Dan
Hi Dr. Cordain this is Dan.

Dr. Cordain
Hi

Dan
Hi there. Thanks for talking to me again, I’ve been looking forward to it.

Dr. Cordain
No problem.

Dan
Thank you so much for your ongoing research into the diet and acne connection. I just can’t wait until we figure out a way to help most people through some sort of holistic method, whether that be diet or supplementation or what have you.

Dr. Cordain
Well I think you’re right Dan. I’ve spoken to many people in the dermatology community around the United States and all over the world and I think it’s high time we get to the bottom of what causes acne and the notion that we’ve stonewalled diet for 30 years on no good rationale or logic or even scientific studies is I think very much recognized now and there is an emerging group of scientists and dermatologists who now believe that diet is not only just a minor part of acne but it is the major underlying environmental factor.

Dan
It makes a lot of common sense, so I’m curious to see what comes out. Could you describe the Paleo Diet, if you had to distill it down into a 30-second bit? How would you describe the Paleo Diet?

Dr. Cordain
It’s real easy. It’s unlimited lean meats, seafood, fish, as much fruits and vegetables as you want to eat. That’s the diet in a nutshell, what you don’t want to eat is processed foods, refined sugars, salts, cereal grains or dairy products.

Dan
Great. So before I launch into my other questions I think it’s important that I present my bias at the top of my interviews.

Dr. Cordain
Absolutely.

Dan
My bias is that I actually tried the Paleo Diet as strictly as I possibly could. I was totally committed. I tried it for about two and a half months, six months to a year ago. I was extremely strict, except I did eat nuts on a daily basis. I had vinegar on my salads almost daily after about a month or so. I started cheating and had vinegar in my salads and I did not always slow-cook everything. I think I may have gone off of it just slightly here and there inadvertently, say if I ate out to a restaurant, I’d get steak and some vegetables and I don’t know if when they cook a steak they put a little sugar in there, I’m not positive. I was as strict as I could possibly be and what happened with me was I felt amazing. I’ve literally never felt better in my life. My energy was even, my emotional state was great, nice and even as well, and I was able to get off my Regimen, my topical anti-acne Regimen, for the first two months or so. I was very excited. I was convinced diet and acne were related and I was ready to tell everyone about it. Then I was posting my success online and there was a user on my message boards who kept saying to me, “The reason that your skin is clear is because you’re losing weight and taking in less calories. You’re going to see that as your weight levels out your skin will go back to how it was.” I didn’t believe him but he was very persistent, and sure enough after about two months–that was the point I stopped losing weight on the diet–my skin started going back to having minor problems. Then there was a period of about a week, week and a half, before Christmas where I just started eating more. I’m not sure why, I think I was just hungrier. And my skin was awful. I had a cyst on my chin, I had probably five or six other pretty bad comedomes on my face. It was the worst my face has been since I can remember, for at least a decade. So I immediately went back on the Regimen at that point. Can you explain why that may have happened to me?

Dr. Cordain
Well you know Dan, we’re at the very beginning of understanding how diet causes acne. We just completed the first clinical trial. There are two epidemiologic studies that were completed by the Harvard Group. As is the case with anything in science that is new, we don’t completely understand the underlying mechanisms and I would be not completely forthright if I did not say that to you. But we have mechanisms that we suspect, and I think you’re absolutely right, when you lose weight and you reduce your calories it immediately improves insulin sensitivity no matter what you’re eating. We believe one of the primary mechanisms that underlie the development of acne is insulin resistance. Why do I say that? I say that because adolescence is a time when virtually all people in the Western World experience some type of acne. Adolescence is a period of natural insulin resistance because insulin resistance is a physiologic state that allows for rapid growth. This is why adolescents become insulin resistant during those growth years, is that it facilitates growth. We believe that tacked on to the typical Western diet, which is a high glycemic low diet, which also exacerbates insulin resistance is one of the major underlying factors and with Neil Mann’s study, he was able to show that insulin resistance is linked to acne. Now, how does insulin resistance in and of itself can cause acne without lying those mechanisms. In a series of scientific papers that I’ve written, we believe that insulin is a master hormone and it causes a cascade of other hormones, which ultimately affect the pilosebaceous unit. The unit that actually causes it, a comedome or zit. I can go into more detail but for your listeners I don’t know if that kind of detail really matters.

Dan
I’m going to link to your website and they’ll be able to find your book and learn about all that stuff. It’s incredibly interesting stuff. I’m hoping to keep this as much as real plain English as possible.

Dr. Cordain
So that’s pretty much what we think is going on. That’s the mechanism. The Harvard Group has identified milk drinking as a liability factor and a number of dermatologists on the East Coast actually do that with teenage acne patients, they just have them stop drinking milk, and a good percentage have complete remission of symptoms or improvement. I have been in contact with Dr. Bill Danby and his group and Balory Traylor, they’re both MD dermatologists and use diet to affect it. They’re also publishing literature and got their own books out on it. We think milk drinking is also involved with acne besides the high glycemic load diet, and we think there are a number of factors in which milk may promote or exacerbate acne symptoms. In addition to getting rid of processed foods, sugary and so forth, we think that milk drinking and dairy products are not a good thing, for a number of reasons. As scientists we speculate what the mechanisms are but it will probably be a decade or more before we find out exactly what’s going on. What we’ve done now is we’ve really raised the bar and we’ve raised the eyebrow of the traditional dermatology community who forever and a decade stonewalled the idea that diet and acne were related. Now we have the first clinical trials showing that indeed a low glycemic load diet improves symptoms. So you’re actually right. There’s an interaction with calories that will take a while for us to figure out with more clinical trials.

Dan
You refer to that one clinical trial. That was one of my questions. How much clinical evidence do we have to back up the diet and acne connection and how conclusive is the evidence at this point?

Dr. Cordain
We have single study that came out of Neil Mann’s laboratory from the Royal Melbourne Institute of Technology. The design of the study was impeccable from the scientific perspective, but it’s a single study and science moves slowly, and one study does not change a discipline, so we need what are called replicate studies and these are in the offing right now. I know a number of groups around the world are in the process of, or have trials currently being conducted. I think that once we have a single trial, like with Neil’s study, then it’s going to promote interest in it. The way to do these studies is with government funding through NIH, National Institute of Health, through the various boards, and we have to get scientists that are interested and then get funding to do the study, because these studies are expensive where we involve humans. And science moves slowly. The Mann Study took two years to complete and another year and a half to two years to get into the scientific literature. So this is why I say it would be probably a decade or decades before the dogma is completely reversed.

Dan
Now you referred to the Harvard Group and a milk connection. Is that a study that the Harvard Group did?

Dr. Cordain
Yes. They published two papers on it and these are what is referred to as epidemiologic papers. The Mann Study was a controlled randomized clinical trial, in which we actually altered the diet of people and used the number of zits or comedomes as the outcome variable. With the Harvard School of Public Health they published their two studies in the epidemiologic literature, and what that is is they look at a large, large groups of people. The Nurses Health Study involves 80,000 women and they look at an association between diet and disease. And what they found, and there are different ways of looking at this, one was looking at a ‘retrospective cohort’, meaning that you look at people backwards in time and then they did a more powerful study called a ‘prospective cohort’, meaning that they follow people over time and they monitor their diet. And in both of these studies what they found was that milk drinking was associated with the development of acne.

Dan
One followup question on the milk studies. In your professional opinion, do you think we’re referring to milk here or any dairy product?

Dr. Cordain
I suspect it’s any dairy product and I suspect there may be degrees of how bad one dairy product affects things. We don’t know what element in milk is causing the association between milk drinking and acne. I was at a conference at Harvard where we talked about this last October. There’s a couple of lines of thought. The first is that there are hormones in milk that actually get past the gut in tact and enter human circulation. This, to my way of thinking, is somewhat unlikely in that most of the gut hormones are broken down by enzymes in the gut. Secondly, these large protein molecules cannot get past the gut barrier. However, there is one exception to this. It’s a hormone in milk called betacellulin. And betacellulin survives the gut enzymes and it also can get into circulation because there is a hormonal receptor in the gut which specifically binds this hormone and draws it into the body. So we believe that there is at least one cow hormone called betacellulin that can get into the circulation. Betacellulin, once it gets into the circulation, can bind other hormonal receptors in the pilosebaceous unit and the function of this hormone is to cause growth. And one of the problems with acne is that there is excessive growth of the cells lining the pilosebaceous unit. So we think that the betacellulin milk may be one of the factors. The other factor that we believe that may be responsible of why milk drinking is associated with acne is that milk paradoxically has a low glycemic index but has a high insulin index, meaning that it doesn’t spike your blood sugar but it makes your blood insulin levels go up. We believe that when blood insulin levels go up it causes this cascade of hormonal effects. It elevates IGF-1 and depresses another hormone called IGF-binding protein-3. And we believe that these hormonal changes cause an increase in the secretion of androgens, male hormones that both women and men secrete, that increase sebum secretion in pilocaebacious unit, which also underlies acne. There’s a variety of factors in milk that scientists suspect may underlie the association of milk drinking in acne. This is why chocolate, forever and a day, has been implicated in acne. When we think about milk chocolate candy, it’s made out of milk solids which contain the same hormones. It’s also made out of sugar which has a high glycemic load. So we believe this is why chocolate may be particularly effective at eliciting acne symptoms.

Dan
Interesting. Getting back to the Paleo Diet again for a moment if we can, I know that a lot of the listeners to this will probably want to try the diet. I noticed that it was incredibly hard for me to stick to the diet, and I was totally committed. You were nice enough to donate about 20-25 of your e-books, and I had a bunch of people on my website try the diet as well. No one really came close to following it as strictly as I did. Do you think it’s really possible for people in the 21st century to follow a caveman-type diet?

Dr. Cordain
Well this is actually how we came to the conclusion that diet and acne were related is that our first study that we published in 2002 were the result of almost a decade worth of research. We went down into very primitive places in the world where the Western culture is absent. We went to an island off the coast of Papua New Guinea called Kitaba and we studied about 3000 people there including almost 300 teenagers and in that entire group of 300 teenagers, we didn’t find a single case of acne, whereas the prevalence of acne in Western teenagers approaches 85-90%. So that kind of tipped us off that it probably is environmental and logically diet in nature. We did another study in which we went down to the jungles of Paraguay and we followed around a group of hunter/gatherers for a two year period, and this was a different approach. This was a longitudinal approach instead of just looking at them in a cross-section. We followed them over a two year period and once again we didn’t find any acne in the entire population. And even though these were two different ends of the world, there were universal characteristics of their diet that kind of stood out for us. One was that they were fairly high in protein and they had virtually no processed foods, and they had a low glycemic load. They obviously didn’t have any dairy products and they didn’t eat any grains either. So, those are the characteristics of the diet that we thought would be helpful and with the Mann study they actually just looked at two elements, the protein and the glycemic load. So to answer your question we’ve kinda been spoiled, the horse is out of the bag. We’ve grown up in the Western world with hamburgers and french fries and pizza and Coke and white bread and donuts and you name it and everything that most of us eat on a daily basis. And you’re absolutely right, I think that it is difficult for people, particularly adolescents and young people to follow this type of a diet. But people that are sick people, the original Paleo Diet wasn’t designed for acne patients, it was designed for people that have serious health problems, cardiovascular disease, type 2 diabetes, morbid obesity, and what we found was that when people are with their back to the wall and the alternative is death or serious illness, following this diet becomes second nature. I think that there is a lead in period that takes people probably six months or longer to be able to do it and during that period they kind of have ups and downs and in both our books we describe the little tricks or methods used to help do this. For some people, going cold turkey works, for others they need to go back and forth. My feeling is that you can get substantial health effects when you’re 85 percent compliant. We also believe that there are different genetic factors that may underlie acne. Your case is one of them, maybe you have a strong genetic susceptibility for these diseases of insulin resistance. We just don’t know. I haven’t seen your blood work up. Other people report dramatic effects when they’re roughly 80-90% compliant.

Dan
Can I ask about that? I had dramatic effects as well but they only lasted about two months while I was losing weight. When you hear these dramatic results from people, at what time period is it that you hear the results?

Dr. Cordain
I’ve reported them in my books, people write in and tell me how they’ve done. Wiley keeps track of these things. We’ve reported about 20 or 30 cases that people can read and each one of them slightly different. We have people of all ages, all walks of life, all genders that have reported success.

Dan
My question I guess is how long into the diet do they report success because if one of my theories is correct, anybody who goes on a calorie restricted diet is going to see an improvement in acne symptoms. And it may simply be that.

Dr. Cordain
I wouldn’t say that’s a theory. I would say that’s a pretty good supposition. We believe the same thing. Calorie-restricted diets, no matter what you eat, are going to improve insulin sensitivity because there’s an interaction between calories and insulin sensitivity and we haven’t untangled that interaction as I mentioned we’ve only got a single study, and that was a confounding factor of Neil’s study so we need to determine what the role of caloric restriction is versus glycemic load. That has yet to be worked out. I honestly do believe that no matter what they eat, if they calorically restrict will have an improvement in acne symptoms. If you have what’s called an isocaloric diet and your reduce the glycemic load, that will be the next experiment that needs to be conducted is to keep the calories constant and reduce the glycemic load and see if acne symptoms subside. We also suspect besides milk and the glycemic load and calories we also suspect that there are certain foods that may interact with the pilosebaceous unit, one of them is peanuts. Peanuts contain a substance called PNA or peanut agglutinin we believe that PNA binds the same gut recepter that betacellulin does. We know from studies in England that PNA gets right into the bloodstream and if it does, then it in all likelihood it is binding these keratinous sites, these cells that line the pilosebaceous unit, if it binds those, and it causes a hormonal effect, like when it binds its own receptor, then it will also increase proliferation. We think that this is why some of the anecdotal evidence suggests that peanuts also exacerbate acne symptoms.

Dan
Interesting. Would you be able to give a few suggestions on how everyday people could modify their diet to improve their acne symptoms?

Dr. Cordain
I think everyday people eat white bread or white flour almost every day of their life, also refined sugars every day of their life. The average American eats close to 160 pounds of sugars on a yearly basis. We eat about a quarter of our calories in white bread. We eat a substantial amount of potatoes. All three of those foods, sugars, potatoes, and white flours yield a high glycemic load so at every turn of the screw, whenever possible, try to avoid those foods. I would also try to avoid dairy products as well. I think that most people, those simple suggestions of reducing or avoiding those types of processed foods will experience significant improvement in their symptoms.

Dan
Would you include peanuts on that list?

Dr. Cordain
Once again, we have no experimental data. What we have is a theoretical basis for this. It’s kind of like putting the dots together. We know that when people eat peanuts, we have scientific evidence to show that a substance in peanuts immediately appears in the bloodstream and we know that it binds a receptor that is located in the pilosebaceous unit. We haven’t put all the dots together. We haven’t actually had people eat peanuts, measure it in their blood, then measure it in the pilosebaceous unit, measure the activity of the pilosebaceous unit and then measure acne symptoms. Those four dots have not been connected they are all isolated at this point. It’s kind of like putting together a detective story is that you see a footprint leading into a house, and then you don’t see it again until it’s in the bathroom and then you don’t see it again until it’s someplace else. And so, that’s what we’re looking at. We see these footprints, these suggestive mechanisms in the body, but we actually haven’t been there to witness the entire series of events and so that’s what future research will focus on is how all of these things work together. Clearly we don’t believe that acne evolves just from a single dietary element, nor do we think that these dietary elements affect all people in the same manner. We think that some people have a much greater genetic susceptibility to acne than others. It’s a moving target right now and that genetic susceptibility makes things tough and unfortunately, I wish you were one of those people who genetically would have right off the bat improved, like other anecdotal stories that have come in. Whether your story would have worked or not would’ve never made any difference in the scientific community. It would have for you, and maybe for your listeners, but it would have not changed one iota in the scientific community. What is required are empirical database studies. That’s a slow process, so what we’re seeing now if the beginning of that process. Unfortunately for you, and others who grew up at this period, you’ll say, “Geez, I wish the scientific community would have figured this out two decades earlier”. Part of it is dogma, and it’s hard to get around the dogma. Through my publications, most of the dermatology community realizes that there is not any good evidence to make the suggestion that diet doesn’t cause acne. We pointed that out. The most frequently cited studies, the Fulton study published in the Journal of the American Medical Association and another one in the Family Practitioner, we blew those out of the water. I teach a research design class at the University and we routinely show that there’s a hole big enough in both of those studies that you can drive a Mack truck through. They’re not good science.

Dan
That sounds like a really big step to me. At least we’ve realized that diet and acne may be related, but maybe the bottom line at this point is that more research is required.

Dr. Cordain
I’ve never suggested anything other than that. All I’ve suggested is that the dogma that diet doesn’t cause acne is not a good position for anyone to take or to believe.

Dan
I guess what confused me as far as what you’ve put out there is the name of the book is “The Dietary Cure for Acne” and so, from that title, I assumed that you were saying that there is a dietary cure for acne.

Dr. Cordain
I believe there is, but again, I’m a scientist and until the science definitively shows that, what I’m giving is my hypothesis and my hypothesis has not been shown to be wrong by the three studies that have come out. All three are in agreement with what we’re saying.

Dan
Okay, well thanks so much for your time. I really appreciate everything that you’re doing.

Dr. Cordain
Okay Dan, well you’re a real warrior and a spirit and hopefully your grassroots effort is going to make a difference.

Dr. Cordain’s web site

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.