Bioidentical hormones - what's the hoo-ha?

Here are the facts:
1. Many peri-menopausal women (and men!) suffer symptoms (which in worst case scenarios have driven depressed women to suicide)& need therapy to function day to day.
2. Since the WHI report about increased risk of breast cancer, many people & doctors have turned away from HRT (hormone replacement therapy).
3. The void for HRT has to be filled - voila - bioidentical hormones!

What are bio-identical hormones (BIH)?
They are structurally identical to hormones naturally secreted by your own body. They can be plant-derived or they can be manufactured artificially.

What's the controversy of BIH v. synthetic hormones?
Proponents of BIH say that BIH is safer than synthetic hormones because the structurally dissimilar synthetic hormones tend to bind incompletely to hormone receptor sites & they break down very slowly leading to side-effects such as increased lipids, blood clotting risk, blood pressure, etc. Opponents say that there is no evidence-based large trials to support this claim that BIH is safer.

Synthetic hormones have been in use the last 5 decades so there has been plenty of pharmaceutical company money poured into large scale randomized double-blind placebo controlled studies. The conclusion is synthetic hormones pose an increased risk of breast cancer for women. Bio-identical hormones have largely been used small scale by compounding pharmacies until it came into vogue in 2002 when the cancer scare about synthetic hormones erupted. At least there are no studies to prove that BIH increase your risk for cancer! In fact, there are small scale European studies showing safety of BIH. There are increasingly available in the market, USA FDA- approved or Australian TGA-approved bio-identical hormones. These products will produce constant, low levels of natural hormones required to reduce menopausal symptoms, with proven endometrial safety profiles.

As to opponents who say that BIH are not effective for menopausal symptoms - this I can say is absolutely untrue because I've had 1st hand information of people whose quality of lives have been vastly improved on BIH (the good quality product), not to mention countless celebrities, individuals & doctors round the world who trumpet its cause.

What say me?

As doctors, we cannot simply condemn something just because it is new, endorsed by celebrities & unproven by large scale trials. If someone said stomach ulcers were caused by bacteria 30 years ago, they would be proverbially burnt at the stake. Today, we know this as a proven fact.

Moreover, if we, as doctors, prescribe synthetic hormones to acne sufferers, menopausal ladies & dwarfs, we would be hypocrites to condemn bio-identical hormones which intuitively would seem safer as it's closer to nature.

What should a consumer choose?

As always, if something ain't broke, you don't try to fix it. If you ARE suffering from peri-menopausal symptoms, i.e. hot flushes, mood swings, sleep disturbances, depression, etc, then you should defintely opt for BIH. But, DO YOUR BLOOD TEST and work with your doctor.

If you're aging & life gets too unbearable with milder symptoms - dry vaginas, wrinkly skin, droopy breasts, forgetfullness, and you want some therapy, BIH over conventional hormones is the way to go. Do discuss with your doctor the pros & cons.

How about the "preventative" anti-aging effects of hormone replacement therapy?
The preventative anti-aging effects of hormone replacement are very real. As an informed consumer, you have to decide if the possibility of a small risk in increase of relative risk of cancer is worth the trade-off of staying younger for longer. But even before jumping on the band wagon, look at your diet, lifestyle & environment - it's more important to "take charge" of your life than sticking on hormone band-aids. There are many women who go through menopause without any symptoms at all because they have stayed healthy, not stressed their hormonal glands & just breezed through it by just eating right, exercising right & living right.

The good thing about all this debate is that it makes people more aware of their own bodies & encourages people to take charge of their own lives.

Elken's Eternal Beauty device

A patient by the name of Diana has asked what I think of Elken's Eternal Beauty device. I have not tried it personally (wouldn't waste my hard earned money buying it) so my comments will be confined to analysis of the claims made on their website.

I've pasted below the claims made on their website. My comments in CAPITALS:

"ETERNAL BEAUTY SG harmonises the beauty of nature with science by using naturally occurring bio materials to produce a multi-functional, home-use beauty and health device. It is an award-winning invention which can naturally emit Far Infrared Rays, Anion and Germanium with Sonic Vibration capabilities. Together, they work to provide maximum benefits to your beauty and health, both inside and out.

4 Technologies in 1 Revolutionary Device

Far Infrared Ray (FIR)
- FIR emission of 90% with the most beneficial wavelength (5-20µm)
- Penetrates up to 40mm into subcutaneous tissue
- Stimulates blood & lymph circulation
- Anti-bacterial"

INFRARED LIGHT IS USED CLINICALLY IN WOUND HEALING & PAIN RELIEF BUT THE WELL-KNOWN DEVICES TYPICALLY USE LIGHT IN THE 600-1000 NM RANGE, NOT THE WAVELENGTHS MENTIONED ABOVE. WOULD LOVE TO SEE THEIR SCIENTIFIC REFERENCES WHICH ARE STARKLY MISSING.


"Anion
- Air vitamins
- Neutralises harmful free radicals
- Promotes epidermal cell renewal"

ANIONS ARE NEGATIVELY CHARGED MOLECULES. WHAT ANIONS ARE THEY REFERRING TO? CYANIDE? FLUORIDE? BICARBONATE?

IONIC AIR PURIFIERS USE ELECTROSTATICALLY CHARGED PLATES TO PRODUCE CHARGED IONS THAT ATTRACT DUST PARTICLES. WHY WOULD YOU WANT A GADGET THAT TREATS THE SKIN TO ATTRACT DUST PARTICLES?!

THE 2ND & 3RD STATEMENT IS AGAIN MORE BS.

"Germanium
- A metalloid (semi-metal) element and a natural semiconductor
- Penetrates skin cells and neutralizes imbalance cells"

GERMANIUM IS A METALLOID SEMICONDUCTOR USED IN THE ELECTRONICS INDUSTRY. THE ONLY JUSTIFIABLE USE IN THIS GADGET IS ITS USE AS AN OPTICAL MATERIAL TO ALLOW INFRARED LIGHT TO PASS THROUGH. THE SECOND STATEMENT "neutralizes imbalance cells" IS JUST UTTER NONSENSE. THEY CAN'T EVEN GET THE ENGLISH GRAMMAR RIGHT.

"Sonic Vibration Technology
- Sonic Vibration output at 11000rpm
- 11000 times of vibrations in 1 minute
- Stimulate and exercise muscles
- Encourages metabolism and formation of elastic fibres"

SONOPHORESIS IS A PROCESS THAT USES ULTRASOUND TECHNOLOGY TO INCREASE ABSORPTION OF COMPOUNDS INTO THE SKIN. IT IS WIDELY USED IN SALONS TO DELIVER GELS & CREAMS INTO THE SKIN. THE 3RD & 4TH CLAIMS ARE AGAIN UTTER NONSENSE. IT CERTAINLY WON'T EXERCISE MUSCLES, IT WOULD JUST MAKE YOUR FAT VIBRATE.

Summary:
The only positive "technologies" I can see in this gadget are infrared light (if they have the correct wavelength) & sonophoresis, both of which are far from "revolutionary".

I hate it when these MLM companies throw around a few chemistry terms in the hope that people will be conned into thinking it's a product based on science. They certainly don't bother to reference their claims to any scientific studies.
Furthermore, they make unsubstantiated scientific claims to justify their RM1700 price tag. You can buy a simple infrared light & ultrasound gadget for a much smaller price tag.

Benefits on skin, breast & cellulite don't come from this gadget - it comes from the compounds that you apply on your skin. Sonophoresis just aids absorption.
The creams from Elken don't particularly have any magical ingredients that will do wonders to your skin either.

So there you have it - a totally impartial view from a non-Elken distributor!

What is mineral makeup?

What is mineral makeup (MMU)?

Mineral makeup (MMU) is makeup made from powdered minerals obtained from mother nature. It’s historical roots go back thousands of years as women & men have been applying “coloured earth” on their skin since the beginning of time.

Why choose Mineral Makeup over the usual commercial makeup?

1) Many of the ingredients have special properties. E.g. zinc oxide is a proven anti-inflammatory agent (even safe to apply on babies’ faces!),which makes it great for skin which has just undergone cosmetic treatments such as chemical peels or laser rejuvenation.

2) Because it is non-comedogenic (won’t clog pores) and oil-free, you can even sleep in it! It is the most ideal makeup for acne-prone skin.

3) It is a natural and effective sunblock as the formula contains titanium dioxide and zinc oxide. In light applications, the SPF is around 10. In heavier applications, the SPF goes up to 35.

4) Coverage is light-weight & complete, which is ideal for problematic skin with rosacea & hyperpigmentation.

5) Mineral Makeup is water-resistant & long-wearing. You can even swim in it & still look glamorous! It is a great choice for people who are physically active or live in hot humid environments like Malaysia.

6) It contains no chemical preservatives (the raw minerals are inert & cannot support the growth of bacteria or mould) so does not irritate even the most sensitive of skins or eczema-prone skin.

7) MMU is fast & easy to apply & gives a flawless finish.

“Bad” ingredients in existing brands of mineral makeup

1) Bismuth oxychloride – It is an ingredient used in cosmetics to produce shimmer. The only thing positive about it is it does not cause cancer (according to a study done by Carcinogenic Potency Project at the University of California). However, it causes bad acne flare-ups & may even cause acne cysts. It also causes rashes in sensitive skin sufferers of eczema & rosacea. Bare Escentuals, Glominerals & Youngblood are 3 common brands that contain this dreaded ingredient.

Pure MMU uses silk & pearl powder in its formulation to give the product a soft silky feel, not cheap fillers like bismuth oxychloride

2) Talc – It has long been known that talc causes ovarian cancer. A study from the Harvard Medical School showed that women who use talcum powder have a 40% higher risk of getting ovarian cancer – something recently highlighted by the Consumer Association of Penang (The Star 18/2/2009). It is also linked to all manner of lung problems. International makeup brands like MAC, Johnson & Johnson baby products all still contain talc!

3) Cornstarch – used as a drying agent for oily skin. It may irritate the skin in some individuals & is a breeding ground for bacteria so check expiration date of the product if it contains cornstarch.

1) Parabens – used in almost all cosmetics as a preservative to prevent contamination by bacteria, yeast & mould. There has been many internet rumours about parabens causing cancer but the National Cancer Institute has found no conclusive link between parabens & cancer. It can however, cause contact allergy. Pure MMU does not use parabens as preservatives, instead uses natural essential oils.

2) Mineral oil – used commonly in cosmetics as a barrier cream to prevent dehydration. If it is cosmetic grade mineral oil, it is safe & doesn’t cause cancer as propounded in internet rumours. It can however, aggravate acne in some people.

3) Lanolin – derived form wool grease is a great moisturizer however, it can cause allergic reactions and clog pores.

How to apply MMU

1. Apply your normal skincare first. The mineral powders adhere to the natural oil of your skin, and if your face is too dry, the powder might end up looking like just that - powder. Apply the base moisturiser and wait 10 minutes, as a face too oily would melt the make-up. Trial and error might be needed to find the perfect balance.
2. Apply eye liner first (to avoid smudges from sprinkles) and use your kabuki brush to dust off any powder droppings from your cheeks
3. Tap a small amount of foundation into the cap of the jar. This helps avoid using too much, and you could always add more layers if denser coverage is desired.
4. Dab on concealer you may need to areas such as under the eyes. Press fingertip in foundation for a concentrated amount and dab your blemishes to make them disappear.
5. Swirl the kabuki brush in the cap, then tap the brush to dust off the extra powder. The brush is most important in covering large areas of your face, and an inferior brush might make the make-up look artificial. You might want to invest in a decent one.
6. Apply the foundation by rubbing the brush on your skin in a circular motion. This is where you decide how the make-up will look. Start lightly on the cheeks and move off to the side of your face. The brush isn't supposed to just dust your skin with powder, it’s going to BUFF the powder, to help it adhere to the oil in your skin. The more you buff, the heavier the coverage will be. This takes practice. Keep applying light layers until you achieve the coverage you want.
7. Once you have the look you want with foundation, apply a setting powder. Apply it the same way you would the foundation. Without it, the make-up will eventually look a little tired. With it, the makeup will hold much longer and look less sweaty. You can really tell the difference between using it and skipping it.

Trouble-shooting Mineral Makeup Application

• Always use a moisturizer that will not clog pores. If your moisturizer does not absorb into your skin, neither will your mineral makeup!
• Use a setting powder on eyelids to set shadows and avoid creases.
• For those with oily skin, use setting powder as a base all over - it will help absorb the oil naturally. Also, finishing off with a setting powder will also aid in oil absorption & help you obtain a matte finish.
• Apply mineral eye shadow as usual- lighter colors under brow line and darker colors on the lid.
• Using a good quality mascara with keratin will help strengthen lashes.
• The foundation will look a little powdery when you first apply it. It will settle into your skin and look much more natural in a few minutes.
• A kabuki brush is essential to covering your face, but a smaller brush will serve to use the powder as a concealer if you want to use it that way.

• If the foundation looks too thick & pasty, check:

1) The brush – you need a brush that has a high density of hair which are short, firm & soft.

2) Is there too much product on the brush? Mineral makeup is very concentrated as it is made up of pure pigment; the same pigments that cosmetics companies use to add color to pressed and liquid foundations. Because there is little “filler” in this type of powder, it is imperative that you put just a little bit of powder on your brush and buff it in well in a circular motion before applying more.

3) Is it the right shade for you? Blending one shade with another will achieve the perfect shade for your desired look.

4) Not enough buffing - Buffing with the brush actually brings out the qualities of the minerals. Use a firm touch, and in a circular motion, blend, or spread the makeup around the cheeks, down the jaw line, over the nose. Do this several times, and you will begin to see your face glow and your skin look flawless and natural.

Face pigmentation - cost-effective management

Increased pigmentation has multiple causes, ranging from hormonal issues to sun exposure and the use of some medications. Any treatment must address the cause where possible.

The bane of most women is melasma, also known as chloasma or the "mask of pregnancy"— a dark skin discoloration found on sun-exposed areas of the face. It is often associated with the female hormones estrogen and progesterone, i.e. pregnant women, women who are taking oral contraceptives, and women who are taking hormone-replacement therapy during menopause. However, it is also seen in women who are not pregnant or on the pill. Rarely, it is seen in men.

Most patients want a quick fix (which, unfortunately, does not exist) and are thus vulnerable to those who will prey on their insecurities. Not uncommonly, I see patients who have paid upwards of RM5000 for a series of laser treatments & promised a miraculous cure - only to have the melasma rebound with a vengeance several weeks later.

Although my clinic has a fractional laser & a double frequency Ndyag laser, I do not treat melasma with laser that can cost thousands. Instead, I always start with Triluma cream - a compound of hydroquinone, tretinoin, and a topical steroid - costing RM250. In more than half the cases, they see lightening of the melasma within 2-3 months.

Unfortunately, not all patients with melasma have this kind of positive response. For example, some patients will not see improvement if they continue to take oral contraceptives or hormone replacement therapy.

For patients with stubborn melasma, I might add some chemical peeling or microdermabrasion (+/- transdermal electroporation - a device that enables 100% penetration of topicals applied). As a last resort, I might try laser-based or intense pulsed light (IPL) treatment.

Each new laser that hits the marketplace seems to make claim of how well it can treat melasma. Usually, the results do not live up to the hype. The latest laser to make this claim is copper bromide laser (brand name Dual Yellow laser). This laser hasn't arrived in Malaysia yet so I can't make further comment about it's effectiveness. Results from lasers or IPL have been mixed, with some patients showing significant improvement and others showing darkening.

Other types of hyperpigmentation, such as that caused by chronic sun damage, is more of a static process that tends to be easier to treat. These are termed lentigines or "liver spots". These are easily treated with a double-frequency Nd:YAG laser. Most patients will see a 70% to 80% improvement with one treatment.

For patients who have many, many spots or who cannot tolerate downtime, IPL would be a better choice. Some lucky patients will see some improvement in fine lines, but more often not. IPL is not good treatment for fine lines.

Fractional CO2 resurfacing has become one of the newest, more exciting advances in laser technology. Compared to traditional laser resurfacing, which treats the entire skin surface, fractional lasers target small microscopic treatment zones, sparing the surrounding skin. During 1 treatment session, only 20% of the skin surface is lasered, preserving the healthy skin between, resulting in rapid healing following treatment. Result is an improvement in color and texture of skin. There is minimal downtime—most patients are back to work within 2 days with some mineral makeup cover. Most patients require 4-6 treatments spaced about a month apart.

There is a confusing array of treatments offered for pigmentation removal out there. It is always best to seek good medical advice firstly to diagnose the type of pigmentation & secondly to get sound medical advice as to what is the most appropriate & cost-effective treatment.

Why isn't my acne treatment working for me?

To those of you who are going from doctor to doctor, salon to salon looking for the acne miracle cure, here are a few pointers to explain why your acne treatment doesn't seem to work for you:

1. Too high or unrealistic expectations

- Key thing to remember about acne is that it is a MANAGEABLE skin problem not CURABLE. ALL ACNE CASES CAN BE ADEQUATELY CONTROLLED. You can remain acne-free as long as you remain under appropriate treatment but once you slack on treatment, acne may flare again.

- Improvement takes time... It takes at least 3 months to see good control of acne - it doesn't happen overnight

2. Using too low dose treatment resulting in ineffective treatment

It's important to follow instructions about how many tablets to take, how much to apply, how frequently, etc

3. Medications having too many side-effects reducing compliance

- antibiotics giving gastric pains & nausea or vomiting

- topical creams which are too irritating & cause too much redness & peeling

4. Intervention is too mild
For example, if you have severe inflammatory or cystic acne, don't hope for any miraculous improvements on topical treatment alone

5. Too high secretion of sebum on face diluting effect of antibiotic
You may need to take Roaccutane

6. Stopping medications too early or taking antibiotics for too long a duration

If doctor tells you to take it for 3 months, please take it for exactly that duration. Too short duration leads to ineffective treatment. Too long duration leads to development of resistant bacteria.

7. Too many clogged pores & cysts

Physical methods of extraction removal may be required

8. Underlying hormonal imbalance esp for women

Please see your doctor for further testing

10. It may not be acne at all

It could be some other bacteria if conventional acne treatment isn't working for you. Please see the doctor for review

JUST REMEMBER, ALL ACNE CASES CAN BE ADEQUATELY CONTROLLED, JUST HAVE PATIENCE & COMPLIANCE!

Stretchmarks- from Dermatologic Surgery

ALTERNATIVE APPROACHES TO STRETCH MARKS

The medical term for stretch marks is striae distensae. These occur when the skin is abnormally stretched in a rapid amount of time (ie, pregnancy, significant weight gain, rapid growth during puberty). As a result, the skin’s support structure of collagen and elastin breaks down and ruptures. Stretch marks are actually a scar that has formed from the inside out, rather than a scar that happens when the skin is externally wounded. Discoloration from these marks tends to fade over time, but the tread-mark appearance of the skin rarely returns to its original smooth state.

Not everyone gets striae though. There appears to be a genetic tendency toward them, but the exact link is not clear. There does not seem to be an ethnic tendency toward stretch marks, as all races can be affected. The type of discoloration may vary, however, in different skin tones, as those with fair to light skin typically have pink-tinged stretch marks while darker skin tones tend to be more heavily pigmented.

Conventional Treatments

Currently, there are a variety of treatments including topical tretinoin, chemical peels, microdermabrasion and non-ablative laser treatments. Brief descriptions of these conventional treatments follow.

Tretinoin: Tretinoin (Retin-A, Renova, or in generic form) can have a modest positive effect. The best results are seen when it is used at the first signs of stretch marks (red) but not when the stretch marks are mature (white).Typical improvement in these trials is a 8% to 20% reduction in length and width. The dilemma for expectant mothers is that tretinoin cannot be used during pregnancy, and is also contraindicated if the mother-to-be intends to breastfeed her baby.

Lasers/Light/Radiofrequency Devices: Intense pulsed light (IPL), pulsed dye lasers (PDL) emitting 585 nanometers (nm) of light, and the xenon-chloride laser (Excimer) emitting 308 nm treatments result in varying degrees of clinical improvement. Neodymium-doped YAG (Nd:YAG), diode and fractional lasers are the newer applications of laser technology to venture into treatment of stretch marks, all showing encouraging preliminary results.

Acid Peels: Trichloroacetic acid (TCA) peels may be of some help for improving the appearance of stretch marks when used at the proper concentration.

Microdermabrasion: There is insufficient literature about the efficacy of microdermabrasion for stretch mark improvement.

Alternative Approaches

Is there something you can do to improve or eliminate the appearance of stretch marks that is natural? The simple answer is not really. There are a lot of creams, ointments, vitamin preparations and plant oils available that largely rely on anecdotal evidence only. Below are some common preparations that you may be seeing in health food or department stores or on the internet.

The preparations below provide hydration to the skin but are unproven regarding stretch mark improvement:

• Hydrating creams: cocoa butter, shea butter
• Vitamin capsules: vitamins E, A and C
• Plant oils: rose hip, emu, jojoba, castor, sweet almond, avocado, wheat germ, eucalyptus

There are also some preparations, tested in Germany and Spain — that are combination topicals that have shown some improvement:

Combination Topicals: Trofolastin, Verum, Alphastria

• Trofolastin cream contains Centella asiatica extract, vitamin E and collagen-elastin hydrolysates.
• Verum ointment contains vitamin E, panthenol, hyaluronic acid, elastin and menthol.
• Alphastria cream contains hyaluronic acid, allantoin, vitamin A, vitamin E and dexpanthenol.

All of the studies for these topicals were tested in too few people and the active compound(s) in these preparations have not been identified so these studies are really not that helpful.

Other Topical Products: StriVectin-SD, Mederma, ScarSof Scar Softening Cream, Vita-K Solution, Magia Bella Ultra-Intensive Anti-Stretch Mark Concentrate, Maternity Solutions Stretch Mark Cream, Phytomer SeaTonic Stretch Mark Reducing Cream, Decleor Stretch Mark Restructuring Cream and Mustela Stretch Marks Double Action

These products are all heavily marketed and available in department stores, drug stores and on the Internet, and in general contain moisturizing agents, emollients and various plant oils. None of them have substantiated evidence they can make a positive impact on the formation or prevention of stretch marks. And they are ridiculously expensive: a 6-oz tube of StriVectin-SD is >RM400!

So far, no single treatment has been proven more effective than the other, although laser technology applications seem the most promising. Lastly, don't waste your money on creams, lotions or plant oils with the exception of tretinoin cream.

"Liquid facelift"?

"Liquid facelift" is a term generally used to describe combined use of botulinum toxin (only BotoxTM & DysportTM are both legally registered brands in Malaysia) together with fillers (many brands available in Malaysia) to achieve a more youthful, relaxed & aesthetically pleasing face shape. It doesn't deliver anti-gravity results like a surgical facelift but they are excellent methods of accomplishing rapid, minimal down time corrections with relatively low risk.

Who will benefit most from this procedure?
Men or women in their mid-30's up to age 60 who are beginning to notice a loss of facial volume, lines, wrinkles & folds. Ideally they should be non-smokers who have realistic expectations. If one already has excessive loose skin or has too much droopy facial fat, then a surgical facelift should be the procedure of choice.

Is it painful? How long does it take? What is the downtime?
Complete anaesthesia can be achieved with a topical cream +/- nerve blocks. The whole procedure usually takes about 1 hour. You might experience mild swelling & pink skin for a few hours. You will be OK to go back to work the next day with makeup. The may be slight bruising which can last about 1 week - easily concealed with makeup.

How long do the effects last?
The botulinum toxin effects generally last 3-6 months depending on dose injected, location, muscle activity, etc. The filler effect can last anything from 3-18 months depending on product used & technique of injection. The results continue to improve over the next 3 months as the filler absorbs fluids & the body builds more collagen around the filler.

Does it matter which brand of product is used?
For botulinum toxin, there is generally not much difference between Botox or Dysport brand.
As for fillers, it does matter very much. I prefer temporary fillers like hyaluronic acid (HA). Permanent fillers are just that - it resides permanently under the skin & will stay despite changes in face shape with age.

Can I combine this with other lasers & peels?
Yes, but it is recommended to wait at least 1 month before embarking on other procedures.

How does it compare with other "nonsurgical facelift" procedures like radiofrequency & threadlift?
Radiofrequency devices like Thermacool are more expensive & doesn't improve skin hydration or restore lost volume like HA fillers do. Results also take >3 months to become apparent whereas you do see an instant improvement with filler volume restoration & line filling. Results with botulinum toxin are apparent within 48-72 hours.
Threadlift does deliver immediate lifting but it does not improve skin hydration, texture or increased volume. How long it lasts is very much technique dependent.

What treatments work well for acne scars?

One reads of many ads in the papers touting acne scar treatment. What really works?

It all depends on the depth and type of scars - I categorize them into:

1) depressed scars - icepick or saucer-shaped

2) keloidal - more common on anterior chest

3) hemosiderin stains - red discolourations

Below is a list of treatments currently on offer with a brief commentary:

Icepick scars - best treatment would be punch excision but this is realistic only if you have a few of them. If you have multiple densely packed icepick scars, then it would be impractical to do this treatment. Another option is subcision and filler - in theory, it is quite appealing but I've seen some cases where the patient ends up with a lump under the scar which is still apparent. Another negative point is the expense of the filler material (if it is temporary then you 'll have to fork out every year). If it is permanent, there are so many controversies about what these permanent foreign bodies under your skin can do to you. Another filler option is your own fat graft but you'll have to find a plastic surgeon who is expert at doing this because fat grafts do regress somewhat.

More affordable options would be needle-abrasion and chemical reconstruction of scars - these are very affordable treatments which give good results.

Saucer-shaped scars - many treatments abound. But over the years, I've concluded that needleabrasion (>1.5 mm needle length) & fractional CO2 laser work the best. Other lasers either don't work at all or require more sessions than frac CO2 laser to achieve the same result. Microdermabrasion can help only very, very shallow scars.

Keloidal scars - Tried and tested options include intralesional steroid injections (it works but can leave red discoloration) , silicone sheet plasters or silicone gel (totally painless but may not work on everyone). Some newer options include radiofrequency, laser or IPL to "soften up" the scar - does not give consistent results but worth a try if the tried and tested options don't yield results.

Hemosiderin stains - pulsed dye laser gives best results but expensive. Cheaper option - good old chemical peel but must be done in experienced hands otherwise can result in chemical burns.

Just a quick comment on some other treatments:

DERMABRASION - it is mechanical sanding of the skin. Not suitable for Asian skin as we tend to develop post- inflammatory pigmentation.

Q-switch NdYag laser (often advertised in CN beauty salon ads) - good for fine lines but doesn't work on scars. Don't waste your money.

The short message is

- prevention is better than cure. One should not wait until it scars before treating acne because a realistic expectation from acne scar treatment is averagely 50% improvement - there can never be 100% reversal of scarred to unscarred skin.

- choose your treatments wisely and budget accordingly (make sure you can afford the full course of treatments) because half-hearted treatments will not give you much results.