. I ain't going anywhere with it. And so I was disconcerted to see the cover of Surge magazine, a publication of the American Academy of Cosmetic Surgery, title the lead article "Stem Cells, Where are we headed in 2011?" To their credit there is plenty of caution in the article such as "Others (physicians) have made claims that they've used stem cells to fortify fat for facial grafting as well as other areas"; and "The FDA … will likely be looking at the way doctors conduct their handling of adipose-derived stem cells"; and "Nonetheless, it will all happen in a clinic near you if not in your own office". I do, however, question the effect of the article in an age of instant messaging as codifying the validity of advertisements promoting stem cell face lifts and stem cell breast augmentation. Injecting fat into breasts and face has changed little in the past 20 years and adding stem cells is similar to arguing whether adding salt to (already salted) chicken soup makes it better. As the promotions continue and medical societies are intimidated into validating the possibilities of unproven claims the only admonition that seems appropriate is “buyer beware”.
By Edward Lack on 2011.05.01
Cancer Risk in Men Treating...
A review of the literature In the Journal of Drugs in Dermatology reveals a risk for increased incidence of breast cancer in men treating hair loss with systemic drugs (specifically Propecia). A short history lesson is in order. Somewhere in the bible vaguely residing in the poorly recalled parts of my memory there was a fellow named Samson, whose strength (and by extension his virility) were embodied in the length of his considerable scalp hair. When Delilah (metaphorically depicting the ubiquitous power clashes between men and women) cut off his hair, he was left powerless and the rest of the story recounting his revenge is probably known to you. Suffice it to say, only when he was able to re-grow his hair could he again assert himself as a man. As history recounts, men ever-after have considered scalp hair a sign of their manhood and by extension virility, ignoring its other implications of boyishness and perhaps immaturity. Women have likewise accepted scalp hair as a sign of feminine attractiveness, power, and sensuality. In 2001 the United States Food and Drug Administration approved dutasteride for treatment of benign prostatic hypertrophy. It is a 5-alpha reductase inhibitor that blocks the conversion of testosterone to dihydrotestosterone , the active hormone which is significantly responsible for both benign prostatic hypertrophy and male pattern baldness. Subsequent research and development produced finasteride, known by its brand name propecia, for the treatment of male pattern baldness. Both drugs have been shown effectiveness in treating male pattern hair loss, arresting hair loss in most males and restoring some hair growth in some. Except for a small percentage of men who experience some sexual dysfunction (which appears readily reversible with Viagra and Cialis) there have been few problems with the drug. That said, it has now been reported that the United Kingdom’s Medicines and Health Care Products Regulatory Agency published a warning in 2009 regarding the risk of males developing breast cancer after use of dutasteride or finasteride. In two separate studies the incidence of breast cancer in men was reported as up to 100 times greater than normal. While that is not a lot of cases (the normal incidence of breast cancer in men is 1 in 100,000) it is still of significance (1 in 1,000) if you are one of the men who develops breast cancer. It would appear that further studies are warranted and will follow. At the least dermatologists will have to inform patients taking finasteride that there is a small but possibly significant risk of developing breast cancer because of the drug, and breast exams will have to be part of the follow-up of such patients. Aside from the obvious cautions for this drug, we are again faced with the paradigm that there is simply no such thing as a free lunch. Or to quote a satirist of the 1960’s, Tom Lehrer, “Life is like a sewer. What you get out of it depends on what you put into it.”
By Edward Lack on 2011.03.21
Vulvodynia- New Concepts
On television and in the movies they may note: the following may be considered graphic. Use parental discretion before viewing. I wonder in this graphic internet world whom they are addressing.So- fair warning to all. If discussing skin problems of genitalia or sexual problems is too graphic for you, parental discretion is advised (I am thinking I have not seen these warnings on the Cialis and Viagra commercials; and isn’t there a commercial for feminine hygiene?) Vulvodynia- painful vulva. This entity has now been anointed legitimate by the medical media but is still in early stages of understanding. The National Vulvodynia Assoc has done much good in educating the public and physicians but it seems to have a schizophrenic philosophy on what constitutes vulvodynia. When I wrote the association an article summarizing the dermatologic causes of vulvodynia they rejected publishing saying that vulvodynia is a state of painful vulvae with no discernable cause. That doesn’t give the millions of women who suffer from this painful disease any solace. According to these experts you can only have a disease if it has no cause, but let’s talk about what we don’t know and maybe we can help you. (In Catch 22 only pilots who were insane could be excused from flying war missions yet any pilot who asked for such an excuse clearly was sane so all pilots had to fly.) Ignoring my disagreement with this association, vulvodynia is a serious disease with only a handful of gynecologists, dermatologists, pathologists, and physical therapists interested in diagnosing and treating these disorders. (I have excluded pain doctors as their expertise generally does not include diagnosis). As this is a disease of the vulva it is not a disease of the vagina but severely limits sexual activity because of the pain it produces. In addition, there are signs of skin disorders that impact this disease. I want to emphasize new findings which show the following: an increase in the presence of pain fibers in the vulva of these patients; a history in some of these patients of birth control pill usage with low estrogen and and anti-androgen activity. Since the vulvae contain a plethora of testosterone receptors and many estrogen receptors the use of such pills may predispose the skin to being susceptible to trauma (as in sexual activity). In later years the deprivation of male hormone stimulation to hormone receptors in the vulva may decrease sexual drive. Lastly, chronic pain leads to contraction of pelvic floor muscles which increases pain with sexual activity. The demonstration of pain fibers in the vulvae and the coincidence of testosterone receptors in the same area coupled in some patients with a history of testosterone deprivation courtesy of some birth control pills are relatively new findings. MetropolitanMD is one of the few dermatologic treatment centers for vulvodynia though many gynecologists grapple with this on a daily basis. After a complete history and physical exam, a biopsy may be needed to rule out certain skin diseases. Then a careful and arduous path of experienced trial and error must begin much as a chef must add and subtract from his recipe to make a dish effective. Given new knowledge the use of topical testosterone and estrogen may be advised in some cases and birth control pills without anti-androgens may be preferred for young women except those suffering from severe acne.
By Edward Lack on 2011.03.10
Acne Therapy in the 21st...
I recently attended the annual Southbeach Symposium which functions somewhat as the premier meeting of dermatology experts in the field of cosmetic dermatology, especially as it relates to lasers and physical therapies of the skin. Under the direction of Dr Mark Nestor this course has been the gold standard for the past 9 years providing objective scientific data on the validity of concepts and devices. Many topics were covered including acne, rosacea, the aging face and body, botox, fillers, and even pediatric dermatology, eczema, and psoriasis. Acne was given a lot of attention as it deals with those most concerned with self image: the adolescents- and then everyone else who uses a mirror. Significantly, mirrors always lie as noted in the Snow White parable of the evil stepmother who asked the mirror each day who was fairest in the land. She might as well have asked who is the ugliest in the land as the mirror always reflects what the viewer wishes to hear (see). For 2011 there is general consensus that antibiotics are almost the last drug of choice for acne because of potential side effects chiefly concerning development of microbial resistance. (A study more than 50 years ago demonstrated that 70% of adolescents could clear their skin with topical agents available at that time and it has taken a half century to incorporate this knowledge into our treatment protocols.) Our chief strategies now involve topical agents which increase cell turnover; topical agents to degrease in the skin; topical agents to reduce inflammation; and light energy systems to reduce bacteria and the size of oil glands. Almost 90% of patients with acne can be treated in this manner. Photodynamic therapy, in which a chemical, aminolevulinic acid, can be applied to the skin followed by stimulation with lasers or other light based devises, was lauded by all as almost always effective and a viable alternative to Acutane, which works reasonably well in severe acne but entails numerous side effects which can be severe if not controversial. Perhaps more controversial are the newer low-strength estrogen birth control pills with anti-androgens which are used to reduce premenstrual flare ups of acne. While these agents reduce acne they also potentially reduce testosterone as well as estrogen stimulation to female genitalia which may have long-term consequences for genital skin integrity and subsequent sexual arousal. While I think I speak for most fathers in lauding anything that reduces sexual proclivity in our daughters and while most adolescent girls would rather have a clear face than be sexually active, this is not true for adult women; especially those premenopausal females who may feel they are being cheated by choosing between a clear complexion and a more satisfying sex life- which reminds me of one of Woody Allen’s parables of a Jewish woman complaining of her recent vacation in the Catskills “Acch, the food was so bad… and the portions were so small!” Thus there is concern regarding the long term effects of taking anti-androgens which I will discuss in another blog. The take-away from this review of acne therapy is that most patients get excellent results with topical agents; some need light (laser) therapy; antibiotics are the last drug of choice; and Acutane remains good and bad depending on the eyes of the beholder.
By Edward Lack on 2011.02.28
Winter and Dry Skin
It’s cold out and my car is snowed in. The sun is shining and the snow is pure white, a sign of innocence and peace. If I don’t turn on my TV I can believe that this is the state of the world. Regardless it is a time to commune with nature and to free associate. When you are a dermatologist and you free associate you might wander to thoughts of the effects of cold temperatures and skin. Studies on ultraviolet light reveal that with decreasing humidity or increasing temperatures or increasing wind the damaging effects of UV light are increased. Conversely in the winter the dehydrating effects of cold which produce damage we complain of as dry skin are worsened by colder temperatures, decreasing humidity, and higher wind. Inside our homes the effects of low humidity persist as the air is heated and expands and the amount of moisture in the air must be spread over a larger area causing the relative humidity within our homes to decrease. Similarly, humidifiers attached to the furnace are subject to expanding air so the amount of moisture in the air also drops as it leaves the humidifier. Ultimately there are two options to humidify your home: install a hot water heater humidifier or (for most of us) purchase a 1 gallon cold water ultrasonic humidifier that can be run in the bedroom while you sleep. The skin itself has interesting defenses against drying as it reconstructs fatty substances that the skin requires to preserve its water content. As the skin dries it manufactures more of these substances until a point is reached where it can no longer keep up and at that point the skin stops creating oily protection and agrees to accept its withered fate. To make its demise even worse, in the Western culture we have a love affair with soap that serves to dehydrate the skin more. Of course many use moisturizing soaps, an oxymoron if I ever heard one, and continue to dry out in the delusion that they have protected themselves. The ideal regimen may be to use shower gel formulations on the skin to protect its outer layers and then apply a moisturizing cream (as opposed to a lotion) while the skin is still damp. Combined with elevated levels of humidity this will minimize the drying effects of winter. Now I leave for a brisk walk in the cold air. The sun is out, the snow still white, the air crisp. More time for free associating.
By Edward Lack on 2011.02.04
Who Do You Trust
Who do you trust? Sounds like a great title for a game show or a self-help book. Maybe I will use it someday. Do you trust your broker or financial adviser? Does your 401K self regenerate? Do you trust your banker? Does the bailout of Citigroup and Bank of America resonate? Do you trust a lawyer….? Excuse the pause. I was choking. Do you, can you, trust anyone anymore? Do you trust your doctor? Today, I am thinking about how to make a decision when a cosmetic surgeon recommends a procedure to improve appearance. Today pediatricians, family docs, gynecologists, dermatologists, facial plastic surgeons, plastic surgeons, dentists, and your hair dresser perform cosmetic procedures and speak with conviction and authority. So you will forgive my cynicism in discounting the vast majority of advice let alone my view of the competence of the vast majority of part-time practitioners of cosmetic surgery. But then I am still left with a significant number of well qualified cosmetic surgeons who differ in their adv ice for a patient. Sometimes the advice is well intentioned, sometimes the advice is self aggrandizing, and sometimes the advice is personally colored. So what is a patient to do? The answer must be to look at the aging process. Good nutrition, good sleep habits, and healthy exercise are the most effective deterrents of aging. After that, everything is an attempt to minimize and camouflage the aging face and the aging body. The face consists of various tissues and each has characteristic changes that can be addressed. Skin is subject to sun damage which damages elastic tissue and collagen and causes DNA damage. We see this as static wrinkles, rough skin texture, pigment changes, enlarged pores, and texture deficiencies. If there were a secret cream, a secret anti-oxidant, a secret serum wouldn’t everyone be using it??? Subcutaneous fat and muscle wither with age and cause the skin to sag, the face to narrow, and hollows to appear in the temples, sides of the cheeks, and around the mouth. Bones also reduce in mass and cause the surrounding tissue to sag, the teeth to move inward, the lips to thin and grow long? (Disclaimer- Any impression that this describes anyone I know is purely coincidence!) So, let’s use a little logic. If the face is collapsed and narrowed and the skin is hanging will a facelift do anything but create another Beattle-juice character? If the cheeks have sagged and involuted and the temples are hollow will 1-2 cc (up to 0.4 teaspoon full) of Restylane solve the problem? If a doctor tells a patient she will have to redo a treatment every 3-6 months did the treatment do anything well applied make-up would not achieve? There really are some answers to these problems but every day I see patients who have been treated by experts who believe one size fits all and either all their patients should be cut or none of their patients should be cut (depending on their training). I will try to address specific problems in coming blogs. In the meantime ask questions, read, and get multiple opinions. Most of all, live healthy.
By Edward Lack on 2011.01.25
Eat for Nutrition and Pleasure
Liposuction is the most popular cosmetic surgical procedure performed in the United States. Liposuction, often termed liposculpture , can be used to enhance body shape. It is not a weight loss procedure. Obesity may be the single greatest problem in the United States. In the future, with young people becoming obese at ever increasing rates it will be the single greatest health problem that we face. What may not seem like a paradox, is! That is, people have increasing weight with disproportionate body shapes and it would seem logical that removing fat would be an appropriate antidote. Here comes the paradox. I have often said that a person who enjoys food can enjoy life, and one who does not is doomed to deprivation. Of course, I did not say eat to excess. Yet, there are some truths that need to be addressed to understand how food contributes to our welfare and how it may detract. First, food is necessary for survival. I will let it go at that. Second, we have 5 given senses: sight, sound, smell, taste, and hearing. All except sound is involved in eating and even that can be argued to have a role. To deprive the senses is to reduce the experience of life. Third, quality of life is significantly impacted by each of us surrendering to sensuous pleasures (in a non-injurious manner) and I do not know of anything more sensuous than the pleasures of eating. Withhold from enjoying the lustfulness of eating and you must withhold all pleasures of sensuality. Age is a determinant of how and what we eat. Hormonal changes in the maturing body make men out of women and women out of men. The older one is, the more amorphous body shape becomes. Accompanying physical sexual indeterminism is a desirable increase in weight which is necessary to project a youthful appearance. As experience matures our senses, there is an opportunity to develop gustatory appreciation rarely possible in the young. Caviar and champagne anyone? Antithetically, a reluctance to evolve and enjoy eating because of fear of weight gain accomplishes the opposite of the desired outcome. Old people who are thin look older. Lastly, many in American society eat too much and get little pleasure from their experience. Oversimplified, these people are trying to fill an emotional hole and much like Sisyphus they are doomed to roll the stone up the hill only to see it roll down again in an endless sequence that defines their lives. It is beyond this discussion to lecture on the merits of intelligent eating and exercise. Rather, I choose to emphasize the following: Eating is as essential to emotional well being as it is to physical survival. Eating may be the single greatest pleasure of life from which all other pleasures derive. Gaining weight in moderation is healthy and not gaining weight is a sign of impaired health. For those who choose, liposculpture is an excellent enhancement which may diminish the gender changes of age and weight gain; it is never a solution for weight loss or a substitute for intelligent eating and exercise. Whether to eat to live or to live to eat is not the question. To comfortably indulge one’s senses to promote emotional well being, is. 
By Edward Lack on 2011.01.16
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U.S. vs. Europe: Health Care

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Fat Returns After Liposuction ...

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