Things You're Too Embarrassed to Ask a Doctor Season 1, Episode 3: Adult Dermatology with Dr. Diana Bolotin

[MUSIC PLAYING] You're listening to Things You're too Embarrassed to Ask a Doctor, a production of UChicago Medicine. Each week, we'll feature one physician and ask them your most-searched questions in their areas of expertise. For more information on our episodes, visit us at www.uchicagomedicine.org/podcast. Have something you're too afraid to ask your doctor? Tweet us @TYTEPodcast.

I'm your host, Kat Carlton.

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As someone nearing my early 30s, I often wonder why my skin seems to act like I'm a teenager hitting puberty. In fact, I know I share this frustration with a lot of people my age. Just the other day, I was talking to a friend who wanted to know, as someone who has struggled with acne my entire adult life, why do I only break out on certain parts of my face? We've both combed through testimonials for skincare products like zit stickers and salicylic acid serums, and the results usually kind of seem all over the place.

That brings me to today's topic, lumps and bumps. I consulted with dermatologist Diana Bolotin at the University of Chicago Medicine to find out just what causes acne, along with other types of common lumps and bumps. Let's turn to Dr. Bolotin for more.

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Welcome to another episode of Things You're too Embarrassed to Ask a Doctor. If you're tuning into this show for the first time, what we do is we talk to real doctors about their areas of expertise using some of the most searched questions in those areas. Joining us today is Dr. Diana Bolotin. Welcome to the show.

Thanks, Kat. Happy to be here.

So Dr. Bolotin specializes in dermatology. Can you tell us a little bit about what you do?

So I am a dermatologist. I actually treat mostly skin cancer patients, but I also see some general dermatology as well. So dermatology is a pretty broad profession. We treat anything from skin cancer, to acne, and little rashes, and big rashes, and complications. It's pretty broad. Both includes medical dermatology and surgeries as well as some kids' dermatology and pediatrics.

Great. So today, we're going to be talking about lumps, bumps, red spots, all that good stuff. We're going to move on to acne now. To start, can you tell us how acne forms?

So acne is really kind of a multi-factorial skin issue. So at its very basic core, it's a blockage of kind of the pore that opens where the oil that normally comes out on your skin comes out. So it's blockage and inflammation of that hair and oil unit, but it's actually a very complicated field because a lot contributes to it.

So genetics contribute to it. Some people are just prone to it, and we're still in the process, as a field, of figuring out exactly what it is that genetically causes that. Certain medication can make you prone to acne. Certain bacteria that normally live on everybody's skin, in some people, makes you more acne-prone or if there is too much of it on your hair follicle.

And then some people make more oil and less oil, and certain topical that you're applying can contribute to it. Things that come in contact with your skin can also occlude the hair follicles and those openings. So there's kind of a lot of reasons of why and how it forms.

So you're saying there's just not one curable cause? That would be so nice.

I wish. I wish we could-- you know, it's funny how many of dermatologic conditions that are super common that you would think there would be one cure, and it isn't. It's a complex thing that you have to kind of tailor treatments for.

A lot of people are also searching, why do I get acne on my back?

So the real answer is, we don't know. Sometimes it's due to occlusion. So wearing tight-fitting clothing, for example, or doing a lot of sweating-- things like that. Sometimes it's hormonal, and sometimes it's something about you that predisposed you to getting it on your back, and we won't know.

What does it mean when acne is on different places on your face?

So sometimes it's a pattern that we can catch of something coming in contact with your face. So for example, occlusion acne can happen with hair bands. So if we see acne that's primarily on the periphery of your face, like upper forehead, then we can kind of say hey, maybe it's something-- are you wearing a hair band all the time? Or it could be a new hair product that you're using that's clogging your pores there.

And interesting acne we sometimes see is on one side of the cheek. We see it less now, but it used to be due to phone use-- so people who hold their phone really close to their cheek and kind of chronically occlude that area. Now that people use more earbuds, it's less common, but still, that's one thing. So in that sense, where it is may make a difference.

Sometimes hormonal acne has a prevalence, in women especially, to be around the mouth and kind of the lower cheeks and chin area. So that can give us a clue as to maybe the etiology and what we should be treating, but sometimes it just happens in random places, and it's just bad luck.

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So we've pretty much covered why acne can happen or does happen. So what about treatment options? Will acne ever go away?

That's a hard one to answer. Yes, acne can be treated. There are a lot of different options that your dermatologist has to treat acne. Sometimes it's going to take time to kind of find the right thing for you specifically, but it can be managed. And with that management, it will get better. And yeah, it can go away.

What is acne vulgaris, and who gets it?

Acne vulgaris is just a medical term for the very basic acne-- so acne that you get as a teenager. It's just another term for acne.

This is probably a bad one-- another bad one, but which acne medication works best?

That's a question that's just hard to answer. Because really, your acne needs evaluation by a dermatologist, and they can decide what the best medication is for your particular type of acne. They can evaluate for causes and give you the best medicine for you. So there's really not one-size-fits all for acne.

There were a few questions related to acne scarring. Is it normal if acne scars are red? If something's red, is it an acne scar?

Yeah. Acne scarring is definitely a good topic. So it is very common for a scar in general to be read at first, and acne scars are no exception. So it's definitely normal for them to be red at first. Over time, the redness tends to fade, and they become either kind of a lighter, pale color or blend with their skin.

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Let's recap what we've learned. There are a bunch of different causes of acne. And there are different treatment options your dermatologist can recommend, but what about the dozens of homeopathic treatments that are constantly flooding the skin care social media scene? Let's take zit stickers, for example. They're these little medicated circular stickers you're supposed to put on a pimple overnight to make it magically shrink. Dr. Bolotin?

So I think the efficacy of the stickers is still up for debate. I think a lot of them are kind of impregnated with medications that we do commonly recommend. So salicylic acid or nicotinamide is sometimes it kind of embedded in that sticker. And with that, those are good medications. But as I mentioned before, there's not a one-size-fits all for acne. So just because they're good doesn't mean they'll be right for you.

The other issue is by being a sticker, it is occlusive. So it's sort of still a question whether you're kind of taking one step forward, two steps back with that or not. So I think the jury's still out on that. I wouldn't say they're bad, but I think we still need more information to see how good are they and who do they help.

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Another big issue faced by acne sufferers can be scarring. Whether that's from picking at pimples or from tough to deal with cystic acne, Dr. Bolotin tells me, physicians treat it all.

Yeah. There are a number of cosmetic treatments out now for acne scars. I think some of it is giving it time. Scars do remodel. Over 6 to 12 months, a scar can change dramatically because your own body's kind of, on the inside, doing its thing and trying to fix whatever happened.

Sometimes that's not enough, and there are a variety of treatments for acne scarring ranging from injectables, and lasers, and other things. The one thing about is that a scar is a scar, and a scar is permanent. And all of these treatments, although can help soften the appearance and make it less noticeable, will likely not completely get rid of them.

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I realized, while making this episode, I could have devoted it entirely to acne, but why don't we have some fun and talk about other kinds of lumps that mysteriously pop up as we age and change? The first one I'm talking about is skin tags.

So the skin tag is a very common finding that we see in the large majority of the population. And in general, what it is just a little out-pouching of normal skin. So in and of itself, it's not even a growth or a lesion. It's just, for whatever reason, your body decided to make a little out-pouching of skin.

And what causes those skin tags?

It's the million dollar question. Truly, we probably don't know what causes them. We do know that it's associated with areas of friction-- so armpits, kind of creases of your neck, under breasts. There's probably some component to weight and weight gain that kind of predisposes you to have more friction in those areas too. But a lot of the times, they just kind of happen as we get older and wiser.

Are they dangerous at all?

Good news is they're not dangerous at all.

How do you remove skin tags, and what kind of removal works best?

So the best thing to do is first to get your skin tag evaluated because there are other growths that can look similar to a skin tag, and the dermatologist can identify that just visually. If they are indeed skin tags, then they can be removed for cosmetic purposes or if they just bug you.

Typically, in an office, we disinfect the area and we just either numb it up and snip it off, or numb it up and cauterize it, or just even without numbing sometimes people tolerate a little snip here and there if it's just a few. Occasionally, they have like a little blood vessel in the center, which is when cauteries comes in useful so that it doesn't bleed a lot. I generally don't recommend removing them at home for those reasons.

And you said you specialize in treating patients with skin cancer. So another question we have is, can a skin tag turn into cancer?

It's an interesting question. Because I think skin tags, in and of themselves, don't turn into skin cancer, but you could get a skin cancer in a skin tag. So it's almost either what we call a collision or kind of it so happens that the two things occurred in the same place, or perhaps the skin tag wasn't a skin tag to begin with and another growth that turned into skin cancer.

Moving on to our final topic, skin cancer and melanoma, can you tell us what is melanoma?

So melanoma is a type of skin cancer. It's not the most common type of skin cancer, but it is the more deadly type of skin cancer. It starts from the cells in your skin that form pigment. So melanocytes, that's where the "mela" comes from. And basically, it's a growth that's out of control that starts as those melanocytes. And most melanomas actually are new, so it's not necessarily that it's a mole that's become a cancer. But a mole can become cancerous too, so one of those things could be a melanoma.

So you said it's not the most common type of skin cancer. What is the most common skin cancer?

The most common skin cancer is a basal cell carcinoma followed by squamous cell carcinoma. So they fall into the non-melanoma subgroup of skin cancers. And they look differently, and they behave differently. So the good news about the non-melanoma group is both basal and squamous are less deadly, but they'll continue to grow where they are. And so they can really present a risk of disfigurement and still require surgery, so they are something that should be caught and treated early as well.

So you mentioned those cancers look differently. What do those cancers look like?

So with melanoma, usually it's a pigmented growth-- so a new dark spot, or a black spot, or a mole that's churn that's growing rapidly or has developed a new different color. And that different color could be black, white, or red, what have you. There are a small minority of melanomas that are without pigment that are called amelanotic melanoma-- so they're usually pink-- but that's a minority of melanomas.

The most common history we get from patients with basal cell is that it's a pimple that they've had for many months that just has not healed. And they think initially it's just a pimple, but here it is six months later. So basal cell typically is pink. Can be a pink rough patch or a pink, raised, kind of pearly looking bump, and there's a whole variety of them.

Squamous cell skin cancers usually have kind of crusty spots that bleed. Some grow rapidly, some grow slowly, and so that's kind of not a differentiator. But if you have a crusty bleeding spot or a pimple that hasn't healed over a few months, that's a reason to see us to value it.

So you just answered half of our next question, which is, can skin cancer itch or bleed?

So yes, it can do both, more commonly bleeding. It's less common to have a skin cancer have symptoms like itching or pain, but bleeding is definitely something that can happen with them. And you may have talked about this before, but which type of skin cancer is the most dangerous.

Yeah. So melanoma is definitely the most dangerous, but the interesting thing about it is if it's caught in its early stages, it actually is quite treatable. But melanoma is the one that can spread and cause harm.

Which is a good lead-in to our next question, which is, when does skin cancer spread?

It's hard to answer the when. With melanoma, your risk of skin cancer spread increases the thicker the lesion is under the microscope. So after it's been biopsied, we can kind of get a better idea for our concern for spread. With the other types of skin cancers, basal cell skin cancer very rarely spreads anywhere other than where it is, but it does grow where it is. So it'll continue to grow and invade into important structures like even muscle and bone if left alone.

Squamous cell skin cancers can spread, but typically, that happens if they're allowed to get quite large or if they're in patients with risk factors for a spread. So patients with poor immune function or solid organ transplants, for example, are at a higher risk for more aggressive squamous cells than healthy patients.

You said some of these cancers are treatable. Are any of them curable?

Yeah, they are. So many of them are curable. Basal cell skin cancer, squamous cell have a very high cure rate, especially if caught early. And same with melanoma, actually. Early-stage melanomas with just local surgery have a very high cure rate-- in the high 90%, like 97%, 98%. So it's really a matter of getting it before it gets too far.

So you do some of these surgeries for skin cancer. Aside from medications, can you talk about some of the-- especially the surgical treatment options that you offer?

Yeah. So for early stage melanoma, we offer excisions in the clinic, actually, in the dermatology procedure area, all done under local without patients needing to be asleep. For the non-melanoma skin cancers, there's a variety of options. For certain skin cancers, we do Mohs surgery, which is, again, a procedure we do in the clinic under local anesthesia.

And the nice thing about Mohs is we don't have to take a wide margin to begin with. We take a thin little rim around the biopsy site, and we test it while the patient's waiting. So we're testing all the edges to see if there's any of that skin cancer left. And if there is, we go back and take more just where we know it's still present.

And if there isn't, we say, well, we didn't need to take a big margin, and you're done. And then we closed you up, and then you heal, and you're done. So for non-melanoma skin cancers, we do Mohs, we do excisions, we do other procedures, and then there are some topical medications that can be used for very superficial forms of those cancers.

One last question. I have this mole. Can you look-- I'm just kidding.

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Anything else that you wanted to--

You should know how often that happens at parties.

At parties?

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Anything else you wanted to add about any of the topics we covered today? I know that your field covers a lot more than this, but these are just kind of just a look at some of the most searched questions we found.

Yeah. I think these are great starter topics. I think they're relevant to everyone. The only thing I would say is, if you have a question about your skin, you should see a board-certified dermatologist so that we can answer it for you. Sometimes the answer is as straightforward as us looking at it and just knowing what it is. And sometimes it's getting to a biopsy quicker and not delaying.

Well, thanks so much, Dr. Bolotin, for being on the show today. It was great to have you.

It was my pleasure. Thank you.

Until next time, this has been Things You're too Embarrassed to Ask Doctor. Once again, I'm Kat Carlton, and you've been listening to Things You're too Embarrassed to Ask a Doctor. Music from today's episode is by Blue Dot Sessions. For more information on our show or to submit a question, visit us at www.uchicagomedicine.org/podcast or tweet us @TYTEPodcast. That's TYTEPodcast.

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