Straight From the Doctor

Internal Skincare: Eating Your Way to Healthier Skin.
Skin Inc. August 2009.

It’s not a myth—we are definitely comprised of the elements that we eat. These elements are absorbed into the bloodstream and feed every cell. Each month we renew our skin, every six weeks we have a new liver and every three months we have new bones. In order to renew and rebuild these organs and tissues, we need to supply our bodies with the materials that have been lost as a result of constant use, degeneration or aging.

The problem is that we’re not getting enough nutrients to keep our cells fed. The Standard American Diet or SAD (an acronym that is most appropriate) is grossly inadequate and almost devoid of many nutrients. Americans are overfed and undernourished. Adding to the problem, many drugs interfere with the absorption of key nutrients. For example, tetracycline interferes with calcium, magnesium and iron absorption, and many antibiotics interfere with the absorption of the B vitamins, while oral contraceptives and hormones reduce levels of water-soluble vitamins.

It has been well documented in scientific literature that nutrition can play a key role in skin health. In relation to skin disease and aging, the bad news is that poor nutrition can accelerate skin degeneration. The good news, however, is that a healthful diet complete with optimal nutrition can help forestall, prevent, and even reverse skin conditions. Knowing this, it becomes clear that if you add an optimal nutrition plan to every skin care regimen, your clients can literally eat their way to healthier skin while they promote their total well-being.

What to Eat
Nutritionists commonly advise that people “eat a rainbow” of fruits and vegetables every day. Whenever possible, fruits and vegetables should be eaten raw. If they are cooked, they should be steamed to retain nutrients, or else lightly boiled. Even better, waterless cooking in the microwave preserves the most nutrients. While many believe that organic food is best, it may not always be available or cost-effective for everyone. In any case, there are 12 foods that should always be bought organically and there are also 12 foods that don’t have to be bought as organically grown products, says The Environmental Working Group (EWG).

Buy organic:
Peaches
Apples
Sweet bell peppers
Celery
Nectarines
Strawberries
Cherries
Pears
Imported grapes
Spinach
Lettuce
Potatoes

Don’t have to buy organic:
Onions
Avocados
Sweet corn
Pineapples
Mangos
Asparagus
Sweet peas
Kiwi
Bananas
Cabbage
Broccoli
Papaya

In addition to fruits and vegetables, whole grains, lean proteins and healthy fats provide the nutrients the body needs for optimal nutrition. Moreover, adding scientifically formulated dietary supplements to the diet can also be helpful as they offer the nutritional insurance needed to further optimize an individual’s personal nutrition profile. Supplements cannot replace foods, however, especially because we need good sources of fiber like fruits and vegetables. Supplements should only be used to augment the diet.

Inflammation and Cell Water Loss
Whether eaten in food form or taken as a supplement, an “internal skin care” program should incorporate plenty of anti-inflammatory foods and dietary nutrients. As we age, the body develops an ability to react disproportionately to what it perceives as an injury or invasion—either too much or too little. Inflammation is really a sign that the body is attempting to protect itself. It is also a sign of cellular water loss. Inflammation causes cell damage and has been linked to countless conditions from Alzheimer’s disease to diabetes to heart disease, and even wrinkles. When cells are not fully hydrated, they cannot function at optimal levels and this leads to cell damage and aging. Additionally, when cells deteriorate, the immune response does not function well. So, based on this “Water Principle,” the collective idea is to reinforce cellular membranes, prevent cell water loss and encourage the accumulation of intracellular water to ensure that all cells and connective tissues function at their best. But drinking water isn’t the answer—the cells have to be fed. An anti-inflammatory diet will fortify connective tissue, cells and their membranes with the antioxidants, vitamins, minerals and lipids they need for quick healing, resiliency, and supple, youthful skin.

Anti-inflammatory Foods
Anti-inflammatory foods include foods stocked with antioxidants or brightly colored fruits and vegetables, and healthful, EFA-rich protein. In skin cells, such as those found in the stratum corneum, EFAs (essential fatty acids), which are found in cell membranes, actually enhance the immune system as they strengthen the skin’s barrier function. In other words, EFAs play a part in cutaneous immunity. In sum, obtaining a good amount of EFAs through outside sources is essential to total health. In addition, alpha linoleic and gamma linolenic acids are ceaseless inflammation stoppers, as is durian extract and even sulfur.

Alpha-linoleic acid (ALA) works together with antioxidants such as vitamins C and E. It is important for growth, helps to prevent cell damage, and helps the body rid itself of harmful substances. ALA is found in vegetables, beans, fruits, flaxseed oil, canola oil, wheat germ, brewer’s yeast, and walnut oil and raw walnuts.

Gamma linolenic acid (GLA) is an EFA in the omega-6 family that is found primarily in plant-based oils. It is less common than ALA, but can be found in seed oils such as borage, evening primrose, black currant and hemp.

Durian is another anti-inflammatory food, but we don’t see much of it in the United States. It’s a native plant to Asia that offers a one-two punch to inflammation. Together, the omega-3 EFAs and antioxidants in durian act synergistically as they moderate the induction of inflammatory mediators, decreasing free-radical tissue damage; and inhibit collagen and elastin breakdown from matrix metalloproteinases (MMPs), natural enzymes in skin that degrade the skin matrix.

Early studies have also indicated that sulfur-containing foods like garlic, onions, meat, and cruciferous vegetables can offer anti-inflammatory and detoxifying benefits. Sulfur is found in every living cell in the body and it plays a key role in collagen synthesis.

Special Concerns
While inflammation-abating foods are good for cell health in general, there are some nutrients that are better than others for specific skin conditions.

Acne: Vitamin A helps normalize the production of excess skin cells within the follicles that clog the pore. Vitamins B1, B2, B3 and B6 assist with tissue growth and repair, and zinc helps reduce the inflammation of acne. Antioxidants like grape seed extract also reduce inflammation from acne and free radicals.

Menopausal Skin Issues: Melatonin, in addition to regulating sleep, is a powerful antioxidant that helps protect nuclear and mitochondrial DNA. Glucosamine is the building block for the ingredients needed to heal or repair the dermis, as well as all of the rest of the connective tissue throughout your body. And GABA, which is responsible for the regulation of muscle tone, is also a key nutrient.

Stressed Skin: B vitamins and glucosamine are essential for tissue repair and healing, as is vitamin C, coenzyme Q 10, and pomegranate, which boosts skin’s natural SPF. In addition, oregano an anti-inflammatory herb and curcumin, which comes from turmeric (found in curries), offer cell protective and anti-cancer benefits. Zinc also relieves inflammation and EFAs strengthen skin cell membranes. Lecithin, which is mainly comprised of phosphatidylcholine, is also excellent for stressed or over-processed skin as it is a major component of cellular membranes. Lecithin makes cell membranes strong so intracellular water doesn’t leak.

The ‘Pitcher’ of Health
Stepping away from the traditional idea of a food pyramid, consider the symbolism of a pitcher—a vessel that provides water. The food groups within the pitcher encourage intracellular water as they give the body the nutrients it needs to feed cells for overall health and youthful skin.

Fruits and vegetables form the base of the pitcher. We should eat more of these foods than any other group—3 or more servings a day of fruits and 5 or more servings of vegetables—for example, a small or medium-sized fruit like an apple is one serving and half a cup of chopped vegetable is one serving. Fruits and vegetables are rich in phytochemicals like polyphenols and the healing antioxidants the body needs.

Whole grains (4 to 8 servings daily) would be the next level up in the pitcher. A serving would be one slice of whole grain bread or a third cup of cooked brown rice. Avoid refined grains and carbohydrates (sugars). Whole grains are sources of magnesium and selenium. Magnesium is a mineral used in building bones and releasing energy from muscles. Selenium protects cells from oxidation, and it is also important for a healthy immune system.

Proteins (4 to 6 servings daily) would be the third level up inside the pitcher and this includes omega-3-rich fish, white-meat chicken, eggs, soy foods, fat-free and low-fat dairy products, and beans and provide most of our amino acids. Avoid high-saturated fat meat products and whole-fat dairy foods. A serving would be one medium egg or 3 ounces of fish. Amino acids give the body all the raw materials it needs to build collagen and elastin, the two substances necessary for keeping the dermis and blood vessels firm, strong, and smooth.

Healthy fats should be limited to just 3 to 4 servings a day and are next up within the pitcher. One serving would be a teaspoon of olive oil or alternatively 6 almonds. “Healthy” fats are unsaturated, such as omega-3, -6, and -9 fatty acids, which are found in flaxseed oil, extra-virgin olive oil, canola oil, natural-style nut butters, cold-water fish, and nuts.

Near the top of the pitcher, is space for supplements and water to address any dietary deficiencies.

Bridging the Nutritional Gap
Most people do not even realize that the skin symptom they see in the mirror and fatigue they feel are the result of nutrient deficiencies. We may not know the precise amounts of nutrients that each person’s body needs to close the gap between what’s consumed and what’s missed, but we do know that certain dietary nutrients can counteract inflammation, stress, and neutralize free radicals. It’s important to remember that before there was medicine, there was food.

While not an exhaustive list, the aforementioned nutrients offer an internal route to skin health. The best that we can do is eat well and take supplemental nutrients in amounts that are greater than we can easily consume in the foods we eat, but not so much that we create imbalances or reach toxic levels. These changes can be part of a long-term, inclusive solution, augmenting current topical skin care regimens to improve the look of skin, while at the same time increasing longevity and health down to the cellular leve



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Cultural Stress is a new type of stress that is superimposed on the normal stresses of everyday life. From the advent of the digital revolution in the 1980s, to increased population and affluence, to the world-changing events on September 11, 2001, to chronic economic concerns, to the compulsion to send an endless stream of texts or to update our network of friends and family on Facebook and Twitter, many of life’s stressors have taken a more prominent and invasive position in our daily lives.

Technology is not entirely to blame for Cultural Stress, but the “freedom” to work and communicate anywhere, anytime, 24 hours a day, keeps America the land of the constantly “logged-on” workforce. Americans work longer hours than nearly anyone in the developed world - even the Japanese. For many professionals, the 40-hour workweek is history. Sixty to eighty hour work weeks are now the norm.

As a result of this pursuit to stay ahead, people experience extreme levels of on-the-job stress. According to data from the National Institute for Occupational Safety and Health, 40% of workers find their jobs stressful and 75% of people surveyed believe their jobs are more stressful now than a generation ago. Nearly 3.5 million Americans spend an hour and a half or more getting to and from work as they are pushed farther away from work in search of more affordable housing. Commuters are filling 4 a.m. trains into major cities and restaurants that opened for breakfast at 6 a.m. are opening earlier to accommodate the bleary-eyed workforce.

Americans in Isolation
Cultural Stress, whether caused by fear, overwork or too many options causing conflict in decision-making, ultimately leads to isolation. I believe isolation to be one of the most prominent diseases in today’s world. Studies have shown that to reduce isolation, people need to have regular physical and social contact, which reduces Cultural Stress and leads to happier, healthier lives.

World events have driven many Americans to isolate themselves, thus increasing depression and suicide. The CDC reported that the suicide rate among middle-aged Americans has reached its highest point in 25 years. Research indicates that Americans have fewer close friends than prior generations reported. Longer hours, lengthier commutes and the substitution of Internet contacts verses real-life connections contribute to the breakdown of social networks.

It Starts Early
Cultural Stress starts young, and while parents may not like to hear this, they are the ones who initiate it in their children. New parents are often anxious about getting their child into the best preschool. In fact, it’s common for unborn children to be placed on a preschool wait list. The next focus is on ensuring that the child is enrolled in all the right extracurricular activities - from preschool through high school. This cycle puts pressure on children to excel at a very young age, while placing a burden on the parents to make more money to pay for the education and extracurricular activities.

This scenario coupled with our society’s increasing affluence has a far-reaching domino effect. In order to make more money to pay for all the activities we are involved in, we are working longer hours. The more money we make, the more things we buy, and this phenomenon extends well beyond possessions. As we have become a more informed society, we are more aware of the endless possibilities available to us in the form of clubs, lifestyles, diets and leisure activities, to name just a few. All of this has put a great strain on our health and well-being, especially because the vast majority of Americans are barely keeping up.

Nutrition, Sleep, Depression and Exercise
Our busy, on-the-go lives have created yet another problem. We have no time to cook at home, so we have grown accustomed to eating out and as a nation we are consuming more processed foods than ever, and more foods that are fried, high in sugar, saturated fats and calories. We are eating less fruits and vegetables and this reduces the amount of antioxidants we consume. The result is high BMI (body mass index) readings and glycation, which makes us more susceptible to diabetes and increases the risk of cardiovascular disease.

Cultural stress is also keeping us up at night. Our national sleep deficit has resulted in an astounding nearly 50 million prescriptions for sleep aids and billions in coffee sales. Americans sleep less than people in any industrialized country. Sleeplessness has been associated with increased risk for illnesses such as colon cancer, breast cancer, heart disease and diabetes. The same sleep deficit that makes us unhealthy and also reduces our ability to be creative and productive.

To help maintain mental and physical health we need to eat complex carbohydrates from whole grains, fruits and vegetables, and good fats, especially omega-3 fatty acids. These not only encourage water to be attracted to the cells, but are also a component of the cell membrane. The Standard American Diet or SAD (an acronym that is most appropriate) is almost devoid of omega-3s. The University of Pittsburgh reported that high levels of omega-3 fatty acids like those found in coldwater fish, flaxseeds, olive oil and raw walnuts lessened bouts of depression as they built more grey matter in “depression” areas of the brain.

According to the National Institute of Mental Health, in any one-year period 9.5% of the population or about 20.9 million American adults, suffer from a mood disorder. Perhaps the best alternative to prescription drugs is exercise. Exercise conditions the body and allows it to detoxify quickly ridding the body of stress byproducts such as cortisol, which is known to impact the immune system. Aside from exercise being an outlet for anger and depression, it reduces boredom and is sometimes referred to as “moving meditation.” It helps many with problem solving as it offers time for reflection. It also increases self-esteem and offers social support. Exercise reduces muscle tension, releases healing endorphins and helps with relaxation and sleep. Finally, exercise makes us more fit to combat Cultural Stress and disease.

Emotions Tied to Skin
Dermatologists have long recognized neuropsychological connections between the appearance of the skin, perception of beauty and health. Anxiety and cultural stressors trigger cellular water loss through perspiration. The skin may flare up with acne or eczema in stressful situations. Recent evidence links the central nervous system and the skin revealing specific communication molecules that originate in both systems. For centuries, ancient medical practices and cultures have appreciated the connections between mind and body in wellness and disease, yet conventional medicine still trivializes this complex set of relationships. The role of modern medicine is so focused on acute disease that we forget to ask ourselves, “What is true health?” In my opinion, being truly healthy does not only mean the body is free of diabetes, cancer or other afflictions—being healthy also involves a passion for life, a true connection with others and an overall positive “sense of self.”

Cultural Stress and Skin
Cultural Stress can cause an outpouring of adrenaline, cortisol and other stress-related hormones that contribute to damaged cell walls which in turn, allows the precious water that keeps them functioning to escape. The water loss has a myriad of effects. It causes our cells and connective tissue to break down, which prevents our heart, lungs, brain and other organs from functioning at optimal levels - all of which become apparent when you look at the skin. Stress induced water loss also contributes to common skin problems – acne, rosacea and even premature signs of aging.

We can encourage more water in the cells and reduce Cultural Stress if we address the body with a comprehensive care program based upon Inclusive Health.® This approach takes all external, internal and emotional factors into account.

1. Topical Care - as the largest organ of the body, the skin is extremely responsive to products applied topically. Appropriate skincare regimen and professional spa treatments will address skincare concerns ranging from acne to wrinkles, while also preventing future damage.



2. Internal Care - we can only address cell health in the top 20% of the skin, the epidermis, with topical care. The cells in the remaining 80%, the dermis, must be addressed internally through diet and supplementation. A diet rich in raw fruits and vegetables and healthy fats such as those found in raw nuts and olive oil will promote the body to create healthy, hydrated cells. Dietary supplements provide the body with a constant supply of essential nutrients that serve as the building blocks of strong healthy cells.



3. Emotional Care - maintain connections with others, discover a passion such as painting or dancing.
   Reducing isolation promotes a healthy sense of self. Seek out the nurturing power of touch through facials and massage.

Tips for Reducing Cultural Stress
• The first step in reducing Cultural Stress is to determine its sources. Once the sources are identified, develop a plan of action to reduce their impact.

• Practice being mindful: Take some time each day to meditate or be quiet and enjoy the simple rhythms of life.


• if you are stuck in traffic and late for an appointment, accept the fact that you can’t control the situation. One thing you can control is how you react to these situations. Try to make the best of it. Why have a bad day when you can have a good day?


• Exercise regularly: Go for a walk, do yoga or take an exercise class. Being physically active, even for just a few minutes can make a difference in the way you feel.


• Nourish your body for optimum health: Make it a habit to avoid the Standard America Diet. Get foods that encourage and increase the water content in your body - a diet full of whole grains, fresh fruit and vegetables, good fats and proteins. Take a nutritional supplement to fill the nutritional gaps in your diet.


• Get a good night’s sleep: Americans sleep less than people in any industrialized country in the world. You need seven to nine hours of sleep every night to fully restore the body. Don’t lose sleep; find the time to recharge your body at night so you have the energy to face the challenges that come up every day.

Connecting the Dots
It’s easy to tell people to relax or to be good to themselves, but when stress is so pervasive that there’s no hiding from or avoiding it, it takes effort to unplug. The reality is that our lives will become even more hectic as time goes on and we will continue to push our children and ourselves to capacity until we wear out. As Americans, it’s not easy to unlearn the need to be on the go, but when it comes to mental and physical health, a day, week or month of complete relaxation may be just what the doctor orders. Everything in moderation is the key and this includes the things that contribute to Cultural Stress. The goal is to reduce Cultural Stress while enjoying the simple pleasures of life.
Howard Murad, M.D., Associate Clinical Professor of Medicine at UCLA and founder of Murad Inc.
Howard Murad, M.D., FAAD has literally changed the face of skincare by devoting his life to making beautiful, healthy skin attainable for everyone. His scientifically-proven formulas and inclusive approach to overall skin and body health have helped millions to live better lives.
A board-certified dermatologist, trained pharmacist and Associate Clinical Professor of Medicine (Dermatology) at the Geffen School of Medicine, UCLA, Dr. Murad has personally treated over 50,000 patients. In 1989, he founded Murad, Inc. as a way to share his groundbreaking skincare formulas which were among the first to achieve significant measurable anti-aging results without surgery. Dr. Murad continues his innovative research and holds 18 patents for advances in the science of skin health. These proprietary breakthroughs help Murad products deliver the real results that make Murad one of the world’s premier clinical skincare brands.



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Most, if not all of your skin care clients, will tell you that skin discoloration isone of their top concerns. Uneven skin tone is usually not a client’s only skin issue as it goes hand in hand with many skin diseases and disorders. Skin discoloration is the result of melanin production (melanogenesis) or the lack of it, and it can complicate skin treatments. Knowing this, it is therefore important to understand melanin and its basic function in skin.

What is Melanin?
Melanin is pigment and it gives our skin, eyes and hair color. Its primary function is to protect the skin from damage including photo-damage and/or trauma and it does this as a direct reaction to inflammation. With sun exposure, microinflammatory processes in skin stimulate the production of melanin. Melanin absorbs and converts sunlight to heat as it helps skin cells scavenge free radicals and prevent malignancies from occurring. Melanogenesis also helps protect skin that is healing. We can see this process clearly with acne scars or macules.

Darker skin means there is more melanin in the skin cells, but it does not mean the skin has more melanocytes. No matter what skin color we have, we are all born with a similar concentration of melanocytes, which are located in the basal layer of skin. Melanocytes are dendritic cells, cells that have branch-like projections known as dendrites, and make up about 3% of the cells in the epidermis. Each melanocyte produces the melanin for about 36 skin cells.

Melanin is often misunderstood, for example, a decrease in melanin is actually what leads to hyperpigmentation disorders, freckles, age spots and melasma. In fair-skinned individuals, basal cells contain only a few small melanin granules that are barely visible. Whereas the basal cells of tanned skin or individuals with darker skin contain a distinct amount of melanin granules. The number of active melanocytes decreases by an estimated 10% to 20% per decade of adult life. The melanocytes that remain attempt to compensate for the missing ones, so you have an overproduction of pigment in one area and a decline or complete absence of melanin in another. This is why age spots form and skin becomes splotched with darker and lighter shades of color. Melanin becomes disproportionately concentrated in moles, freckles, etc. During a skin evaluation, the presence of uneven skin tone or freckles indicates that there is a lower amount of melanin in the skin, thus a reduced capacity for DNA repair. In sum, the client is at increased risk for photocarcinogenesis and great care must be taken to prevent further skin damage with sun protection.

The relationship between melanocytes and keratinocytes (skin cells) is referred to as the epidermal-melanin unit. The melanin produced in the melanocyte is transported by melanosomes through the dendrites, which transfer the melanosomes to the kertinocytes. Melanocytes produce two types of melanin: eumelanin and pheomelanin. Eumelanin is brown to black, while pheomelanin is yellow to red.

In tanned skin, eumelanin is the pigment that has been stimulated. Interestingly, women have more pheomelanin than men, so women’s skin is generally redder than men’s. Those with red hair have high levels of pheomelanin, which imparts a pink to red hue. Pheomelanin is particularly concentrated in the lips and nipples.

How Melanin is Produced
Melanin production and its resultant hyperpigmentation or tanning actually begins in the brain. The pituitary gland is attached to the base of the brain and secretes hormones that govern many body functions. In the case of melanin, the gland is responsible for creating and releasing a class of peptide hormones called intermedins or melanocyte-stimulating hormones (MSH). When skin is exposed to sun or experiences trauma, inflammation occurs, putting inflammatory mediators into motion, telling the brain’s pituitary to send assistance with MSH. Once in the bloodstream, MSH stimulates the adrenal gland, which triggers tyrosine, an amino acid found in the body. Tyrosinase breaks down by tyrosine. Tyrosinase is broken down further to dopamine, and through a process of many more interactions, and broken-down elements, the melanocytes pump out melanin to protect skin cells from damage. This explanation is overly simplified as the actual process of melanogenesis involves many factors and several hormones and interactions that are not completely understood. In general, however, scientists believe that melanogenesis occurs because of a combination of factors including DNA damage, and these factors may vary from client to client. Having said that, you can see why treating hyperpigmentation can be difficult—as much as we know, we still don’t know everything.

Prevention and Treatment
Because the release of melanin begins in the basal layer, the deepest layer of the epidermis, and the layer where new cells are “born” each day, it can be difficult to treat existing hyperpigmentation with esthetic treatments. Additionally, treatments will take at least a month to work as basal cells move up through the layers of skin to the outermost stratum corneum and become sloughed off with exfoliation.

The best treatment for sun-induced hyperpigmentation is sunscreen, which will help prevent further photo-induced inflammatory processes from occurring. This allows skin to normalize more quickly.

The most common treatment for too much pigment or uneven distribution of melanin, is hydroquinone. It’s not exactly bleach, though some people refer to products that contain hydroquinone as skin-bleaching creams. Hydroquinone lightens the skin by inhibiting the chemical reactions that create melanin. It attacks melanocytes as it occupies their receptor sites, blocking tyrosinase. It can be combined with AHAs, which increase cell turnover, hastening skin normalization. Over-the-counter skin lighteners that contain a 2% concentration of hydroquinone or less are adequate for most people. Higher concentrations are available by prescription only. There are also drug formulas that combine hydroquinone with Retin-A and other ingredients. Care must be taken with these prescription products because they can be too irritating and may actually contribute to pigment problems. I often suggest that people alternate hydroquinone-containing products with those that contain other types of brightening agents, or use one type of lightener in the morning, the other at night. Pregnant or nursing women should not use hydroquinone because the appropriate safety studies have never been done.

There are many ways to treat already-existing hyperpigmentation with other hydroquinone-free products and treatments such as chemical peels; tyrosinase inhibitors, such as arbutin, which acts like hydroquinone on the melanocyte receptor sites, bearberry, licorice, kojic acid; in addition to peptides; soothing ingredients; LED; microdermabrasion; retinoids; alpha hydroxy acids; vitamin C; and topical corticosteroids. Vitamin C infusions and in-spa facials will help lighten pigmentation. And with any treatment, sun protection is necessary as a final step to protect the skin.

Inhibit Inflammation with Food
Because an inflammatory process stimulates melanogenesis, certain inflammation-abating foods may also be helpful in preventing skin discoloration including foods stocked with antioxidants or brightly colored fruits and vegetables, and healthful, EFA-rich protein. During inflammation, intracellular water loss is encouraged, and this can further damage melanocytes and cause them to function erratically or not at all. Therefore, a diet or regimen that encourages the retention of cell water inside the cell and in the cell membrane, will fortify melanocyte integrity, ultimately, making skin less prone to discoloration.

While not a complete list, some nutrients to consider adding to the diet include alpha-linoleic acid (ALA), which is found in vegetables, beans, fruits, flaxseed oil; gamma linolenic acid, which can be found in seed oils such as borage, evening primrose, black currant and hemp; durian and sulfur-containing foods like garlic, onions, meat, and cruciferous vegetables; zinc, which assists with inflammation from acne; grape seed extract; vitamin C; coenzyme Q 10; and pomegranate, which boosts skin’s natural SPF.

We are fortunate to live during an age where we have learned so much about the skin and how it connects to all systems in the body. As scientists research melanogenesis and the body’s microprocesses, we may, someday, have a near-cure to a problem that complicates our treatments and so many of our client’s lives.



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It’s human nature to reevaluate the way things are done. Think about fashion, food and design. These industries are constantly evolving, borrowing from what’s been done in the past, improving methods and products for the future. It’s no different in the spa industry where the basic facial, before there were AHAs, included just the minimum steps. It’s true that American spas got their start with methods and products from Europe, however, the changing landscape of our country, the entrepreneurship of U.S. business and the ingenuity of today’s scientific researchers have pulled the skin care and spa industry in a very different direction than from where it started. What’s certain is that where we are today will likely evolve in the years to come.

Today’s spas would largely be unrecognizable from those in the 1980s. In a nutshell, the American spa has gone from an exclusive venue where treatments were more pampering, to an inclusive one where treatments are custom-designed and therapeutic. Along the way, we’ve seen therapies come and go, and come again—sometimes tweaked, sometimes renamed. We’ve also witnessed an explosion in the number of medispas in our nation. With this explosion, many have asked if the holistic approach disappeared. The answer, simply, is “no”—it has just evolved into an advanced, inclusive health care approach, which will be the wave of the future in U.S. spas, medispas and medical facilities.

Where Did We Start?
To understand the inclusive health care approach, we have to step back and see the pattern from where we came. Briefly, the pampering spa of the 1980s was an imported model from Europe. Treatments used French, German or Italian cosmetics, methods were less therapeutic and the exclusive environment catered to the wealthy. Fast-forwarding to the 1990s, U.S. spas became holistic centers. Many spa owners decided to strike out on their own to venture down a path rarely taken in the Western world. The holistic movement argued that long-term solutions could never be achieved without finding and treating a root cause. This movement was in defiance of the medical world, which has its therapies based more on systemic drug therapy. Thus, there was a gradual progression down the well-being path in the 1990s—a path replete with alternative therapies and saturated with Asian philosophies.

All the while, a large portion of the industry remained ever focused on medical esthetics. Slowly, acceptance of the spa environment and esthetics practitioners occurred in the medical world. Doctors began partnering with estheticians and bodywork professionals to augment waning revenues, which the decrepit U.S. health care system helped shrink. But adding skin care and holistic services to their invoices did more than just pad revenues. Clients and patients were asking for more and experiencing real results. The spa environment offered the softness and caring service so absent from traditional medical care. And holistic treatments from the alternative world and Far East satisfied the growing natural movement. As a result of these trends, which overlapped and intermingled, the skin care and spa industry gave birth to its newest creation: the medispa.

What Changed?
Through their partnerships with spa pros, cosmetic physicians in the medispa were introduced to a multidisciplinary strategy of treatment where each professional worked toward wellness, within the confines of their respective specialty. Often, the protocols were under the direction of a physician, and while the packages aimed at being therapeutic, in many cases, they were heavy on the medical side. In addition, there was a lack of synergy across specialties: the left hand didn’t know what the right hand was doing. Packages were a mishmash of therapies that sometimes made no sense or could be counterintuitive to the patient/client’s goals. Some overbearing physicians caused resentment among the medispa staff members, who felt there should be more of a partnership or yin and yang in treating clients/patients. All of this started to change as time went on. A shift in the physician-dominated spa model began to occur because consumers demanded less invasive or non-invasive medical procedures.

Moving away from invasive procedures, an increase in the collaboration between specialties occurred, and new systems and protocols that integrated other fields were discovered. The physician’s leading role became diluted. At the same time, the practice of integrative medicine proved to be incomplete. Fundamentally, integrative medicine could not work because it is flawed as it allows for only some therapies to integrate or “come in.” Integrated modes of treatment are often secondary to and not as good as primary medical care. As such, there still remained a great disconnect among healthcare and spa professionals and the very patients and clients they treated.

What is Inclusive Health?
To address the across-the-board disconnect, an inclusive system of care had to be introduced to U.S. spas. Now practiced in some medispa facilities across the nation, inclusive health care involves a team of professionals who partner with the client/patient to achieve long-lasting cosmetic goals and total wellness.

After a thorough examination of a patient’s health, internally, externally and emotionally, a mutually agreed upon goal is discussed with the client and a treatment protocol is outlined with the input from all medispa staff members, which could include a physician, lifestyle practitioners, estheticians, body workers, etc. Each participant, including the patient/client shares an equal responsibility in achieving the common goal(s). For organization’s sake, inclusive health programs are subdivided into categories such as: external care (facials, skin care, cosmetic surgery), internal care (nutrition, supplements, medication), and emotional care (relaxation spa services, stress-reduction, psychoanalysis, support groups).

Take, for example, a client/patient with severe acne. In an inclusive health care environment, the treatment would begin with a thorough, physical and clinical evaluation with lab tests to reveal lifestyle, nutrition, stress levels and hormonal balance, and blood composition. From there, an esthetician might begin enzyme facials and assign a home care regimen to complement in-house procedures. A physician could then work on acne scarring with medical solutions if needed. A nutritionist could administer a recommended immunity-boosting diet to fortify cellular health and healing as well as supplements. A massage therapist could offer body services to reduce stress. A psychiatrist or support group may help with the mentally debilitating aspect of acne and acne scarring. A makeup artist could offer makeup application tips on covering up blemishes as they heal. And if the acne is related to a medical issue such as polycystic ovarian syndrome, and excess weight is an issue, exercise physiology professionals may assist in weight loss goals, while an endocrinologist could prescribe the appropriate care for any concomitant, underlying medical issues.

Scientific study has brought us to where we are today and consumers have pushed the industry to honor their requests for better and longer-lasting results. As more has been learned about the human body and mind, a full story has begun to appear (but we still have much to discover). We’ve learned a great deal, down to the body’s miniscule cellular components. What these tiny parts tell us is that everything is connected, from what we feel to what we eat, our lifestyles, our sleeping habits … all body parts including muscles, blood vessels and connective tissue rely on each other, all organs are connected, and all cells work together. Making changes in internal health and emotional composition, in addition to therapeutic esthetics, produces profound results in patients and on their skin.

In sum, today’s inclusive health care environment aims at being noninvasive, goes beyond the holistic approach and includes nutrition, hormone therapy, exercise physiology, psychological health, etc., in addition to medical treatments, spa services and therapeutic skin care. Collectively, the result is optimum health and beauty that lasts.

A Comparison to Overseas Spas
Inclusive health is truly an American creation with roots in European and Asian philosophies. While international concepts have been imported to the U.S. spa industry, they’ve also been adapted for the needs and demands of the American clientele. Interestingly, Europe is now looking at America for cues on how to become more relevant to European consumers. European spas have historically been based on treatments that use natural resources and incorporate some medical care, but not to the extent of being whole-health, inclusive care centers, such as those found in the United States now. While European spas have traditionally focused on a comprehensive approach to therapeutic stays that may last for weeks, the newest trend is to offer shorter daylong packages that provide the cosmetic aspect of inclusive care, which marries health services to esthetic treatments for total well-being. All things considered, there are still many differences between U.S. and foreign spas.

The biggest difference between U.S. spas and those in Europe—other than the lax attitude (according to American standards) toward nudity—is water therapies and the use of oils. Water services still remain a tough sell in most American spas and are largely absent in medispas. In the U.S., water does not form the foundation for all other treatments as it does overseas. Oils, because of their feel, are generally not used as often in the U.S. either as cleanliness-obsessed Americans are broadly adverse to greasy-feeling skin.

Long ago in Europe, health, wellness and beauty, surrounded the use of balneotherapy including drinking natural spring water. Still today in Europe, it is widely acknowledged that water therapies have a “noticeable effect on motor skills, skin, mental health, and other conditions.” As such, the water features are much more elaborate and form the core of a spa-goer’s therapies. For example, in France, the birthplace of thalassotherapy, bathing in sea minerals is believed to keep infection at bay, promote pain relief, assist in the rejuvenation of skin cells, and promote a healthy exchange of minerals and toxins between the blood and water.

But things are beginning to merge. For example, in Germany, in addition to skin care treatments, there are spa treatments for cardiovascular disease, musculo-skeletal illnesses, rheumatic diseases, gynecological problems, disorders of the nervous system, psychosomatic fatigue, general infirmity and convalescence. Russia has a similar feel where each guest undergoes a medical evaluation, receives prescriptions if needed, and a treatment schedule of walks and massages for relaxation and health benefits. However, during an average three-week stay at a Russian spa, days are still structured around meals and mineral waters, be it drinking them or bathing in them.

In Italy, where spa visits date back to ancient Rome, today’s services have evolved with the inclusive approach. Interestingly, the fastest-growing area in Italian spas is anti-aging and cosmetic procedures. A spa stay may include a guest evaluation that focuses on biological age and everything from health history to emotional countenance, stress levels to memory, skin and body composition, in addition to flexibility. A team of experts then outlines a list of health services (mind and body) in addition to external treatments from microdermabrasion to massage, filler injections to mud therapy and bathing with vegetable, mineral or marine extracts.

Total Care
Like the aforementioned overseas spa industries, the face of the U.S. spa market is continually changing. A look back offers us a glimpse of just how much. Holism is not dead. Along with countless other therapies and methods, it has simply been reborn as inclusive health care, a revolutionary strategy that will ultimately help make people as healthy as they can be inside and out. Inclusive health care can foster wellness, encourage skin health and thwart aging on every front—externally, internally and emotionally. In this new era of the skin and spa industry, health and beauty in the United States have become synonymous. Taking notes from our successes, it’s ironic that spas overseas—from which we derive our foundation—are now looking to America for the next thing: spa protocols to treat the mind, skin, body and spirit—inclusively.



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We have all heard timeless sayings such as “chocolate causes acne” and “consuming eight glasses of water is the only real course into proper hydration.” I’d like to set the record straight by debunking common myths associated with health, beauty and the aging process. Based on years of research, the list of myths and truths I’ve outlined below reveal just how inflammation, hydration, and other factors really affect health and the aging process.

MYTH – Your weight and vital signs are ultimate markers of health.
TRUTH – Blood pressure, pulse, cholesterol, and weight are all important statistics for understanding your overall health. But the common pathway to all aging and disease is cellular water loss. The health of our cells is the ultimate marker of the true health of our body, which can be measure by the Phase Angle (PA). The PA uses electrical resistance to give a quantifiable measurement of the extracellular and intracellular water in the body, an excellent indicator of cell strength. Age and free radical damage wear out cells by creating small holes in the cell membranes enabling water to leak out. Without optimum water levels inside the cell, the cell loses its ability to function properly, advancing the aging process exponentially.

MYTH – You cannot slow down the aging process.
TRUTH – By focusing on Inclusive Health, one can not only slow down the aging process but also help reverse the visible signs of aging. In my latest book, The Water Secret I attempt to demonstrate how the fundamental marker of youthful good health is the ability of the cell membrane to efficiently hold water. This can be accomplished by tending to one’s internal, topical and emotional self care. Everything from getting regular exercise, taking daily supplements, getting sleep and taking time for oneself will encourage an increase in intercellular water.

MYTH- Inflammation is bad for you.
TRUTH- Inflammation is routinely advertised as something bad for your health. In truth, inflammation is a warning sign that the body is trying to heal itself and thus a key to survival. To put this into perspective, disease causes inflammation, inflammation does not cause disease. Inflammation is a symptom of something else going on in the body that ushers the inflammatory response for help. It is very difficult, if not impossible, to “treat’ inflammation as you have to treat the causes of inflammation and thus helping heal your body and your health.

MYTH – You need eight glasses of water a day.
TRUTH – Eight glasses means eight trips to the bathroom, flushing the system of vital nutrients and minerals. Colorful raw fruits and vegetables are the best form of water for your cells as they provide structured water and antioxidants so that the hydration stays in your system long enough for your body to put it to good use. Try to replace one glass of water a day with a raw fruit or vegetable. Through proper nutrition, you will help repair the cell membrane to attract and maintain intercellular water as well as help your body feel more hydrated.

MYTH – Modern stress is an unavoidable part of life.
TRUTH – Cultural Stress is a phrase I use to describe the type of constant and pervasive stress through living a maxed-out, multi-tasking life. Cultural Stress takes a dramatic toll on overall health so it’s important to understand it, address your stressors and take steps to combat it such as surrounding yourself with people you care about, quieting your mind by turning off your cell phone and television before bed, participating in a physical activity, and of course, smiling and laughing freely. These small efforts will bring you big emotional changes, helping you destress and enjoy life.



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Without a doubt, skin hyperpigmentation remains the most common epidermal problem within the cosmetic physician’s office. Whatever it may be from, skin discoloration can also be the most difficult to treat and, in most cases, requires a great deal of patience not only on the patient’s part, but on the physician’s or staff’s part as well. Notwithstanding, the task of discerning a patient’s hyperpigmentation source for healing and prevention can be daunting. Skin discoloration often goes hand in hand with an array of diseases and disorders, which range from the benign to the life-threatening. In my experience, however, unless you remove the source, you will not be successful in treating hyperpigmentation for the long-term.

Modern Thinking
There is no escape from the modernization that has happened in our world. Try explaining the flipping mechanism, which stopped reel-to-reel film from jumping in a projector, to students today who happily click twice on their iPads to open a video, log on to hear a podcast, or attend their professor’s newest webinar—all while checking e-mails and firing off texts to friends and colleagues. Just as we have experienced technological advances in every aspect of our lives, so too have we experienced a myriad of new advances in skin rejuvenation.

Hyperpigmentation treatments have also experienced a paradigm shift in method. With hyperpigmentation, however, technology has somewhat taken a back seat. This movement has occurred in the wake of the changes that have happened in facial rejuvenation. In the past, epidermal rejuvenation included the standard use of high-power, high-density, ablative CO2 laser treatments. Today, we have entered a phase of “less is more.” Along those lines, treatment for hyperpigmentation has, on the whole, become more minimally invasive, with an overriding “do-no-harm” methodology, but has also become increasingly multidisciplinary. In my practice, the collaboration between specialties, new systems and protocols has shown to be useful.

With this in mind, I have taken a sort of “back to basics” mentality—one that focuses on intracellular water, cell membrane fortification, and cellular health.1 The melanocyte is, after all, a cell. Bleaching compounds, in general, are fairly ineffective on dermal accumulation of melanin.2

Anatomy of the Melanocyte
Melanogenesis is a process that begins in the brain and melanocytes are dendritic cells, and make up about 3% of the cells in the epidermis. The relationship between melanocytes and keratinocytes is referred to as the epidermal-melanin unit. The melanin produced in the melanocyte is transported by melanosomes through the dendrites, which transfer the melanosomes to the kertinocytes. Melanocytes produce two types of melanin: eumelanin and pheomelanin. Eumelanin is brown to black, while pheomelanin is yellow to red.

In tanned skin, eumelanin is the pigment that has been stimulated. Interestingly, I have found that women have more pheomelanin than men, so women’s skin is generally redder than men’s. Those with red hair have high levels of pheomelanin, which imparts a pink to red hue. Pheomelanin is particularly concentrated in the lips and nipples.

The pituitary gland, in the case of melanogenesis, is responsible for creating and releasing intermedins (peptide hormones) or melanocyte-stimulating hormones (MSH). When skin is exposed to sun or experiences trauma, inflammation occurs, which sends inflammatory mediators to initiate the brain’s pituitary response with MSH. Once in the bloodstream, MSH stimulates the adrenal gland, which triggers tyrosine. Tyrosine breaks down tyrosinase and tyrosinase is broken down further to dopamine. Through a process of many more interactions, and broken-down elements, the melanocytes pump out melanin to protect skin cells from damage. This overly simplified explanation of melanogenesis involves many factors and several hormones and interactions that are not completely understood. In general, however, melanogenesis occurs because of a combination of factors including DNA damage, and these factors may vary from patient to patient.3

Two Processes and Three Steps
In my experience, the causes of hyperpigmentation can be traced to the presentation and activity of the melanocytes. In general, there are two basic processes that cause hyperpigmentation: 1) an increase in melanin production and/or 2) an increase in the number of melanocytes. Post-inflammatory hyperpigmentation (PIH), café au lait macules, melasma, Addison’s disease, sun exposure, and hemochromatosis all stimulate the increased production of melanin. Seborrheic keratosis, acanthosis nigricans (due to diabetes and obesity), lentigines, phototoxicity or photo-allergic reactions (ingestion or exposure), on the other hand, increase the proliferation of melanocytes.4

Depigmenting relies on three basic steps: 1) regulating the transcription and activity of tyrosinase, tyrosinase related protein-1 (TRP-1), tyrosinase related protein-2 (TRP-2),
and/or peroxidase; 2) regulating the uptake and distribution of melanosomes in recipient keratinocytes; and 3) melanin and melanosome degradation and turnover of “pigmented”
keratinocytes.2 Above all, however, the main goal with hyperpigmentation treatment, especially PIH, is to reduce inflammation, regardless of etiology.

Inclusive Health Approach
As many of you have probably experienced, hyperpigmentation may not only have a topical component, but also an internal one and even an emotional aspect. The reality is that, therapy is obviously a lot more complex than the simple application of hydroquinone. In fact, to be successful in treating hyperpigmentation, a comprehensive method, possibly multidisciplinary, is required to target the source, remove the discoloration, and prevent further pigmentation problems. I call this comprehensive method an “inclusive health” approach. It includes a formulaic, three-pillar protocol, which I apply to every one of my patients. Generally, it breaks down the treatment strategy into topical, internal, and emotional categories and helps create a roadmap to the treatment goal.

Through a series of standard checks and evaluations, an inclusive program is initiated targeting each patient’s specific needs. While no protocol is exactly the same, the three-step approach offers a complete strategy toward removing any source and presentation of hyperpigmentation, and has the added benefit of placing a patient on the track toward total wellness.

Getting Started
In my practice, the initial consultation with any patient begins with a quid-pro-quo session on what the patient has experienced, what I have experienced, what the patient knows about hyperpigmentation and what I can teach him or her. Having said that, education, by far, is the first step in any treatment protocol. Realistic expectations must be laid out, otherwise you will have very unhappy patients. I always explain that it will take at least 30 days for improvements to be seen because of the nature of how skin sloughs. I also explain that treatment must be ongoing to completely resolve hyperpigmentation and prevent it from recurring, and I ensure that they understand that any underlying issue must be followed and treated for optimum results. During the initial skin examination, I look for the presence of uneven skin tone or freckles, which indicate that there is a lower amount of melanin in the skin, thus a reduced capacity for DNA repair. In other words, the patient is at increased risk for photocarcinogenesis and great care must be taken to prevent further skin damage with sun protection. Simple tips on prevention with appropriate application of SPF and sun avoidance, at this meeting, are imperative as subsequent treatment depends on the patient’s commitment to the inclusive program. While second nature to those of us in the clinical setting, most patients do not know what SPF to use or that it is necessary for every Fitzpatrick skin type. Beyond that, most patients are remiss in their application of sun protection creams, so it is useful to pair retail with instruction at this initial consultation. Home care for daily exfoliation and skin treatment is also essential. I provide patients with a combination of ingredients such as AHAs and BHAs to reduce excess skin cell build-up, as well as vitamin C products because they are also beneficial for brightening the complexion.

Because we are definitely comprised of the elements that we eat, I also begin my patients on a nutritional program that includes supplements to flush the body with the nutrients needed to fortify cellular health, immunity, and to increase intracellular water.5,6 When cell membranes are fortified, and intracellular water is maintained or increased, cells function at the highest levels to correct ROS-induced damage on the outside and inside of the cell.7-10 This protects the nuclear membrane, the mitochondria and DNA transcription processes and cell water transfer is flawless, bathing structures with nutrients and removing cytoplastic accumulations of waste materials.11 It also halts inflammatory cascades in tissues.12



It has been well documented in scientific literature that nutrition can play a key role in skin health.13 Poor nutrition can also accelerate skin degeneration. I have seen, first-hand, how a healthful diet complete with optimal nutrition can help forestall, prevent, and even reverse skin conditions and improve overall health.14 Because the standard American diet is sub-par, supplements are given to every patient at this initial meeting, as well. The following illustrates the inclusive health program’s three categories (topical, external, emotional):

I. Topical care
Topical care is used to enhance cutaneous immunity, reduce inflammation, and treat epidermal conditions. This includes topical treatments such as esthetic facials, appropriate skin care regimens, and cosmetic medical services. Because the release of melanin begins in the basal layer, the deepest layer of the epidermis, it can be difficult to treat existing hyperpigmentation with esthetic treatments. Additionally, treatments will take at least a month to work as basal cells move up through the layers of skin to the outermost stratum corneum and become sloughed off with exfoliation.

With regard to any hyperpigmentation, excluding melanoma, no matter the Fitzpatrick skin type, the topical portion of my inclusive health formula always remains the same for every patient. I use a gentle combination of peels including salicylic acid, glycolic acid, retinol, and niacinamide. I have found combination therapies to be more successful than single agents used alone. In the plastic surgeon’s office, IPL, vitamin C peels, topical infusions and lasers may also be used. Aggressive techniques may cause inflammation, more hyperpigmentation, and may be more trouble than they are worth. This combination of peels performed in-office once every 2 to 4 weeks (depending on how it is tolerated) is the standard protocol I begin with. Paired with any needed internal care and home care, which prepares the skin and enhances the in-office peel combination, most hyperpigmentation issues will begin to fade by 30 to 45 days.

Salicylic acid: Superficial salicylic acid peels have shown to be both safe and effective at treating PIH even on darker skin tones. Salicylic acid is a keratolytic and comedolytic agent that helps stimulate rapid cell turnover and quash macule formation post-acne.

Glycolic acid: A workhorse in the dermatologist’s office, glycolic acid can be used on even the darkest skin tones. It effectively loosens cell-binding lipids between keratinocytes to exfoliate the stratum corneum.15

Retinol: The precise mechanism for why retinoids work with hyperpigmentation is unclear, however, they are thought to inhibit the induction of melanogenesis, while they also stimulate rapid skin cell turnover as they promote new cell growth.

Niacinamide: Also known as niacin, vitamin B3 or nicotinic acid, niacinamide has shown to inhibit melanosome transfer from the melanocytes to the keratinocytes and it is also anti-inflammatory.16

Botanical and Anti-inflammatory Ingredients
Botanical ingredients is one area of study that has garnered significant attention from the cosmetics community. Specifically, many early studies have suggested that there are quite a few natural fruit, vegetable and herbal ingredients that offer anti-inflammatory and sun-protection boosting capabilities.17 With regard to hyperpigmentation, cell fortification, immunity, and cellular water, the ones that stand out include those highest in antioxidants, essential fatty acids, and polyphenols.

For decades, the medical field and esthetics industry has highlighted inflammation as the greatest villain to body health and skin rejuvenation. And this is true if the inflammation is chronic, an overreaction or cannot be repaired. It is important to note, however, that inflammation does not cause disease; rather, it is disease that causes inflammation. The best way to forestall disease is to make the body more resilient to it, which means the immune system and nutrition play very important roles. Healing slows when inflammation is present. Skin texture may be rough and dry with discoloration from PIH. On the inside there may be underlying problems or inflammatory diseases such as Crohn’s disease, ulcerative colitis, nephritis, and systemic lupus erythematosus. In addition, diabetes, heart disease, arthritis and cancer can cause inflammatory responses in the body as well. The simple truth is that any overreaction or chronic inflammation within the body, will likely exhibit effects on the skin as well and make hyperpigmentation treatment harder.

II. Internal care
Internal care is used to support all aspects of a healthy lifestyle. This includes nutrition, supplements, and prescription medication. Medical history will tell you if your patient has any internal disorders that may be the causative factor for his or her hyperpigmentation. If no internal disorders are known, blood tests may be useful. A nutritional food plan, which includes high amounts of antioxidant, anti-inflammatory foods, is recommended, as well as a daily supplement regimen:

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• Multivitamin and mineral supplement. Select a comprehensive and balanced formula containing all the major vitamins, minerals, and trace minerals; select an iron-free formula for patients who are postmenopausal.


• Sleep-promoting supplements including those featuring up to 1 mg of melatonin and gama aminobutyric acid (GABA).


• Antioxidant supplement formula


• High-potency B complex supplement providing all eight essential B vitamins: thiamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), folic acid (B9), cyanocobalamin (B12), biotin (B7).


• Essential fatty acid supplement providing omega-3 fatty acids. This may be in the form of fish oil, flaxseed oil, or ground flaxseeds added to food, or in capsule form. Vegetarians or those not eating fish or taking fish oil supplements should add a micro-algae-derived DHA supplement.


• Lecithin supplement. Recommend soy lecithin granules sprinkled on or added to foods or a liquid soy lecithin in capsule form.


• Glucosamine


• Calcium supplement for bone health. Most women should take 1000 mg to 1500 mg of calcium with vitamin D daily, depending on their dietary intake of calcium.

III. Emotional care
Emotional care will help patients achieve psychological and social balance. Significant negative psychological issues result from hyperpigmentation. In my patients, it is often noted as a source for social stress. Literature suggests that hyperpigmentation problems have the power to reduce productivity at the office and in school as the skin condition erodes self-esteem. Hyperpigmentation is a considerable “quality of life” issue for its sufferers. As such, we recommend our patients partake in stress-reduction spa services, exercise, or even receive some emotional self-care to cope.

As far as diseases and internal conditions are concerned, skin cancer, diabetes and obesity seem to contribute the most hyperpigmentation problems—this is perhaps symptomatic of the rising statistics of these health epidemics, but they still only account for a smaller percentage of patients. The majority of patients I see exhibit what I term “polka-dot syndrome.” I also see a large amount of melasma and lentigines.

Polka-dot Syndrome
This includes PIH, acne macules, and freckles. Because of the amount of pigment in dark skin, discoloration problems are very common and their visual effects can be similar to a polka-dot pattern.

PIH is more of a problem in those with Fitzpatrick IV to VI and can be the result of both exogenous or endogenous inflammation, which may be the result of skin conditions or mechanical trauma, radiation, phototoxicity, laser procedures, or even temperature. In general, sunscreen is useful and anti-inflammatory services and retail products have shown to be effective in my patients.

Regardless of sun exposure, hyperpigmentation can develop at the site of an injury or after a blemish has healed. I have found that endogenous porphyrins, which cause acne macules, can be removed through the use of light emitting diode treatments. Porphyrins released by P. acnes attract certain wavelengths of light. Targeting the porphyrins alone has offered my patients promising results. At a microscopic level, light excites these P. acnes porphyrins, which release singlet oxygen when they are excited. This oxygen, in turn, kills P. acnes. Porphyrins absorb the most light at 415 nm (blue light) and 630 nm (red light), thus both red and blue light are effective at circumventing PIH and macules. Red light has been purported to stimulate healing and reduce inflammation. So, red and blue light work well together on inflamed acne and to prevent hyperpigmentation.

Melasma
Melasma is characterized by darkened pigmentation, usually down the center of the face. It typically involves the nose, the cheeks, the upper lip and sometimes the forehead. I almost never see melasma in men. It seems to be caused by the combination of pregnancy or birth control pills and exposure to sunlight. It is especially difficult to cure melasma on black skin. Perfumes and even some cosmetics can cause allergic reactions with symptoms similar to melasma. If a patient who appears to have melasma is taking birth control pills, I suggest that she try taking her usual dose at night rather than in the morning in order to minimize the amount of estrogen in the bloodstream during sunlight hours. A pill with a lower dose estrogen may be useful as well.

Hydroquinone 2% to 4% or azelaic acid 20% will suppress and gradually lighten epidermal hyperpigmentation from melasma. Vitamin A (tretinoin/retinol) and/or glycolic, lactic or salicylic acids allow for improved penetration of hydroquinone. Laser treatments specific for pigment disorders are often helpful alone or in combination with topical therapy. High levels of vitamin C with glycolic peels and IPL (intense pulsed light) can also provide results. Sun exposure should be avoided and daily application of a broad-spectrum sunscreen is recommended.

Lentigines
Lentigines or solar lentigos, commonly referred to as liver spots, are found on sun-exposed skin among middle-aged and elderly adults. They are flat, evenly pigmented (tan or brown) spots with well-defined borders and range between 2 mm to 30 mm in size. Chronic sun exposure and genetic predisposition are causative factors for solar lentigos, which lead to local proliferation of melanocytes. While there is no potential for malignancy with solar lentigos, the appearance of lentigines indicates a degree of ultraviolet skin damage. Patient should avoid sun exposure and use a high SPF, broad-spectrum sunscreen daily. Epidermal peeling, lasers and cryotherapy help remove abnormal melanocytes and reduce the appearance of dark spots. Hydroquinone and tretinoin may gradually decrease the darkness associated with lentigines over months.

Total Wellness, Lasting Beauty
I have merged thinking on cellular health and immunity with treatments that work topically, internally and emotionally to produce the best results possible for my patients. Through the use of home care, gentle in-office peel combinations, nutrition, prescription medications, modern technology, and tried and true complimentary therapies, it is possible for patients to be cured of hyperpigmentation, and experience a better overall quality of life.

Scientific study has brought us to where we are today and consumers have pushed the industry to honor their requests for better and longer-lasting results. Today’s inclusive health care environment aims at being noninvasive, but is ever more thorough at removing the underlying problem. Collectively, the result is optimum health and beauty that lasts.



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