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Acne 101

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Acne is a widespread disorder that we treat in the office. From babies to the elderly, it impacts how we present ourselves to the world each day.  Clear skin is always our goal.  We want your skin to be not just good, but great!  With a little work and some help from medications, you can have clear skin! 

But why do I have acne?  

That is complicated because acne is a multifactorial disorder.  Let’s look at each facet separately.  Hopefully, this will help you understand the various aspects of treatment as well! 

Clogged pores!  Acne generally begins with a clogged pore called a comedone.  Pores get clogged for two main reasons.  First, the skin sometimes does not grow and shed correctly; for lack of a better simple description, dead skin clumps in the pores.  Second, the sebaceous glands produce excess oil or sebum that further clogs the pores.  The combination of these two things leads to blackheads and whiteheads.  I like to emphasize that this process can happen independently of how well we wash our skin.  In fact, over scrubbing the skin can make acne worse.  To improve this facet of acne, we use medications that decrease sebum and help the skin grow more healthily.  

Bacteria!  Once we have clogged pores, the bacteria that commonly participate in acne called Cutibacterium acnes (C. acnes)  get into the clogged pores and begin to feed off the contents of the clogged pore.  Traditionally, C. acnes has been the most common bacteria involved in acne.  However, I often find that those with treatment-resistant acne also have other bacteria growing on their skin.  For this reason, we often do a bacterial culture of one of the whiteheads.  The bacterial culture tells us precisely what kind of bacteria is growing AND exactly which topical and oral treatments will most effectively kill that bacteria. 

Inflammation!  The bacteria cause the skin to produce inflammatory mediators that result in the redness, inflammation, tenderness, and swelling that can be seen in more juicy red pimples and deep under the skin lesions.  

Hormones!  Hormonal changes can drive all of this, which is why we see acne most often in babies, developing teens, and menopausal women who are all undergoing hormonal changes.  In more severe cases, we often will test the blood for hormonal levels.  Those with altered hormone levels can benefit from oral medications that help normalize the hormones. Usually, acne is driven by increased levels a few hormones, including testosterone, DHEA, progesterone, growth hormone, and Insulin-Like Growth Factor.  

Stains and Scars!  Many people are just as bothered by the marks left behind after acne leaves as they are by the acne lesions themselves.  I like to divide these marks into two categories, stains, and scars.  Stains are temporary discoloration from either a bruise-like effect or increased pigmentation at the site of old acne lesions.  These can take months to fade but will fade in time.  Scars are deeper, more traumatic, and more likely to stay for decades.  In all cases, the more we pick or traumatize the lesions, the more likely we are to have stains and scars.  Fingers OFF! 

Food!  Generally, food has little to no impact on acne.  Some people flare with different foods, and if so, I recommend they avoid those foods.  However, no food is off-limits when it comes to acne in my book.  Always eat healthily.  Drinking water never hurts, but it is impossible to drink enough water to fix your skin.  There are a few exceptions to this rule.  There was one study that showed that hormones in milk and other dairy products might increase acne.  However, most milk no longer contains hormones.  Other studies suggest that acne is worsened by a high sugar or high glycemic diet. 

Acne Treatment 

For almost all acne treatment regimens, most doctors tell their patients that they will get worse for the first 8-12 weeks.  You want results NOW, not in 12 weeks.  Dr. Rosenberger is pretty aggressive in treating acne and works to target each stage of acne.  By doing this, most of her patients are somewhat improved by their six-week visit.  You must return for a follow-up.  Dr. Rosenberger will see you at six to 12-week intervals until you are clear or very close to clear.  If you do not follow up, and if you do not use your medications, you will not have the most effective response.  Dr. Rosenberger also likes to taper down your medication as you get better, working to have you as “clear as possible on as little medicine as possible.” She has a set way of doing this that she tailors to each patient. 

Treatment for Blackheads and Clogged Pores- the first stage of acne. 

As stated above, acne generally gets started because the pores are clogged with our own dead skin that does not shed as well as it should.  This, combined with the dirt and oils on our skin, leads to clogged pores and blackheads.  Many OTC regimens do not specifically target this beginning stage of acne.  For this reason, OTC regimens, including systems like Proactiv, do not lead to long term clearance.  Not targeting the beginning lesion of acne leads to just “putting a bandaid on lesions as they come.”  We want to stop acne from the earliest stage.   

Topical Retinoids – Topical retinoids, vitamin A derivative creams, include RetinA or tretinoin, Aklief, Differin/adapalene, Epiduo, and Epiduo Forte, and Tazorac/Fabior.  Retinoids work in a variety of ways.  These medications may initially irritate the skin because they cause the skin to peel.  By forcing the skin to peel initially, these medications remove all of the old dead skin, clogging the pores.  After the initial transition phase with redness and peeling, which may last 6-18 weeks, the skin begins to shed in a normal, healthy way.  In the long term, these medications improve skin texture and tone, reducing pore size, and building up collagen.  Building up collagen helps reduce the appearance of acne scars with time.  If you have irritation that persists beyond 12-18 weeks, Dr. Rosenberger may reduce the strength or change your retinoid.  These medications are traditionally used at night because RetinA and tretinoin are broken down and inactivated by sunlight. It is very important to stick with these medications.  In the long term, this is the medication acne patients should never stop.  Every time you do stop and start, you WILL have the same peeling and redness that you had initially.  If you feel like your skin is too dry, you can add Cetaphil cream as needed.  Other options to manage this include a ZO facial peel, ZO Exfoliation Accelerator, or ZO Enzymatic Peel, an at-home peel.   

Salicylic Acid – Salicylic acid is the acid form of aspirin.  It helps acne in two major ways.  First, just like aspirin, it can be anti-inflammatory, helping to calm down red, irritated skin lesions.  Secondly, salicylic acid also can help break down dead skin and help skin shed as it should.  Salicylic acid can be found in acne washes, acne topicals, and chemical peels.  The ZO skin care line we sell in the office includes products that contain salicylic acid in both the wash and the pore and oil control therapy.  It is most appropriate for those with oily skin and lots of clogged pores.  It works great on stubborn clogged pores.  The ZO Facial Peels we offer in the office also utilize salicylic acid.  

Topical Antibiotics 

Topical Sulfur and Sodium Sulfacetamide – These ingredients are old fashioned treatments for acne and rosacea making their way around again because they are incredibly effective.  There are topical creams, masks, washes, and pre-medicated cleansing cloths.  Name brands include Plexion and Avar, but there are MANY generics.  These help kill bacteria and are very anti-inflammatory.  Dr. Rosenberger likes the medicated cleansing cloths formulation for their ease of use.  These cloths make an excellent cleanser.  They are individually packaged and just require a little water to be added.  She recommends these for athletes and those who work in an acne-causing environment.  These work great on back and chest acne because they do not bleach clothing like benzoyl peroxide washes.   The ZO skin care line also includes a Sulfur Masque.  The Sulfur Masque is also used in the ZO Acne Facial Peel. 

Topical Benzoyl Peroxide– Helps to kill C. acnes, the bacteria involved in acne.  This ingredient is commonly seen in OTC medications.  There are prescription-strength creams and gels as well. Unfortunately, many studies have shown that many people who have used these medications have developed bacteria resistant to this medication, which is why combination medications described below were developed.  REMEMBER – products containing Benzoyl peroxide can bleach washcloths, pillowcases, and clothing, so be very careful.   

Topical Clindamycin- this is another topical antibiotic that has been shown to be effective in killing C. acnes, the bacteria that is involved in acne. There are lotions, creams, gels, and solutions available.  Unfortunately, several studies have shown that many people who have used these medications also have developed bacteria that are resistant to this medication.  This is why the combination medications described below were developed.  

Combination Topical Clindamycin and Benzoyl Peroxide – These topical medications were designed to treat those resistant to the above antibiotics.  The use of these medications is also less likely to trigger resistant bacteria in the future.  There are a number of trade name products – Benzaclin, Acanya, Onexton & Duac.  All have the same active ingredients.   

Oral Antibiotics  

Oral antibiotics in the tetracycline class have been used for acne for many years.  In our experience, patients have a quicker and more thorough improvement when oral antibiotics are added to their regimen.  The most common side effects of these medications are GI upset.  These medications are often taken long term, even many years, to help keep acne under control.  However, recent studies have shown that we can often gradually reduce the dose to a very low dose with time.  These newer “low dose” regimens help acne by their anti-inflammatory effect without affecting bacteria levels.  The two most commonly used antibiotics are doxycycline and minocycline. 

Doxycycline – Most common side effects include GI upset and sun sensitivity.  The maximum and starting doses are 100mg twice a day.  The original low dose studies were done with doxycycline.  Often one can take as little as 20mg twice a day to effectively treat acne.  Name brands of these low dose medications to include Oracea (40mg) and Periostat (20mg twice a day), and Targadox  (50mg). Often Dr. Rosenberger prescribes generic doxycycline.  However, for those who cannot take a pill, name brand Doryx delayed-release tablets can be crushed and mixed into foods.   

Minocycline – Maximum and starting doses are 100mg twice a day.   GI upset and sun sensitivity are rare.  However, there are two rare side effects, which include a lupus-like reaction which resembles a flu-like illness, and a blue-gray discoloration.  These side effects are rare, but Dr. Rosenberger has seen them both.  The blue-gray discoloration can appear in scars, ears, eyes, teeth, and other cartilage areas; this is seen most often only in those who have been on minocycline for an extended period.  Often Dr. Rosenberger prescribes generic minocycline.  However, there are low dose extended-release forms of minocycline, Ximino, and Solodyn, that have a superior side effect profile.  These are dosed based on the patient’s weight, which can dramatically reduce the amount of medication a patient receives and thus reduce long term risk of the blue-gray discoloration.   

Treatment for Severe Nodular or Cystic Acne 

A dermatologist should treat people with nodules or cysts. For patients with severe inflammatory acne that does not improve with medicines such as those described above, a doctor may prescribe isotretinoin, which is a form of Vitamin A (name brands –Accutane, Amnesteen, Claravis, and Sotret). It markedly reduces the size of the oil glands so that much less oil is produced. As a result, the growth of bacteria is decreased. 

Advantages of Isotretinoin (Accutane) Isotretinoin is a very effective medicine that can help prevent scarring. After 15 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in up to 90 percent of patients. In those patients where acne recurs after a course of isotretinoin, the doctor may institute another course of the same treatment or prescribe other medicines.  

Disadvantages of Isotretinoin (Accutane) Isotretinoin can cause congenital disabilities in the developing fetus of a pregnant woman. It is essential that women of childbearing age are not pregnant and do not get pregnant while taking this medicine. Women must use two separate effective forms of birth control simultaneously for one month before treatment begins, during the entire course of treatment, and for one full month after stopping the drug. They should ask their doctor when it is safe to get pregnant after they have stopped taking Accutane. 

Other Considerations Some people with acne become depressed by the changes in the appearance of their skin. Changes in mental health may be intensified during treatment or soon after completing medicines like Accutane. A doctor should be consulted if a person feels unusually sad or has other symptoms of depression, such as loss of appetite or trouble concentrating.  Most patients treated with Isotretinoin have reduced depressive symptoms after treatment because they are so happy with their healthy new skin.  

Other possible side effects include dry eyes, mouth, lips, nose, or skin; itching; nosebleeds; muscle aches; sensitivity to the sun; and, sometimes, poor night vision. More serious side effects include changes in the blood, such as an increase in triglycerides and cholesterol, or a change in liver function. To make sure Accutane is stopped if side effects occur, the doctor monitors blood studies that are done before treatment is started and periodically during treatment. Side effects usually go away after the medicine is stopped. 

Treatments for Hormonally Influenced Acne in Women 

Clues that help the doctor determine whether acne in an adult woman is due to an excess of androgen hormones are hirsutism (excessive growth of hair in unusual places), premenstrual acne flares, irregular menstrual cycles, and elevated blood levels of certain androgens like DHEA and Testosterone.  Birth control pills can be prescribed to help with hormonally induced acne.  It is important to realize that not all birth control pills make acne better, and many make it worse.  Here’s why.  Most birth control pills contain both estrogen and a type of progesterone.  Estrogen is the primary female hormone and has less of an effect on acne.  The progesterone varies between each type of birth control pills.  Some types of progesterone are highly androgenic (contain lots of the male hormone androgen properties), some are low androgenic, and others are anti-androgenic.  I recommend Yasmin or Yaz as a birth control pill of choice for women with hormonally induced acne.  The progesterone in Yasmin or Yaz is anti-androgenic.  For women who are no longer able to have children, we can use spironolactone.  Spironolactone is a diuretic that contains anti-androgenic side effects.  This medicine can impact potassium levels, so potassium needs to be monitored.   

Other Treatments for Acne 

Doctors may use other types of procedures in addition to drug therapy to treat patients with acne. For example, the doctor may remove the patient’s comedones during office visits. Sometimes the doctor will inject cortisone directly into lesions to help reduce the size and pain of inflamed cysts and nodules.  These techniques are often reserved for patients not responding to other methods because they can cause scarring.   We almost NEVER do either of these things.  

Chemical peels can also be used to help those with large pores and lots of comedones.  For acne, we use a type of chemical peel called salicylic acid.  This acid is fat-soluble, so it is attracted to the clogged and dilated pores.  It works by breaking down the adhesion of the contents in the blackheads to be more easily shed when the skin “peels.”  We now offer ZO Acne Facials, which include a chemical peel with salicylic acid.  

Photodynamic Therapy for Acne Treatment 

Photodynamic Therapy is a procedure that uses a topical medicine called aminolevulinic acid ( name brands are Levulan and Ameluz.  These treatments can be beneficial, but are usually reserved for patients who have failed other treatments or who can not take oral medications and Accutane for some reason.  Although some insurance companies may reimburse for a portion of the cost of treatment, the entire cost of treatment is often not covered by the insurance company.  The cost of the treatment is 600/per session, and usually, 3-4 treatments are required as well as maintenance treatments. The majority of the cost is the solution we apply called Levulan or Ameluz, which is $290-450.  Some patients can get this medication using their pharmacy benefits to reduce the cost of the procedure.   Payment is required in full before each treatment. Any amount reimbursed by your insurance company will then be directly refunded to you.  If you would like to check on your insurance company’s reimbursement, you will need the following codes – 99211 modifier 25, 17111, J7308 for the Ameluz solution, Diagnosis of Acne Vulgaris ICD9 L70.0. 

Treatment for Acne Scars

Step 1 – Completely clear the acne.  Do not pick! 

Step 2 – Continue a topical retinoid to help with acne scarring along with other maintenance medications needed.   

Step 3- Consider Laser Genesis or Microneedling. 

Early aggressive treatment and avoiding picking at lesions is the best way to prevent acne scars. Once scarring has occurred, a laser may be used to treat irregular scars.  We use a treatment called Laser Genesis to help stimulate collagen and improve color in acne scars.  The benefit of Laser Genesis is that there is no downtime, but it can take months to see the full result.  Another treatment for acne scarring is subcision, which involves freeing up the depressed scars from the underlying tissue.  Dermabrasion (or microdermabrasion), a form of “sanding down” scars, is sometimes combined with the subsurface laser treatment; however, Dr Rosenberger prefers to use more effective and less invasive treatments.  The newest modality available for treating acne scarring is microneedling.  In this procedure, the device pokes thousands of holes in the skin to help stimulate new healthy skin through the old scars.  It works quite well but does also have a few days’ downtime.  Insurance does not pay for any of the procedures available for acne scarring.   

How Should People With Acne Care for Their Skin? 

Clean Skin Gently Most doctors recommend that people with acne gently wash their skin with a mild cleanser, once in the morning and once in the evening, and after heavy exercise. Some people with acne may try to stop outbreaks and oil production by scrubbing their skin and using strong detergent soaps and rough scrub pads. However, scrubbing will not improve acne; in fact, it can make the problem worse. Patients should wash their face from under the jaw to the hairline. It is essential that patients thoroughly rinse their skin after washing it. Astringents are unnecessary unless the skin is very oily, and then they should be used only on oily spots. We also recommend that patients regularly shampoo their hair. Those with oily hair should shampoo it every day.  Females should tie up their hair while drying and at night while sleeping.   

My preferences for OTC skincare- I prefer Neutrogena Oil-Free acne wash, Cetaphil deep cleansing bar, Cetaphil gentle cleansing wash for those with dry or irritated skin, and the Cetaphil Oil Control.  For more advanced cleansing, I like ZO Exfoliating facial cleanser and sulfur-based prescription washes and cloths.   

Avoid Frequent Handling of the Skin People who squeeze, pinch, or pick their blemishes risk developing scars or dark blotches. People should avoid rubbing and touching their skin lesions. 

Shave Carefully Men who shave and who have acne can test both electric and safety razors to see which is more comfortable. Men who use a safety razor should use a sharp blade and soften their beard thoroughly with soap and water before applying shaving cream. Nicking blemishes can be avoided by shaving lightly and only when necessary.  When we shave, we make hundreds of microscopic nicks in the skin.  Bacteria on the skin rush into the open pores and nicks in the skin.  Those with acne irritated by shaving and lots of ingrown hairs may want to consider laser hair removal. My husband favors Neutrogena Men’s Shave Gel.  After shaving, those with acne in the beard area should use a topical antibiotic such as Clindagel in the freshly shaved area to avoid bacteria entering the pores. I prefer the non- benzoyl peroxide topicals because otherwise, shirt collars end up bleached by the benzoyl peroxide.    

Avoid a Sunburn or Suntan Many of the medicines used to treat acne can make a person more prone to sunburn.  The retinoids peel off your dead skin and leave a fresh new baby layer of skin more prone to sunburn. A sunburn that reddens the skin or suntan that darkens the skin may make blemishes less visible and make the skin feel drier. However, these benefits are only temporary, and there are known risks of excessive sun exposure, such as more rapid skin aging and a risk of developing skin cancer.  Scars will take longer to fade if continually stimulated by the sun. When we are trying to improve scars, we work to build up collagen.  Sunlight and UV exposure breaks down collagen and impairs healing of scars.   Many with acne are hesitant to wear sunscreens. Look for one that is labeled non-comedogenic/doesn’t clog pores.  

Choose Cosmetics Carefully  People being treated for acne often need to change some of the cosmetics they use. All cosmetics and moisturizers, such as foundation, blush, eye shadow, and moisturizers, should be labeled NON-COMODOGENIC/Doesn’t clog pores. If a product does not say this, it will clog your pores and make your acne worse. Patients may find it difficult to apply foundation evenly during the first few weeks of treatment because the skin may be red or scaly, particularly with topical tretinoin or benzoyl peroxide. Oily hair products, especially hair pomades, may eventually spread over the forehead, causing closed comedones. I prefer and recommend Oxygenetix Sunscreen sold in the Spring Boutique as a foundation for acne-prone skin. 

What about the skin care line we sell in the Spring Boutique?  ZO Skin Care Line Standouts! 

ZO skincare is the latest innovation of Dr. Zein Obagi. You can learn more and shop here. Products can be purchased in the office or online.  Products designed to treat acne include:

Exfoliating Cleanser –Exfoliating cleanser for normal to oily skin.   

Sulfur Masque – I often recommend this if a patient’s insurance does not cover the prescription sulfur washes.   

Oil Control Pads – pads that contain salicylic acid as well as a number of anti-inflammatory agents. 

Acne Control– Contains prescription strength 10% benzoyl peroxide as well as other anti-inflammatory ingredients.  Great for a spot treatment.  

Instant Pore Refiner – Refines enlarged pores by minimizing the amount of oil on the surface of the skin for a shine-free, matte appearance.  Also works to exfoliate dead skin cells around pores and reduce inflammation. 

Enzymatic Peel– This at home chemical peel can be a real social life saver to those who are frustrated with the peeling from retinoids.  No downtime, but great results.  

Sunscreen + Primer and NEW Powder Sunscreen – a high SPF chemical sunscreen that leaves a super smooth matte finish for those who have oily skin. 

FINAL THOUGHTS FOR ACNE PATIENTS 

FOLLOW UP & CONSISTENCY IS ESSENTIAL!  Remember that we shed our skin every 6-8 weeks. That means your skin WILL NOT be better in 6-8 days.  It takes time.  Realistically it will take 2-3 months to see a consistent, long-lasting change toward long term clearer skin.   

IF YOU WANT TO BE BETTER, IT TAKES TIME AND ENERGY!  Use your medications as directed.  If you are having trouble with medicine not agreeing with you or if something is too expensive, LET US KNOW!  We want to help. You can reach us and fully describe your problem at the Patient Portal or using the Healow app.  Under the “Ask the Doctor” feature, you can send a message directly to your doctor, and we can reply directly to YOU!   

COME TO YOUR FOLLOW UP VISIT!  This is where we tweak things up, to optimize your regimen for CLEAR SKIN!   

NEW! ACNE 12 WEEK GET CLEAR PLAN 

What is it?  An advanced acne treatment regimen for those who want quick results and are willing to invest time, energy, and resources to make it happen. 

OK, But what is it? A structured, but individually tailored, plan utilizing our 15 years of experience, close follow-up and in office treatments. 

OK, But what is it really and what is the cost? 

Initial Visit (Week 0)  (Copay/Insurance Billed or $125 self pay) 

  • VISIA analysis and baseline photos 
  • Consultation with Doctor or Nurse Practitioner 
  • Skin culture 
  • Prescriptions for oral and topical treatment 
  • BLU-U Blue Light Acne treatment 

Follow Up Visits at Weeks 4, 8 and 12.  

(Copay/Insurance Billed + $100 OR $175 self pay) 

  • VISIA analysis and photos  
  • Consultation with the Doctor or Nurse Practitioner to review and tailor a prescription regimen 
  • ZO Acne Facial with additional BLU-U Treatment  

BLU-U Blue light acne treatments twice a week. (Package of 20/$400) 

Photodynamic Therapy at 6 weeks ($450 if insurance does not cover Levulan) 

Because of the structured nature of this plan, we will have: 

  • Scheduled start dates each month. 
  • Pre-scheduled and reserved days for visits and facials 
  • Limited availability.  

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Carissa Santmyire, RN

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 Santmyire, APRN-BC, DNP

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.

Beth Santmyire-Rosenberger, MD PhD
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

Eskata

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.

Colorescience

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Laser Vein Reduction

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.

Intense Pulsed Light

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 Blue Light Acne Treatment

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. 

 

 

Excimer Laser

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.

Phototherapy

What is UVB and how does it work?

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. 

How is UVB administered?

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.

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 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.

What are the side effects of UVB treatment?

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.

Sunburn

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.

Skin cancer

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.

Insurance Coverage and Prior Authorization

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.

Photodynamic Therapy
Photodynamic Therapy

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…

  • Cryosurgery or freezing –Best if there are just a few lesions. Benefit is that it is quick and easy and most insurances cover this therapy.  After treatment in the office, the treated spots usually fall off in 7-21 days.  Biggest negative is that it can leave some discoloration or a scar.
  • Creams – There are a variety of chemotherapy creams available. Generally, I consider this to be the most effective and thorough option, but it is miserable and expensive.  As a positive, it can be thorough in that it can be applied to a large area.  Application of creams to the area causes destruction of any abnormal cells.  Lesions usually resolve nicely without any discoloration or scarring. However, any abnormal areas turn red, scabby and crusty for about 6 weeks.  Most of the creams are applied for 30 days and it takes a few weeks for the reaction to resolve. Unfortunately, the price on these creams has greatly increased to over $1000 in many cases.  To read more about these creams, check out our prior post on Topical Chemotherapy for your skin.
  • Photodynamic therapy (PDT)– is a light treatment that is done in the office and is covered by many but not all insurances. Usually performed on the entire face or scalp, the benefit again is that we can be very thorough without the extensive redness, scabbing and crusting.

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

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

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.

Zo Peels and Facials

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.

 
 

 

Microneedling
Microneedling

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.

Kybella

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.

Fillers

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!  

BOTOX , Xeomin &Jeuveau
 First, let’s review the science. Botulinum toxins have been used for almost 20 years to relax muscles. Botox was first FDA approved in 2002, followed by Dysport in 2009. Xeomin in 2011,  Jeuveau in 2019, and Daxxify in 2022.  These toxins work by binding the neuromuscular junction.  Once bound, botulinum toxin blocks the release of Acetylcholine, which sends the signal from the nerve to the muscle, preventing muscles from contracting.  The effect of relaxing the muscle generally lasts 3-4 months.  In that time the Botulinum toxin molecule is degraded and no longer performs its relaxation function.  The effect is in no way permanent.
 

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!   

 
ISDIN

Eryfotona Actinica

Photo Eryfotona Ageless

SI- Nails