Appalachian Spring Dermatology
My Picks for 2020 A DERMATOLOGISTS FAVORITE SUNSCREEN PICKS! HOW DO I CHOOSE? 1 – Check the Active Ingredients – I particularly like sunscreens containing zinc oxide and titanium dioxide ONLY. Zinc and titanium are physical barriers that work much better and last longer than the chemical sunscreens. Zinc has a more complete and broader coverage than titanium. Chemical sunscreens have …
As many of my readers know, I’m a little obsessed with sunscreen. If you ask me, “What’s the best sunscreen to buy?” My answer will be WAY TOO LONG and include the word “zinc” about a thousand times. Each year at this time, I usually go to Walmart to scope out what’s on the shelves for this …
The most common question I am asked is , “Which SPF should I get?” As you will read, you will learn that I care more about the active ingredients than the SPF, here’s why: SPF measures the length of time a product protects against skin reddening from UVB, compared to how long the skin takes …
5 Answers to Common Questions about this Condition What is this discolored rash on my chest, back, and arms? Tinea versicolor, otherwise known as pityriasis Versicolor, is a harmless but cosmetically disturbing rash that is most often seen on the trunk, arms, and neck. It is sometimes itchy, but not always. It can be a variety …
Tips for Skin Cancer Prevention Unfortunately, this question is quite common. 1 in 5 Americans will develop skin cancer in their lifetime. Fortunately, most skin cancers occur locally and do not spread to other parts of the body. But still, most of us would prefer never to have another one. Here are a few options that have been SCIENTIFICALLY …
May is skin cancer awareness month. As a dermatologist, I feel like I just can’t get people to take it seriously enough. Here are some facts from the Skin Cancer Foundation. Yet, still, we have tons of Americans tanning indoors and outdoors each spring and summer trying to achieve a golden tan while increasing their risk of …
Carissa Santmyire, RN is the newest addition to our staff at Appalachian Spring Dermatology. If the name sounds familiar, it’s all in the family! Carissa is Beth and Aaron’s sister.
Carissa received her nursing degree from Allegany College of Maryland in 2009. Since then she has been working at Western Maryland Health System as a MED/SURG and Oncology nurse.
We are excited to have Carissa join our staff. She performs a number of cosmetic procedures in the office including Coolsculpting, Botox, Kybella and Laser Hair Removal.
Carissa recently amplified her Coolsculpting training at Coolsculpting University in Reston, VA. This is the highest level of training and education that can be achieved for Coolsculpting professionals.
When not working, Carissa enjoys spending time with her family, especially her six year old son Zechariah. She loves the beach.
Carissa brings a compassionate, kind and loving spirit to all she meets!
Aaron is now in Kenya continuing his missionary work. He plans to return in Summer 2021! If you think the name sounds familiar, yes Aaron Santmyire and Beth Santmyire-Rosenberger are brother and sister.
Aaron began his nursing career as a Registered Nurse, after his gradation in 1997 from Allegany College of Maryland.
In 2006, Aaron continued his nursing training and graduated from Graceland University with a Masters in Nursing. He then received certification as a Nurse Practitioner. Aaron continued his studies and in 2013 received his Doctorate in Nursing Practice from West Virginia University . His current credentials are APRN-BC, DNP which stands for Advanced Practice Registered Nurse – Board Certified, Doctor of Nursing Practice. More recently, Aaron completed his Master’s in Business Administration from Southwestern Assemblies of God University.
Aaron currently lives in Nairobi, Kenya with his wife and children. His varied experience provides him with a unique set of skills and expertise.
Dr. Rosenberger is a West Virginia native from Wiley Ford, WV. She received her undergraduate degrees in Biology and Chemistry from West Virginia Wesleyan College in 1994. Following undergraduate, she entered the MD/ Ph.D. program at West Virginia University where she received both her MD as well as a Ph.D. in Physiology in 2001.After completion of medical school, Dr. Rosenberger ventured to Washington DC to further broaden her education as a Dermatology Resident at Washington Hospital Center, serving as Chief Resident during her final year of residency in 2004. While training in Washington DC, Dr. Rosenberger also treated patients at the Children’s National Medical Center and the National Rehabilitation Hospital and attended conferences at the National Institute of Health. Dr. Rosenberger was trained to treat patients of all ages, skin types and ethnic groups in our multicultural nation’s capital. Following her training in DC, Dr. Rosenberger returned to West Virginia and founded Appalachian Spring Dermatology PLLC in 2005.
Dr. Rosenberger is Board Certified by the American Board of Dermatology.
Dr. Rosenberger is a member of the American Academy of Dermatology, American Society of Dermatologic Surgery, American Medical Association, West Virginia State Medical Association, WV Dermatologic Society and the Christian Medical and Dental Association. She is currently serving as Vice President of the WV Dermatologic Society.
Dr. Rosenberger enjoys cooking, flower gardening, running and swimming. She is an active member of South Ridge Church.
“Although I love being a dermatologist, my most important job remains that of wife to David and mom of Lily and Ella.” Beth
How does it work?
Eskata is a super-concentrated solution (40%) hydrogen peroxide that comes in an applicator with a felt-tipped pen. It is applied to the skin as seen in the photos. It is only sold to and applied by health professionals. The lesion turns white and then develops redness around it that lasts at least 24 hours. The redness then subsides and the lesion eventually falls off.
How does it differ from other treatment options like cryosurgery or freezing?
Compared to cryosurgery/freezing, the lesion stays red for less time and takes longer to fall off and resolve. In clinical trials, lesions were evaluated and retreated at three weeks if not resolved. It is less painful, and in clinical trials had less scarring compared to cryosurgery or freezing. See the Table Below for a comparison.
Which one should I pick?
Looking at the chart below, if time and cost are not a factor, Eskata would win. However, time and money are almost always a factor. For many patients who cannot tolerate freezing, I think the pain will be a deciding factor. My goal is to provide options so patients can choose.
What is the cost?
One applicator of Eskata is $125 at this time. If lesions require a second treatment, an additional $125 cost would apply. The cost of the Eskata will be added to the “per lesion” charge that we already charge in the office for cryosurgery.
Who will apply the Eskata? Can I do it at home?
Eskata will be applied by a nurse or medical assistant in our office. Dr. Rosenberger will work with patients to pre-identify which lesions are suitable for treatment with Eskata, but the actual application is time-consuming and will be performed by one of our trained and qualified staff. You cannot apply it at home.
How will I know if a lesion needs a second treatment? If it doesn’t fall off, it needs a second treatment. We will recommend a one month follow up evaluation to determine the effectiveness of treatment and need for retreatment.
All Calm
Beauty On The Go Palette
Bronzing Duo
Brow Kit
Brush On Shield – Deep
Brush On Shield – Light
Brush On Shield – Medium
Brush On Shield – Tan
Cleansing Cloths
Champagne Kiss Illuminator
Corrector Pallette
Even UP
Gel Eye Liner
Hydrating Mist
Lip Shine – Champagne
Lip Shine – Clear
Lip Shine – Coral
Lip Shine – Pink
Lip Shine – Rose
Mascara – Black
Morning Glow Illuminator
Pep Up
Pressed Foundation – Ivory
Pressed Foundation – Med. Bisque
Pressed Foundation – Med. Sand
Pressed Foundation – Med. Sunlight
Pressed Foundation – Tan Golden
Pressed Foundation – Tan Natural
Sunforgettable Sports Stick
Sunforgettable Glow
Sunforgettable Color Balms (all colors)
Tint Whipped – Deep
Tint Whipped – Light
Tint Whipped – Medium
Tint Whipped – Tan
Total Eye
Total Eye Kit
Total Eye Consentrated Kit
Total Protection SPF 50
Order via our unique URL
Body Emulsions
Brightalive
Calming Toner
C-Bright
Cellulite Cream
Complexion Pads
Concealer
Daily Power Defense
Daily Sheer
Dual Action Scrub
Exfoliating Acceliator
Exfoliating Cleanser
Exfoliating Polish
Enzymatic Peel
Eye Repair
Firming Serum
Gentle Cleanser
Growth Factor
HYDRAFIRM
Hydrating Cleanser
Hydrating Crème
Instant Pore Refiner
Oclipse C SPF 50
Oil Control Pads
Pigment control + Brightening
Pigment Control
Pigment Control + Blending
Radical Night Repair
Recovery Crème
Refissa-Tret 0.05%
Renewal Cream
Retinol Skinbrightening 0.5%
Retinol Skinbrightening 1%
Rozatrol
Smart Tone
Sulfur Masque
Sunscreen + Primer SPF 30
Wrinkle + Texture Repair
To order visit our unique ZO page
Laser Vein Reduction Treatments
We are pleased to offer our patients over 12 years experience treating both facial and leg veins with our 1064 NdYag laser. More than other treatments, laser vein reduction requires a consultation to determine if our laser will work the best to treat your veins. Both on the face and the legs, there is an optimal size and color that responds well to laser treatment. Veins that are thin, fine and red may not respond as well as larger, purple and blue veins. Our laser will not work well on larger reticular or varicose veins.
How does it work?
Lasers produce a specific wavelength of light that can a specific object in the skin. In Laser Vein Reduction, the laser targets blood in the blood vessels. The interaction produces energy, which is best described and feels like heat, that damages the wall of the blood vessel. Once the blood vessel wall is damaged the blood vessel often immediately collapses. This leads to the deceiving appearance that the blood vessel is immediately removed. Actually, the blood vessel will be reabsorbed by the body over 6-8 weeks. While face vein treatments often have no down time, leg veins ofter look worse initially and require 2-3 months to look good.
What results can be expected?
If a vein goes completely away with treatment, it should not return. Occasionally the body reopens the vessel before it is completely reabsorbed or the vessel only partially responds. Because of this, we find that patients may need 3-4 treatments that are 6-8 weeks apart. Also, the factors that contributed to the enlarged leg veins such as standing for long periods of time, female hormones, pregnancy, being overweight, or a family history of varicose veins may not change, and therefore, new veins tend to form over time. For facial veins, the underlying causes such as rosacea may still be present and new vessels may continue to develop. Most people are extremely happy with facial vein treatment. Leg veins, admittedly, are more difficult and take more treatments and time to look good.
What is Laser Vein Reduction like?
During a Laser Vein treatment, we will apply aloe vera gel to the area being treated. Depending on the extent of the veins, each treatment takes between 10 and 30 minutes. Subsequent treatments are performed no closer than 6 to 8 week intervals.
Most people find treatment of facial veins slightly uncomfortable, but treatment of leg veins is more painful. No sedation or pain reliever is desired or required, but patients should expect discomfort with both procedures.
The leg veins treated will usually look darker and a bit swollen after the procedure. There may be small pink bumps that resemble mosquito bites that can last a day or two. We recommend wearing medical grade support stockings for seven days after the procedure to alleviate these symptoms and to prevent the leg veins from reopening.
When we treat larger veins it is possible that a small amount of blood can “leak” out of the vessel before it is heat-sealed resulting in a bruise or discoloration of the skin. Bruises are temporary and resolve in 1-2 weeks. The risk increases if you take aspirin products or are on blood thinners. Because blood contains iron, it is possible for a brownish discoloration to result. This is temporary and will resolve in 2-3 months.
Uncommonly, a skin wound such as superficial blisters and scabs can occur, which heal within 2 days to 14 days. Use of antibiotic ointment on a regular basis usually results in uneventful healing. There is a <0.5% possibility of a skin wound leaving behind a permanent scar. It is also rare for an infection to occur since the skin is usually not broken.
What happens after Laser Vein treaments?
You may go directly back to work or your regular activities after a procedure. For face veins we recommend applying sunscreen daily and being extra gentle to the skin for one week. For leg veins, we recommend wearing medical grade support stockings for a minimum of seven days after the procedure. You should avoid strenuous exercise, alcohol, and aspirin products for 48 hours following the procedure.
We are pleased to continue offering Intense Pulsed Light treatments with Cutera Xeo in our office since 2005. Wow, that’s a long time! All those years of experience pay off for our patients. We have an excellent concept of what will and will not respond best to Intense Pulsed Light. We also know and understand that other treatments may be more efficient and less expensive, so we often recommend those first.
Intense Pulsed Light treatments use multiple wavelengths of light to target multiple things in the skin simultaneously. In contrast, a true laser (see our 1064 NdYag page) uses a single wavelength of light for more specific targeting of structures in the skin.
We most often use and recommend Intense Pulsed Light to treat those with rosacea who have persistent and troublesome redness that has been unresponsive to topical and oral treatments. Since rosacea is a progressive and multifaceted condition, Intense Pulsed Light is just one modality used to bring rosacea under control. Treatments are spaced 6 weeks to 6 months apart. Often three treatments are recommended initially 6-12 weeks apart followed by maintenance every 4-6 months. Some insurance companies cover these treatments for rosacea, but it is often an out of pocket cost. More recently, there has been a surge of using IPL to treat Ocular Rosacea. To learn more about rosacea and treatments for rosacea, see our updated rosacea page.
Intense Pulsed Light is often marketed to treat brown spots. However, it is neither the most effective or cost effective method to treat brown spots. For brown spots, Dr. Rosenberger recommends a regimen including tretinoin/retinol, hydroquinone and zinc containing sunscreen. To read our post about treatments for brown spots, click here.
For best success, and to limit risk of adverse events, patients must avoid significant sun exposure especially in the 1 week prior to treatment. Dr. Rosenberger will postpone a treatment if a patient arrives with too much recent sun exposure. There is little to no downtime. Sunscreen is applied prior to patient leaving the office.
Check out some of our Before and Afters below. These are very representative of how the average patient responds. Note that not everything is perfect in every picture. We try to present very realistic pictures.
BLU-U light treatment has been available in our office since 2011. This light treatment is done alone or along with a solution called Levulan (aminolevulinic acid) that increases the potency of the light treatments. When the solution is used, the procedure is called photodynamic therapy which we also use to treat rosacea and precancer spots.
Lasers and light are used to treat many skin conditions. The different types of light are described by their wavelength in nanometers (nm). Some types of light are visible and colored and some are not. Many types of laser and light devices have been tried to treat acne. Blue light has been shown to be the most effective at the lowest cost with no downtime. BLU-U treatments use a panel of blue colored lights (417nm). The treatment is painless and lasts 17 minutes. Patients wear goggles for the treatment and can read, use their phone, or just relax.
BLU-U works to treat acne by decreasing growth of the most common bacteria involved in acne called Propionibacterium acnes. One recent analysis showed a 60-70% decrease in inflammatory lesions after twice weekly treatments for four weeks. This treatment is particularly useful for those who cannot take oral antibiotics due to intestinal issues, pregnancy or breastfeeding. We recommend not using blue light alone to treat acne because it will not treat clogged pores and blackheads which are the beginning stage of acne. At your acne office visits we can recommend a multi-faceted therapeutic regimen.
There are at home devices light devices used to treat acne as well. These generally are not as powerful as in office treatments, but they can be performed more often at home. We recommend patients try in office treatment first before spending money on an at home device. Below is a recent article reviewing available commercially available blue lights.
Because we want to be able to add this treatment to as many patients as possible in our acne treatment center, blue light treatments are affordably priced for our patients. Call the office for current pricing. Most insurances will not cover these treatments, so they will be an out of pocket cost. Patients will not see the doctor at the time of light treatments, so treatment should be a quick in and out procedure. We recommend twice weekly treatments for 4-6 weeks when clearing acne and as needed once clear.
We use a traditional BLU-U device available from DUSA or a Blue LED light.
To learn more check out the articles below.
American Academy of Dermatology’s statement on light treatment for acne.
What is an Excimer Laser? An Excimer Laser is a special type of laser that uses NBUVB light to treat a variety of skin conditions particularly psoriasis and vitiligo. There are multiple manufacturers of excimer lasers. We have been doing these procedures in the office since 2011. We initially had the name brand XTRAC, but in 2014 switched to what we consider to be a superior excimer laser by Ra Medical called Pharos .
What is the procedure like? Excimer laser treatments are a painless in-office procedure that are relatively quick and simple compared to other treatments. In our office, the procedure is performed by our medical assistant under the supervision of Dr. Rosenberger. It takes about 10 minutes depending on the size of the area we are treating. The first exposure to the laser is usually quite short, lasting as little as a few seconds. Exposure time depends on the person’s skin type and the thickness of the skin. People with lighter skin start with shorter exposure times than people with darker skin. Normally, treatment times are gradually increased until clearing occurs, unless the last session produced itching and/or skin tenderness. Because administering excimer laser light is not an exact science, each person’s reaction to the light is not completely predictable. Subsequent sessions of excimer laser are adjusted according to a person’s individual response.
How many treatments does it take? That can vary, depending on the disorder being treated, size of the area being treated, location on the body and the thickness of the skin. On average patients will see an excellent result within 10 weeks at twice a week. Many of our patients will do some sort of maintenance therapy at the first appearance of a new flare because they are happy with the therapy. In the past year we have been using a new protocol that is producing much quicker clearance with improvement often seen in as little as 2-3 weeks.
It is so hard to get an appointment though! No worries. For excimer laser treatments, you will be on a separate medical assistant schedule to assure you super prompt service, with no wait to see Dr. Rosenberger.
How does it work? Present in natural sunlight, ultraviolet light B (UVB) is an effective treatment for a number of skin conditions – psoriasis, eczema, vitiligo and alopecia areata. UVB treatment involves exposing the skin to an artificial UVB light source for a set length of time on a regular schedule. As we learn more about these diseases, the theories on how UVB is effective constantly changes and is clearer. For now, we know it works. In treatment resistant conditions, just knowing it works is often good enough.
There are two types of UVB treatment, broad band and narrow band. Broad-band UVB is an older method that has been more commonly used in the United States; however, narrow-band UVB is similar in many ways and is becoming more widely used. The major difference between broad-band and narrow-band UVB is that narrow-band UVB units emit a more specific range of UV wavelengths. UVB includes all wavelengths of light between 290-320nm. Narrow band UVB (NBUVB) includes only wavelengths between 311-313nm. NBUVB is available both in a light booth and in the Excimer laser. To learn more about NBUVB light booth treatments, check out our phototherapy page.
Who is a candidate for Excimer laser? Excimer laser treatment can be used by adults and children. We often recommend this treatment to patients who have psoriasis in a limited area (hands, feet, scalp) and to those who have been resistant to treatment with topical therapy.
Excimer laser may be used alone or in combination with other topical and systemic treatments. More recently, we have been treating patients with both Otezla and Excimer and seeing some remarkable responses. In patients with vitiligo, we usually recommend augmenting the treatment with topical tacrolimus.
What happens once the skin clears? Once the skin clears, the treatments can be stopped. They should be resumed if the lesions begin to reappear. Sometimes Excimer laser can be continued on a maintenance basis. Studies show that treatment with NBUVB as maintenance can increase remission time..
What are the side effects of Excimer laser treatment? The skin may itch and become red because of exposure to the UVB light. The amount of UVB administered may need to be reduced to avoid further irritation. In our initial years, we would often see some patients develop blistering after treatment. The Pharos laser is a superior device and blistering is very uncommon now. UVB is an established carcinogen (cancer-causing substance or agent) in humans. However, there is no direct evidence of increased risk of skin cancer from UVB treatment for skin disease. It is important to have a doctor examine your skin periodically. Skin cancers generally can be removed easily if detected early.
Insurance Coverage and Prior Authorization We may ask you to contact your insurance company regarding insurance coverage and prior authorization. The Codes you will need are CPT 96920, 96921 and 96922 depending on the size of area treated. Generally, it is well covered by most insurances including Medicare for psoriasis. It is less often covered for vitiligo and other skin conditions
To learn more about this and other treatment options for psoriasis, I would recommend visiting the National Psoriasis Foundation website .
Excimer laser requires a significant time commitment. People get the best results when they keep scheduled appointments and follow treatment directions carefully. We look forward to helping you achieve the clear skin you desire.
Present in natural sunlight, ultraviolet light B (UVB) is an effective treatment for psoriasis. UVB treatment involves exposing the skin to an artificial UVB light source for a set length of time on a regular schedule. As we learn more about these diseases, the theories on how UVB is effective constantly changes and is clearer. For now, we know it works. In treatment resistant conditions, just knowing it works is often good enough.
There are two types of UVB treatment, broad band and narrow band. Broad-band UVB is an older method that has been more commonly used in the United States; however, narrow-band UVB is similar in many ways and is becoming more widely used. The major difference between broad-band and narrow-band UVB is that narrow-band UVB units emit a more specific range of UV wavelengths. UVB includes all wavelengths of light between 290-320nm. Narrow band UVB (NBUVB) includes only wavelengths between 311-313nm.
Several studies indicate that narrow-band UVB clears psoriasis faster and produces longer remissions than broad-band UVB. Narrow-band UVB may be effective with fewer treatments per week than broad-band UVB. Narrow-band UVB is also emerging as an alternative to PUVA, the light-sensitizing medication psoralen plus exposure to ultraviolet light A. Although not quite as effective as PUVA, narrow-band UVB is easier for people to undergo and may be safer over the long term.
The use of narrow-band UVB is increasing as doctors and patients learn more about its effectiveness and improved safety. Dr Rosenberger’s phototherapy units utilize Narrow-band UVB bulbs. She is pleased to offer this advanced and cutting edge therapy.
The patient stands in a treatment light box lined with UVB lamps. A person undresses to expose all affected areas to the ultraviolet light. A patient generally will receive treatments two to three times per week. It takes an average of 25 treatments to reach maximum improvement of psoriasis lesions.
The first exposure to the light is usually quite short, lasting as little as a few seconds. Exposure time depends on the person’s skin type and the intensity of the light emitted from the bulbs. People with lighter skin start with shorter exposure times than people with darker skin.
Normally, treatment times are gradually increased until clearing occurs, unless the last session produced itching and/or skin tenderness. Because administering UVB light is not an exact science, each person’s reaction to the light is not completely predictable. Subsequent sessions of UVB are adjusted according to a person’s individual response.
For people with psoriasis in more limited areas, we also have the same light in laser formulation called Excimer laser. To learn more about that therapy, see our Excimer Laser page.
UVB requires a significant time commitment. People get the best results when they keep scheduled appointments and follow treatment directions carefully.
In order to improve safety and efficacy of NBUVB treatments we recommend patients:
-make our staff aware of any medical or medication changes that occur during treatment.
-cover or apply sunscreen to uninvolved areas to shield from unwanted light exposure.
-apply mineral oil in a thin layer before treatment to improve the ability of the light to penetrate the skin.
Once the skin clears, the treatments can be stopped. They should be resumed if the lesions begin to reappear. Sometimes UVB is continued on a maintenance basis. This varies alot from person to person. Some patients prefer to continue maintenance once a week or once every other week. Other patients tend to pop in in the winter when their skin begins to flare.
During treatment, psoriasis may worsen temporarily before improving. The skin may itch and become red because of exposure to the UVB light. The amount of UVB administered may need to be reduced to avoid further irritation. Occasionally, temporary flares occur even with non-burning doses of UVB. These reactions may resolve with continued UVB treatment.
Certain medications, herbal supplements and topical ingredients can cause sensitivity to light; it is important to tell your doctor about all medications, treatments and supplements you are taking. Patients should avoid exposure to natural sunlight on UVB treatment days. Overexposure to ultraviolet light can cause a serious burn.
UVB is an established carcinogen (cancer-causing substance or agent) in humans. However, there is no direct evidence of increased risk of skin cancer from UVB treatment for psoriasis. It is important to have a doctor examine your skin periodically. Skin cancers generally can be removed easily if detected early.
As stated above, we recommend the use of sunscreen on uninvolved skin as a means of minimizing exposure to UVB. The face, for example, is exposed to a great deal of natural sunlight. If there is no psoriasis on the face or genitalia, a person should avoid UVB exposure there.
You will need to contact your insurance company regarding insurance coverage and prior authorization. The Codes you will need are CPT 96910
For more information, we recommend you visit the National Psoriasis Foundation site, to full explore this and other treatment options.
If you are interested in starting NBUVB treatments, please schedule an appointment for evaluation.
We have been performing photodynamic therapy in the office since we started in 2005. It has been widely used throughout the world for about 20 years now. Personally, Dr. Rosenberger does this treatment does this to herself once or twice a year to treat sun damage and rosacea.
What is Photodynamic Therapy? When discussing treatment options for Actinic Keratoses, precancerous red scaling spots, I usually present them with three major choices. In general the three major options and their ups and downs are…
In photodynamic therapy (PDT) patients come into the office. After washing the area to be treated, a solution called aminolevulanic acid ( name brands Levulan or Ameluz ) is applied. The solution is then allowed to incubate for 60-90 minutes. During the incubation period, the solution is preferentially absorbed by abnormal precancerous cells. After the incubation period, the patient sits under a panel of red or blue lights. As an addition benefit, the solution is also absorbed by oil glands causing improvement in enlarged oil glands, rosacea and acne. Finally, this treatment greatly improves the appearance of the skin all around improving texture, tone and youthfulness of the skin.
Who is a candidate? Patient with diffuse actinic keratoses, moderate to severe acne and/or rosacea, or moderate to extensive sun damage are good candidates for photodynamic therapy. If you are pregnant, have been on Accutane within 3 months, or have an active cold sore you should not have this procedure.
How many treatments are required? For precancerous actinic keratosis, a number of more recent studies show that patients have a better longer term result if two treatments are performed within a few months. Occasionally, thicker actinic keratoses may not fully respond to light treatments, and alternative treatments, such as cryotherapy or topical chemotherapy, may be necessary. Subsequent actinic keratoses may develop over time and future treatments may be needed. If there is one lesion that is particularly resilient, we will biopsy any resistant lesions.
Acne breakouts can be greatly reduced in three treatments and rosacea is usually improved in three to five treatments. Rosacea and acne can be chronic conditions, and maintenance treatments may be necessary to remain in remission.
Are there any negatives? Some patients experience minimal tingling and burning when the solution is first applied. Rarely, patients experience discomfort while sitting under the lights. ALL PATIENTS will be extremely sensitive to ALL LIGHT for 24 to 48 hours. For this reason, we recommend that patients STAY INSIDE in dim light especially for the first 24 hours. Sunscreen WITH ZINC will need to be applied every 2 hours while awake for the first 48 hours. Those who follow this instruction experience redness and peeling similar to that seen with a decent sunburn that resolves in 4-7 days. PATIENTS WHO DO NOT FOLLOW THESE INSTRUCTIONS WILL HAVE SEVERE REDNESS AND BLISTERING, LONGER HEALING TIME AND POSSIBLE SCARRING!
Also, if someone is prone to having cold sores, the treatment could bring on a cold sore. If you are prone to cold sores or if you have had shingles on your face, please let us know so we can prescribe you preventive medications.
What happens after Photodynamic Therapy? A sunblock containing zinc oxide should be used every 2 hours while awake for at least 48 hours following a treatment. Consider a broad rimmed hat even when going to and from your car. Makeup may be applied immediately after your treatment. Normal skin care can be resumed after 48 hours unless otherwise directed by your provider. It will take at least 6-8 weeks to see the full result.
Can another type of light be used? We can use intense pulsed light which may be more effective for those with rosacea or discoloration. Also, studies are currently underway to use outdoor UV light in addition to red or blue light.
What is the cost? For the treatment of actinic keratoses, most insurances including Medicare now cover this procedure. However, treatments for conditions such as acne, rosacea, and sun damage are at this time rarely covered by insurance. For these conditions, the cost of the treatment is 150/per session PLUS the cost of the solution ($75-425 depending on pharmacy benefits). Payment is required in full prior to each treatment. Any amount reimbursed by your insurance company will then be directly reimbursed to you. If you would like to check on your insurance company’s reimbursement, you will need the following codes 96573 and J7308 for Diagnosis (ICD10) of Actinic Keratoses L57.0.
What should I do to treat my skin after the initial healing? I often recommend that patients consider two things to prolong and enhance their result. Start using prescription strength Retin A nightly AND Start wearing a sunscreen daily.
If you have a friend or relative with extensive sun damage, please share this information with them!
PDT Update In March 2019, Dr Rosenberger attended the annual Photodynamic Therapy course and will be implementing a number of improvements in PDT in the office to make it even more effective.
Pretreating with a retinoid! Retin A helps remove old skin cells to prepare the skin to more readily absorb ALA. The most inexpensive and least irritating way to prepare the skin with a retinoid is using Differin (generic – adapalene) available OTC and by prescription. We will start recommending pretreating with Differin nightly for three weeks prior to PDT.
Saran Wrap! Wow, now that is scientific advancement. Seriously! In dermatology we often place medications on the skin “under occlusion” to increase their penetration. We will start using plastic wrap to improve penetration on the scalp and other non-hair bearing flat areas. On the face, we will use a plastic gel mask to improve penetration.
Heat! There have been a number of studies evaluating ways to make the ALA penetrate better and more effective. In addition to occlusion with plastic wrap, heat improves efficacy. We are experimenting with heat using warm packs, warming gel masks and space heaters
Meet Poly! Poly is our new light for PDT. In addition to providing the traditional blue light, Poly uses red light. Poly’s panels can also be molded to get conform better to the targeted are and get closer to the skin as well.
Red light! The diagram below demonstrates that ALA can be activated by both red and blue light. The benefit of red light for treating precancerous cells and sun damage is that red light penetrates deeper in the skin than blue light. However, blue light remains the treatment of choice for acne and rosacea, because only blue light targets bacteria seen in acne and rosacea.
If you would like to schedule a consultation to see if this procedure is right for you, call the office at 3043680111 or schedule online.
Laser Genesis is a non-ablative laser procedure which means that it does not injure or break the surface of the skin using Cutera 1064nm NdYAG. It works by gently warming the upper dermis layer of the skin, stimulating the growth of new collagen to improve the appearance of your skin. The result is a healthy looking and vibrant appearance. This procedure was originally designed to treat fine lines, pore size and redness. We often use it for scarring and stretch marks as well.
Laser Genesis is a comfortable, relaxing “no down time” procedure. Typically patients describe the treatment as a gentle warming of the surface of the skin. The laser handpiece does not touch the skin in Laser Genesis treatments. Instead, it is slowly waved about an inch above the treated area, causing a gentle rise in the temperature of the deeper layers of the skin until reaching the therapeutic level.
This is a no down time procedure, which can be both bad and good. Good that you look exactly the same when you leave, and bad that you look exactly the same when you leave. If you are expecting an immediate transformation, you will be very disappointed. Because Laser Genesis works by stimulating collagen in the skin, it takes a long time to generate enough microscopic molecules to be able to see a difference. Expect to wait 3-6 months to be impressed with your results. The treatment results are initially subtle and are cumulative. On average you may require two to six treatments in order to achieve their desired results. Every patient’s conditions and needs vary.
We have been performing this procedure in the office since 2005. After many years of experience, I have been most impressed with this procedure in treating acne scarring. I recommend using a topical retinoid to increase efficacy. Now that we have added microneedling, we will consider doing a series of microneedling and Laser Genesis for those with extensive scarring.
Laser Genesis has been FDA cleared. It has been rigorously tested in clinical studies.
The cost will vary with the extent of the area to be treated. The exact cost can be determined at the time of your consultation.
Check out some of our Before and Afters below. These are very representative of how the average patient responds. Note that not everything is perfect in every picture. CLICK ON AN IMAGE TO ENLARGE TO SEE MORE. Please read the captions to note that these are long term photos, not a quick fix.
LASER HAIR REDUCTION
What is a LASER? A laser is a medical device that uses a focused beam of light to target specific structures in the skin. By definition a laser has a single wavelength of light. The wavelength we use is a 1064nm NdYag laser – called the Cutera Xeo Cool Glide. Why is this important? The higher the number (up to about 1300nm), the longer the wavelength and the deeper the laser light penetrates in the skin. Only a 1064nm laser effectively penetrates to the deeper layers of the skin where the root of the hair lies. In contrast, an intense pulsed light device (which we also have in the office but we do not use for hair removal very often) contains many wavelengths of light between 560nm and 1200nm. This type of device is generally less effective for permanent hair removal. Many things are marketed as a “laser”. It is important to understand the above information to evaluate laser hair removal options in an educated manner. It is also important to note that in the state of WV, use of a laser is allowed for physicians and those under direct on site supervision of a physician.
How does Laser Hair Removal Work? In laser hair removal, the laser light targets the pigment in the hair. In the skin, hairs are generated by and sit in hair follicles. The interaction between the laser and the pigment in the hair generates energy in the hair, best described as heat. This energy is transferred from the hair to the hair follicle. By damaging the hair follicle, we prevent that hair follicle from generating new hairs in the future. Over a few weeks after the laser treatment, the old hair is pushed out of the hair follicle (this can make it seem like the hair is actually growing). Once the old hair falls out, no new one grows back. Because the laser targets the actual hair, the hairs need to be present for the laser to work. You can shave prior to treatment, but we recommend no waxing or plucking for at least six weeks prior to treatment.
Sound great! What’s the catch? Because the laser works by targeting the pigment in the hair, it is most effective on thick, dark hair. It does not work on blond, gray or white hair. The laser simply has no target if there is no pigment. Fine blond hairs that normally occur on the skin also will not respond.
Why does it take multiple treatments? All hairs on the body progress through three major stages of growth – Anagen, catagen and telogen. Anagen phase is the active growing phase, catagen is a short transition phase and telogen is the resting phase. The length of hair is determined by the length of the anagen phase. Different regions of the body have different anagen lengths, causing scalp hair to be longer than eyelash hair, etc. Different regions also have a greater percentage of hairs in the anagen phase at any given point in time. Only the anagen, actively growing hairs, are anchored well enough to the hair follicle to allow effective transfer of the laser energy. Therefore, the laser is only effective on the anagen hairs. If in a given body area 50% of the hairs are actively growing, then the first treatment would target 50%, the second 50% of the 50% that remain and so on. This is why it takes multiple treatments. Treatments are scheduled 6-10 weeks apart, enough time to allow a new group of anagen hairs to grow. Many factors influence hair growth cycle, such as age, weight, ethnicity, hormones, diet, medications, metabolism and stress. Each area can require 6 treatments to effectively remove the hairs.
Is it really permanent? Yes., but treatment results may vary among patients. The FDA approves the Xeo Cutera 1064 NdYag CoolGlide Laser ® for Permanent Hair Reduction. The FDA defines permanent hair reduction as the long term, stable reduction in the number of hairs re-growing after a treatment regimen. In clinical studies patients were followed for one year after completing two treatments. The reduction in hair growth proved to be stable for that period of time. However, this is new technology, and we have less than 15 years of long term data, so we can’t say 100% that the results will last forever. However, this does appear to be the case.
How does the CoolGlide® laser treatment compare with other hair removal methods? Shaving, waxing, plucking and depilatory creams provide temporary results. These treatments must be repeated frequently. Electrolysis is tedious, invasive, and often painful. It can result in scarring. It involves inserting a needle into each hair follicle and delivering an electrical charge to destroy them one a time. Electrolysis often requires years of treatments at regular intervals and treats one hair at a time. Laser treatment delivers non-invasive laser light energy to hundreds of hair follicles at one time. In just a few minutes laser can effectively treat an area that would take over an hour with electrolysis.
Are laser treatment safe? Lasers have been in existence for more than 40 years and are used by a wide range of medical specialists. Since only light is used to remove hair, it is totally non-invasive. Therefore, it does not cause some of the irritations typically found with other hair removal methods.
What do the laser treatments feel like? Our laser Xeo CoolGlide® handpiece, as the name implies, cools and soothes the skin as it glides along the treatment area. When the light pulse is delivered, some patients experience a mild stinging or pinching sensation for a fraction of a second. No local anesthetic or pain medication is usually required. Because the CoolGlide® incorporates a large spot size and a high rate of energy delivery, treatments are extremely fast and effective.
What is it important for Dr Rosenberger to know prior to any laser treatments? Inform Dr. Rosenberger if you have a history of sun/fever blisters, cold sores or facial herpes. A history of keloids, hypertrophic scarring, vitiligo, gold therapy, tattoos in the targeted area, and darkening of the skin after procedures are all relative contraindications to laser hair removal.
Are there side effects? Short-term side effects include slight reddening of the skin or local hive like swelling. Rarely a pimple like lesion can develop at the site of an ingrown hair. Blisters are unexpected, but do rarely occur. Most side effects are typically transient, lasting from 15 minutes to two hours. Most patients can go right back to work or social activities on the day of treatment. Rarely, discoloration can occur at the laser site.
How long do the treatments take? An upper lip, chin ,underarms or bikini often only takes 10 minutes. Legs and backs take longer. Very often, follow-up treatments are shorter because there is much less hair to treat. Hair density, area treated and phase of hair growth can affect length of treatments.
What happens after the treatments? Following the treatment you can return to normal activities immediately. SPF 30 sunscreen is recommended for the entire treatment period on any areas exposed to the sun. We can treat tan skin and dark skin, but not sunburned or recently tanned skin. In the next two weeks you may experience what seems to be regrowth of hair. Most of these hairs are being shed as a result of your treatment and are not regrowing. In between treatments you should not wax or pluck the hair. Shaving is OK as it will not hinder your end results. There is often no immediate change. Don’t worry if you do not see an obvious change immediately after your first treatment.
Can all skin types and colors be treated safely with the CoolGlide® system? The CoolGlide®laser has an advantage over other laser hair removal systems because it allows treatment of all skin types, including lightly tanned and dark-skinned patients.
We are excited to begin offering in-office peels and facials utilizing ZO skin care products. These treatments are designed to augment your skin care regimen and can be done as much or as little as you please or need. All treatments will be provided to our specially ZO trained staff.
ZO Stimulator Peel
This gentle yet effective peel includes a combination of citric, lactic and glycolic acids as well as potent antioxidant and anti-inflammatory ingredients to improve skin texture and tone by encouraging both epidermal exfoliation and renewal. This peel helps to soften and rejuvenate sun-damaged skin, reduce the appearance of age spots, and stimulate the growth of healthy cells. With little to no downtime, this peel is an excellent way to enhance and accelerate the results of your ZO skincare regimen.
ZO Ultra Hydration Peel and Massage
An elegant treatment that begins with gentle hydrating, cleansing and micro-exfoliation to remove surface debris in preparation for a ZO Stimulator Peel. Following the Stimulator Peel, ZO® Aloe Hydra gel is applied to cool, calm and soothe the skin, To complete your experience, a pressure point massage is performed to minimize facial stress and maximize relaxation.
Acne Peel & Treatment
This peel can enhance your response to any acne and oil reducing regimen. Following cleansing and exfoliation, a ZO Stimulator Peel is performed. Following the peel, a sulfur masque is applied to absorb excess oil and spot treatment is applied to active acne lesions. This treatment can be accentuated with a BLU-U treatment.
BLU-U Acne Treatment
BLU-U light treatment is performed in office as a stand alone or add on treatment. BLU-U light treatments are most effective when performed, 1-2 times per week for 4-6 weeks. BLU-U light works by killing P. acnes, the most common acne causing bacteria, and by reducing inflammation in the skin. The treatments are painless, and there is no down time.
Skin Brightening Treatment
This treatment is designed to enhance results and alleviate irritation from an at home skin brightening and lightening regimen. Following cleansing and exfoliation, a ZO Stimulator Peel is performed. To enhance the peel effect, an Ossential® Skin Brightening Sheet Masque is applied. The mask contains aloe, Vitamin E and green tea, which work to minimize the production of excess skin pigmentation and supply ample hydration to the tissue.
I have to admit that microneedling was a buzzword that I didn’t pay much attention to at first. However, my eyes were opened a little when I attended the American Academy of Dermatology Conference. Numerous vendors were selling microneedling devices and solutions. I quickly realized that this was a trend much larger than I realized. I also quickly realized that writing about the topic would be daunting. Why? The microneedling industry varies greatly from at home procedures with devices purchased on Amazon to aggressive in-office procedures.
What is it? Microneedling is a procedure where a roller device with a varying number of needles of varying length is rolled over the skin. The intent is to generate thousands of microscopic holes of injury where new skin will be regenerated. Regeneration of new skin can improve the texture tone and appearance of the skin.
Who comes up with these things? Microneedling was first described in 1995 by Orentreich, but has recently gained extensive popularity and attention in the cosmetic realm. Major advances in the field have been in the past ten years by Dr. Desmond Fernandez of South Africa.
What conditions are treated with microneedling? A little bit of everything. Scarring of any kind, acne scarring, pigmentation problems, skin texture and tone, sun damaged skin, wrinkles and more are all addressed with this technique. We have also seen great results for those with many milia and with sebaceous gland hyperplasia.
Who makes the devices? Two of the first leaders in the industry were the Dermapen and Dermaroller . The devices can vary GREATLY. If you are considering buying one or having a treatment, I would encourage you to check out these links.
Should you do this at home? According to my research, done mainly on the web, because there is not a lot in the medical literature, lots of people do this at home, in spas, in salons and everywhere in between. The biggest risk is further scarring, infection, and worsening of skin disease or the skin condition to be treated. The other issue is pain and bleeding which may not be well controlled at home. I would be VERY cautious before I did this at home or outside a dermatologist or plastic surgeon’s office.
Do we do this in the office? And what device do you use? Yes, we perform microneedling with Dermapen3, one of the industry’s most advanced device worldwide. This automated device uses a disposable, and thus safe and sterile, needle cartridge containing twelve 33 Guage needles. The device oscillates and moves the needle cartridge to insert hundreds of holes per second during a treatment session. During and after the procedure we will apply a series of topical agents to infuse them into the holes or channels that have been made.
DP Dermaceutical Products
What should I expect post procedure? You should be able to return to normal activities and work. It is recommended that you avoid heavy exercise for two days. We must wait two weeks before and after microneedling to perform other procedures. We will prescribe a post care regimen of DP Dermaceuticals to be used after your procedure to ensure the most effective treatment and quickest recovery.
Is it painful? And what about all that bleeding? When administered correctly with the advanced Dermapen3 and topical numbing medication, pain and bleeding are very minimal. Dr. Rosenberger has treated herself, so it can’t be too bad.
To learn more about the Dermapen3, check out the video below.
PLEASE NOTE. There is an extensive amount of controversy and litigation in the microneedling industry. There is an extensive controversy between Dermapen USA and Dermapen World, surrounding questions about trademark and patents. In essence, DermapenWorld does not have the trademark to distribute its products. The good news is we got a superior device prior to the controversy.
Because we like to be open about controversies, we encourage you to read the following articles before pursuing microneedling treatments. I know these articles would interest me if I were a patient. However, we continue to acknowledge Dermapen World as the worldwide leader in microneedling. Dermapen3 is a safe, superior and effective device.
http://dermapen.com/dermapen-3/ In this article, the company that currently owns the Dermapen trademark is very critical of other devices.
FDA’s preliminary statement regarding microneedling devices. The FDA indicates that…” At the time of issuance of this draft guidance, microneedling devices do not fall within any classification regulation, and there is no legally marketed predicate device upon which to base a determination of substantial equivalence. ”
Microneedling: FDA Fact or Fiction is an article written by a lawyer reminding us that currently, NO MICRONEEDLING DEVICES ARE FDA APPROVED IN THE UNITED STATES.
When was the first time you realized you had a “double chin”? For me, I was about 10 years old, and it was painfully obvious in that lovely portrait my parents had on the wall. As a child, I did chin exercises to try to help. Well, needless to say, 30 years later I still HAD a “double chin”. My jawline is not perfect now, but it is much better. Thanks to Kybella! If you would like to view my initial before and after videos and photos, check out our facebook page.
Kybella is a FDA improved injection that dissolves the fat in the chin that so many people hate. Both men and women and all ages are often bothered by the appearance of their jawline. Traditional treatment for this problem area has been liposuction of the neck, with or without a neck lift by a plastic surgeon. However, there are often complications with the surgical procedure and significant down time. Although Kybella injections are often a series of injections and there is some post procedure swelling for a few weeks, the down time and risk is significantly less.
The active ingredient in KYBELLA® is deoxycholic acid, a naturally-occurring molecule in the body that aids in the breakdown and absorption of dietary fat.
When injected into the fat beneath your chin, KYBELLA® causes the destruction of fat cells. Once destroyed, those cells cannot store or accumulate fat. The results are permanent.
The use of naturally occurring molecules to dissolve fat, called mesotherapy, has been a common procedure throughout Europe for many years. In the past, the solutions were often made by individual physicians and pharmacists, and there was not standardized dosing or clinical trials of these other concoctions.
KYBELLA® treatment regimens are customized based on the patient’s current and desired chin profile. Many patients experience visible results in 1 to 3 treatment sessions. Up to 6 treatment sessions may be administered spaced no less than six weeks apart.
The biggest negative to Kybella is cost. We have found that often doing only one vial at a time greatly reduces swelling and down time, plus we get more result with less cost by just being patient.
Personally, I am so delighted with the improvement in my “double chin”. After 30 years of positioning myself just right in photos, it is wonderful!
2019 UPDATE! We have also started using Kybella on small pockets of fat not treatable with Coolsculpting as well as a few lipomas with great results. We are excited about this, but these treatments are considered “off-label”.
To learn more, check out treatment photos and much more, http://consumers.mykybella.com/
KYBELLA® has been the focus of a global clinical development program involving over 20 clinical studies with more than 2,600 patients worldwide, of which over 1,600 have been treated with KYBELLA®. It was FDA approved in 2015.
The safety profile of KYBELLA® is well characterized. The most common side effects are swelling, bruising, pain, numbness, redness and areas of hardness around the treatment area. KYBELLA® can cause serious side effects, including trouble swallowing and nerve injury in the jaw that can cause an uneven smile or facial muscle weakness.2 In almost all cases, even the most severe adverse events resolved within a few months of treatment.
But wait! There’s another treatment for under chin fat. If those needles don’t appeal to you, consider Coolsculpting! Check out my blog post comparing Kybella and Coolsculpting for under the chin fat.
We are pleased to offer over 20 years of experience in injecting fillers to achieve a natural result, revealing the best you! Dr Rosenberger aims to not alter your appearance, but instead accentuate and augment your natural features.
We offer a wider range of fillers including the Juvederm and Restylane family of products as well as Sculptra. We purchase our fillers directly from the manufacturers. We NEVER use cheaper, adulterated alternatives.
Check out some of our Before and Afters below. These are very representative of how the average patient responds. Note that not everything is perfect in every picture. One concern patients often have is how the filler will look as it wears off and fades away, so some of the series of photos address this concern. Lines will gradually reappear, and we retreat as needed, usually at 6-9 months. We aim to keep you looking normal, accentuating the best version of you!
Which toxin is best? Well, that’s like asking a car salesman which car runs better. They’re all pretty equally effective. However, if you look at the scientific details, there are slight differences. Scientifically, Xeomin, Jeuveau, and Daxxify are newer, cleaner molecules. The BOTOX molecule has some accessory proteins attached to it. Xeomin, Jeuveau and Daxxify removed those extra proteins. In real-life patient use, the three can be used interchangeably because Botox, Jeuveau, and Xeomin are all dosed the same. Daxxify is dosed a little differently, but Dr Rosenberger can easity use it interchangeably as well. Daxxify has the added edge of increased longevity often lasting 5-6 months, but there it costs more as well. Dysport performs and is dosed differently, so Dr. Rosenberger very very rarely uses Dysport.
Which product does Dr. Rosenberger use the most? Primarily, Dr. Rosenberger uses Botox since founding Appalachian Spring Dermatology in 2005 because that is the name people know and expect. We have used Xeomin, Jeuveau, and Daxxify as well as soon they were available for commercial use.
Here’s a summary of each toxin:
Botox (Onabotulinumtoxin A)– FDA approved in 2002. Botox is made and marketed by Allergan. Onset in 3-4 days, lasting 3-4 months. Botox is the gold standard to which all other toxins are compared. Excellent rewards program called Alle, previously called Brilliant Distinctions. www.Alle.com
Xeomin (Incobotulinumtoxin A) – FDA approved in 2011. Made and marketed by Merz. One small study showed a slightly faster onset of action and longer duration. However, in our practical real-life experience, the difference is negligible. Their rewards program has floundered a lot in the past, using PIN codes for VISA gift cards. There current rewards program is xperiencemerz. To learn more check it out at www.xperiencemerz.com
Jeuveau (Prabotulinumtoxin A) – Nicknamed “Newtox” FDA approved in 2019. Made and marked by Evolus. Onset and duration of action were similar to Botox in scientific studies. However, in real-life use some find that Jeuveau doesn’t last as long as the other toxins, 2-3 months instead of 3-4 months. The Evolus Rewards program works through text. Check it out at https://jeuveau.evolus.com/#rewards-signup
Daxxify ( Daxibotulinumtoxin A) –FDA approved in 2022. Made and marked by Revance Aesthetics. Onset is a little faster than other toxins and it lasts longer. Marketed as lasting UP TO 6 months, after use in the office we think 5 months duration is more realistic. There is no rewards program to date.
I still can’t get past the word toxin, is it safe? Yes, all Botulinum Toxins are extremely safe when it is REAL product administered by an EXPERIENCED medical professional.
What do you mean “real”? A lot of black market product is available at a lower cost. You can know you are receiving real product by verifying that the physician purchases product from the only legitimate source. We only purchase directly from the makers listed above.
What qualifies as experienced? Well, this is harder to judge, but use your gut. Dr. Rosenberger was trained to administer BOTOX during her residency and received a certificate from her training at a BOTOX®Cosmetic National Education Facility in 2004. Personally, Dr. Rosenberger has administered well over 10000 BOTOX treatments. That’s experience. We encourage patients to ask about the injector’s experience and ask to see some before and after photos.
Check out some of our Before and Afters below. These are very representative of how the average patient responds. Note that not everything is perfect in every picture. We aim to keep you looking normal by accentuating the best version of you!
Eryfotona Actinica
Photo Eryfotona Ageless
SI- Nails
