Dan
Welcome, Dr. Goodheart.
Could you tell me a little bit about your background?

Dr. Goodheart
I’m a dermatologist. Just to let your audience know, dermatologists are doctors that take care of the skin. And we take care of disorders anywhere from acne to skin cancers but we also care for hair and nails as well.

Dan
A question that I have is when you’re teaching dermatology or when a student is learning to become a dermatologist, how much time do they spend learning about acne versus skin cancer or other skin diseases?

Dr. Goodheart
Not enough, frankly. There’s a real paucity of education when it comes … because acne is a very complicated disease, believe it or not … or skin condition … I don’t know if you would call it a disease but for some people it is because it can be devastating. I think there’s a real need for more teaching of how to deal with acne, especially on the psychological level.

Dan
If you had to boil down your best advice into three points what would they be?

Dr. Goodheart
As far as advice, one of the things I tell most of my patients when their acne is relatively mild: I think the best product they can use is benzoyl peroxide. I think that’s a given. I think we all know that. All dermatologists know that. The other thing is: I try to control acne, if possible, with topical therapy alone, and try to avoid systemic medications. The third thing is: just make them feel better about themselves.

Dan
Where do you see research going in the future?

Dr. Goodheart
Right now, there’s this whole tendency to look for alternatives to oral antibiotics, and even accutane if possible. We’re looking into light therapy: be it laser, or pulse dye laser, or different types of light therapy. So far the results are mixed, at best, and I’m not that enthusiastic about it, yet. Until we find the right laser, the right type of light to deliver, it becomes very expensive, people have to come back for many, many visits, and it’s not covered by insurance for the most part. So very few people are really doing this unless they have no other alternative or could afford it.

Dan
What I hope to do with Acne.org is to gather the information and the intelligence of the medical community and the general population and … I’d like to get rid of acne … I was hoping to hear from you that research is so promising and there’s things right around the corner.

Dr. Goodheart
There’s wonderful research. We have wonderful research organizations within dermatology: something called the Leader’s Society, the Dermatology Foundation … a lot of money is being poured into that for research … just like we have the Psoriasis Foundation … there is a lot of research and there’s some wonderful experts on acne who are out there really doing a lot of work and a lot of clinical trials … quite a bit of hope.

Dr. Goodheart’s web site

Q: Why did you become a physician?
A: My father was an orthopedic surgeon and my grandfather was in radiology. I spent time growing up with my father’s best friend who was a plastic surgeon and got exposed to the field and saw it as an avenue that appealed to me because plastic surgery has a wide variety of treatment modalities.

Q: If someone has acne scarring, what doctor should they go to a dermatologist or a plastic surgeon?
A: Either one. It varies from city to city. In some cities the dermatologists stay strictly medical and in some cities the dermatologists have gotten into the cosmetic aspect. Now it seems that most dermatologists are doing a lot of surgical procedures. But with acne scarring the technologies are more commonly utilized in the cosmetic fields. I was a personal sufferer of acne in the 1960s and treatments were limited. It affected me deeply. As a personal sufferer and now as a physician and as a sufferer I try to be very honest with patients. What happens is emotional scars go hand in hand with the physical scars - I totally get it. We as humans are seeking solutions, and oftentimes patients are disappointed that there is no fast or clear-cut solution. I am the first to admit we can only improve acne scars and not remove them–it is the nature of the beast. Prevention is so important. There are many things that I have not performed on myself that are out there because I look at the risk/reward outcome and with my olive skin tone it is hard to treat. I think as we get a little older, and as we mature, we realize that we all have scars, emotionally or physically. Do I still have acne scars? Yes, I do what I can to minimize it the best I can. People want the facts, the realistic facts, and I treat my patients from a deep understanding of the physical and emotional scars. I think one of the values of Acne.org is that it allows people to realize they are not alone.

Q: What can people do for acne scars?
A: We do not have the technology to eliminate scarring but we are working towards it. Acne scarring is deep in the skin. Acne scars are depressed because the scars are so deep and that is the challenge. Some companies in Europe are coming out with new fillers that may minimize scars - I look forward to this development. I am a huge believer in dietary modification. There is truth in this–not necessarily in chocolate causing acne et cetera but there is some truth in non-inflammatory diets. Omega-3 and Omega-6 in our diets have a big effect. Studies on acne in way out there places such as New Guinea showed that teenagers had very little acne and as soon as the Western diet moved there the teenagers broke out. We will see a lot more of this as time goes on throughout the world. Acne scaring in patients is only going to grow because of the Western diet. What we see now is just a fraction.

Q: Have you seen people with long term results with dietary changes?
A: Human nature is that we do not stay on it. The key to success is to stay on a diet long term, especially a non-inflammatory diet such as the glycemic index diet. You are only as bad as your last meal and only as good as your next one. Just get on target. Even if you cannot do it exactly, at least try to get closer to a non-inflammatory diet and understand that the closer you are the less damage the potential can be.

Q: Are vitamins / supplements a source good for anti-inflammation?
A: Some great supplements include things like red wine extract, pine bark extract, the Omegas, and vitamin E as a mixed tocopherol, and zinc gluconate. The issue is our genes are set up so that we have nutritional triggers. If you do not have this susceptibility to respond to supplements it won’t work. Nutritional supplements are safe and not that expensive. It has to be trial and error. There is no silver bullet.

Q: Dan recommends Omega-3’s and zinc.
A: Yes, this is solid science. Omega-3 and zinc helps over 80% of people. Topical things like skin toners actually dry the skin and create a bigger problem. It is a matter of balance. It is better to get what you need from food sources if possible. So much of the fish is toxic so I would go with the pills for the Omegas. Stay with a good brand / company but my preference is to get it through food. And I treat acne as a diseased state so you need to take more than the minimal requirement on the label. 1000mg of DHA and EPA is a good idea. Acne patients need to take bigger doses.

Q: How do you treat active acne? If a patient comes into your office,
what is the experience like?
A: Typically the patient will be treated by medication which will make your acne out of control for a little while. The purpose of that with Tazorac and Retin-A is to purge the skin as much as you can to clean it.

Q: What if a patient comes to you with acne scarring?
A: We will meet and see if the patient will benefit from punch excision, subcision, or resurfacing. I would also create a maintenance program often including cleaning facials and microdermabrasion to maintain the skin’s health. Surgical options exist but as a surgeon we are very seriously limited. As we age the skin loosens and the acne scars tend to look worse. As you age it may look like the scars came back because the skin’s tightness is gone. Acne scar maintenance is a lifetime commitment. This is something people need to know.

Q: Are a combination of procedures necessary?
A: I’d say 50% of the time. Ice-pick scars will not be improved by resurfacing. We excise those. I will do subcisions if there are deep scars. Lasers can help too depending on the case. One good thing about resurfacing is that an acne patient heals faster than a wrinkle patient because by definition we have more oil in the skin.

Q: What about microdermabrasion?
A: It is minimally effective because it is very superficial but it is very good for maintaining skin health.

Q: And dermabrasion?
A: I’ve used it but I think there is more control with a laser. Dermabrasion has too many variables with the spinning diamonds, et cetera. There could be operator error. The face is curved. If it were flat it would work better. Lasers create heat which creates collagen contraction.

Q: Fillers?
A: I use fillers sometimes. It is an option. Long term fillers can have long term good and long term bad results. Long term bad could include lumps. Sometimes the patient may need to have the material cut out. Also understand injecting acne scars is difficult because the area itself is hard. What is more effective is subcision with a filler. However, all treatments have to be customized.

Q: What is recovery like?
A: Most patients with a deep acne treatment who elect laser resurfacing are looking at a 2 week downtime with pinkness up to 4-6 weeks. They often need to repeat this about once per year. Lighter treatments (nonablative) have less downtime but require more frequent procedures.

Q: In your opinion which is the best ablative laser.
A: CO2.

Q: And the best nonablative?
A: I don’t think they work.

Q: What about silicon microdroplets?
A: They are illegal in many states. I think they’re dangerous. They can migrate and can be hard to get in the right place. They can sometimes all become a big ball.

Q: What about topical?
A: Nothing works for acne scars.

Q: Do peels work for scars?
A: They’re good for controlling the skin but not even a TCA peel will do much for scarring. Chemical peels do not have a great safety margin.

Q: What about Fraxel?
A: The problem is that it is ablative, painful, and if you think about it you are only treating a fraction of the problem. If Fraxel is so good, then why did they come out with a newer version?

Q: What is the typical cost for procedure?
A: You can expect $25-75 per subscision, $25-100 for each punch excision, $3500-4500 for aggressive resurfacing (once a year). Then there is the cost of the products and ongoing maintenance. I would say someone would need to budget $500-750 per month long term.

Member questions:

Q: What is his opinion on fillers and what type of scars will they work on best?
A: I often perform subcision first so the scar is not tethered. I usually use Juvederm Ultra and/or Perlane.

Q: What exactly are redmarks? I heard they were hyperpigmentation or they are damaged blood vessels. So which is it? I also have had the same redmarks for about a year and there is no sign of fading. Is this normal? What is the best treatment for the red marks.
A: Redness is from broken blood vessels, and thin skin. Try to let the body do its magic and heal on its own. I would perhaps add squalane oil, and Omega-3s to the diet. Also when you’re handling your skin make sure to pat dry and not use irritating products.

Q: question, about fraxel: 1st: it works better on what kind of scars?
2nd: so far, how much improvement have they noticed between
fraxel 1 to the fraxel 2? 3rd: on average, how much improvement do doctors see with fraxel
2 on the patients? 4th: is fraxel the best treatment for acne scars on the market now? thanks, as i will be considering this treatment when i am done with accutane.
A: Fraxel is best for shallow rolling soft shoulder scars. (see full interview for more on Fraxel)

Q: 1) Why is it that TCA cross is not a common procedure for scar treatments among doctors today? 2) What is the longest lasting filler on the market; any news on the potential fillers in the future?
A: The TCA cross does not work very well. The longest filler on the market is probably radius right now. A new filler coming out is called artifill. But be cautioned that depressed scars will need to be released first before filler is injected.

Q: I’d like to ask him if sea water is any effective on red marks?
A: I don’t think you’ll notice a huge difference. Some things that may help a bit are squalane, topicals that contain copper, and vitamin C orally.

Q: is the co2 ultrapulsed laser the best treatment for acne scars?
A: The pixilated CO2 is good. However, other CO2s are comparable. This is not the only one. Pulsed computerized is probably the standard of care as of now. Keep in mind that I don’t think any laser is perfect.

Q: Is there any deep research being done on controlling/slowing down/curing hyperactive sebaceous glands? I’m talking for those of us who become an oil slick minutes after a thorough washing, even with so called oil control cleansers.

Perhaps the medical industry has something now available I’m not aware of
A: Blue light and IPL may help to a mild extent. Accutane obviously can shrink oil glands significantly and permanently. Jojoba and emu oil can also help control oil.

Q: Do you see potential for substantially better treatment of scars in any current developing science / technology (stem cell, recell, laser etc) ? Which appears most promising and how soon do you think it will be available?
A: Hopefully within the next two years we’ll see some strides. I do think we’ll see a huge difference in the future. For instance, tumor necrosis factor is interesting.

Q: A lot of questions here are for serious problems. I am curious what Dr. Garcia recommends for mild acne and how to treat/maintain this with over the counter products.

Also, when having used to much of a topical, skin can flare up with red spots and irritation. are there some recommendations on how to repair your skin before using the topical again? I ask this because I think irritation may be something that sustains my acne….on the other hand, completely stopping with medication is also not acceptable.
A: For mild acne I would recommend a mild facial cleanser, Omega-3s, a low glycemic diet, retinols, microdermabrasion for some people, IPLs. Eliminate aggravating factors if and when possible.

Q: What OTC product is best for little red marks?
A: Squalane oil, emu oil, jojoba oil, and even just regular extra virgin olive oil can help a bit.

Q: When is scar revision / excision the best option for acne scarring?
A: Scar revision can be particularly rewarding when the acne scar is deep and sharply demarcated. Typically we call such scars ice-pick scars. Large depressed scars are also a good candidate for this procedure. Though depressed scars respond well to facial fillers.

Q: Won’t this leave the patient with another scar? Why is this a good option?
A: Great question. It is important to understand what makes some scars more noticeable then others. What people don’t immediately realize is that it is not the scar which is noticeable – it is the shadow of the scar. When the scar is protruding or indented or wide it is more noticeable. The goal with scar revision is to substitute those scars with scars that are a fine line – it is much less noticeable. Additionally, after scar excision if the patient elected for additional treatments such as laser the result is dramatic.

Q: But ice-picks are so small. Would the excision lead to a larger scar?
A: You don’t operate on ice-pick scars that are extraordinarily small. The typical ice-pick that we operate on is from 1 ½ mm - 4 mm. The problems with these scars are that they are so depressed that they cast a shadow and require very heavy make-up to cover. A fine line is easy to cover and, again, is less noticeable.

Q: What are the common types of acne scars that you treat?
A: The most common acne scarring in general is wide and superficial scarring which can cover a broad area of skin and these scars for obvious reason have no direct surgical treatment because the problem lies with a very large surface of skin.

Q: How do you treat those types of scars?
A: Those types of scars are generally treated with resurfacing techniques.
Which means we are not removing the tissue because there is too much of it to be removed, but instead we are trying to polish the surface so it will look smoother and more pleasing. Different technologies have tried to accomplish the same goals. These technologies include CO2 resurfacing, Erbium laser resurfacing, and various other modalities including most recently Fraxel.

Q: These lasers are ablative. What is the down-time with these procedures typically?
A: You are looking at about a week of serious down-time meaning raw potentially painful skin and several weeks of redness. What is unique about newer treatments such as Fraxel is that the down-time is less severe. The question is if the results are sufficient.

Q: With these ablative lasers how much improvement can be expected?
A: It really depends on the case. An experienced doctor can give you a realistic idea of how much you can expect to improve. Damaged and scarred skin can be improved but it can never be truly replaced with healthy unscarred skin. In general these treatments give the acne scarred face a much better appearance.

Q: What about Zplasty or Flap reconstruction?
A: One of the biggest issues that determine how noticeable a scar is on the face is the direction of the scar. When a scar follows the direction of normal skin creases it is much less noticeable then when it goes across the normal grooves and creases of the skin. Operations like Zplasty are designed essentially to alter the direction of the scar.

Q: What is the best procedure for acne scars?
A: Firstly, you should not have active acne when seeking these treatments. Often times with acne scars multiple modalities are required. The best procedure depends on the type of acne scar. Also, with acne scars sunscreen is a must.

For broad based scars (scars you stretch with your skin) you can use Medlite C laser (as well as other non-ablative lasers) and facial fillers. For ice pick scars, the most difficult ones to treat, the best option would be punch excision, or punching and skin grafting. For hypertrophic acne scars (thicker scars) steroid injections are the safest and most effective. Scar bandages including silicon sheets or Kelocote (a silicone gel) are also very effective for keloid scars.

Q: Can you tell me about facial fillers?
A: There are many categories. Facial fillers are a fast painless treatment which gives immediate results with no down-time. Some fillers are designed to last between 4-6 months and those are defined as a short duration filler. These fillers include the collagen based fillers Zyderm and Zyplast which are derived from highly purified bovine tissue and the human based collagen products which include Cosmoderm and Cosmoplast (with these the advantage is you don’t have to be skin tested). Hyaluronic acid fillers last for about 6-9 months ; these fillers include Captique, Hylaform, Restylane, Juvederm, and Perlane. The next category of fillers lasts a year to several years and these include Radiesse and Sculptra. Permanent fillers include Artefill and Silicone.

Q: Which type of acne scarring responds best to facial fillers?
A: Broad-based scars - meaning depressed, atrophic scars.

Q: What are your thoughts on chemical peels?
A: Chemical peels are good for people who have post-inflammatory hyper-pigmentation (just brown marks) and want to get rid of them but it is important to use light acids as stronger acids penetrate deeper and can cause more discoloration.

Q: What about the post red marks from acne?
A: The Genesis Laser and the Cool Glide laser are extremely effective.

Q: What kind of scars would benefit from subcision?
A: The scars that are bound down with deeper scar tissue.

Q: What do you mean?
A: The best way to describe it would be to think of a mattress then think of how the buttons are bound down. Some scars are bound down by scar tissue and need to be released.

Q: What about needeling for bound scars?
A: That does very well and is a very effective inexpensive procedure.

Q: What scars are treated with dermabrasion and does it work?
A: Very effective but requires two weeks of down-time and then redness can persist for months.

Q: Is microdermabrasion effective?
A: Yes, it helps with texture, color (brown discoloration) and makes the skin smoother and helps with the exfoliation. This also helps to increase the effectiveness of the products you use.

Q: What about silicone microdroplets?
A: Very effective for scars. It is most effective when performed every 4-6 weeks and the big advantage is this procedure treats many scars in the same treatment session and tends to be less expensive then facial fillers.

Q: Fraxel laser seems to be the next big thing. Can you tell me about this?
A: The Fraxel laser requires about 5 (if not many more) treatments. The way it works is it takes away about 20% of your skin at each session. The skin is heated and prompts new collagen formation. The big advantage is minimal downtime then other ablative lasers but it requires at lot of patience to see results and it is also very expensive.

Q: What about topicals for scar treatments such as copper peptides, alpha lipoic acid, Mederma, etc?
A: The only topicals that I have ever seen improve a scar include Renova, Retin-A, and Tazorac and silicone sheeting and gels.