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Sunscreen: What you need to know

March 26, 2021Angelita Chand Blog Products

Are you ready for Spring? Bring on the sun, shades and SUNSCREEN.

One of the common questions we get asked as Dermatologists is, what should I be looking for in a sunscreen? Well, we are going to recommend some tips that will help you decide which sunscreen is right for you and still approved by your dermatologist. After discussing with our Physician Assistant Gina Mower- she recommends you try the sunscreens before purchasing. Trying out the product allows you to feel the texture and get a sense of the smell. When you know the product feels great on your skin and has a smell you love, you are more likely to use it. Depending on how you feel about chemicals in your products you always want to look at the ingredients. You want to look for products containing the minerals zinc oxide and/or titanium dioxide. These physical blockers are the main ingredient to look for when shopping for sunscreens because they help block the sun’s UVA and UVB radiation from being absorbed into your skin which makes them broad-spectrum.

Besides cost what is the difference between drug store brands and the brands you find at a clinic? The products you find at a dermatologist or most clinics are always tested and researched by the providers to make sure their patients are getting the ingredients that are important for their skin. At Dermatology of Seattle and Bellevue we make sure to give patients and their skin what they deserve. We carry two different lines called Elta MD and Epionce. Elta MD products have medical–grade ingredients which are also paraben free, gluten free, and sulfate free. There are no filler ingredients that you typically find in drug store brands and online. Epionce is a product line created by a dermatologist based in Idaho containing ingredients with a focus on nurturing the skin in a positive way.

Sunscreens should be applied daily even if you aren’t sitting directly in the sun. A great way to get in the habit of using sunscreens is by adding them to your morning regimen. Brandon, our Bellevue office manager, starts his morning routine with the Epionce gentle foaming cleanser because he loves the smell, and it works great for is combination oily-dry skin. Then he applies a moisturizer that works with his skin type, Sente ultra-light defense moisturizer. After that, he finishes with ELTA MD- UV Clear to ensure his skin is protected from the damaging effects of the sun. This specific product comes in a non-tinted and a tinted finish for that added sun-kissed glow. If you haven’t established a skin care routine, come in and see our Master Aesthetician Holly for a complimentary appointment. She will be able to help you customize your routine and help you achieve the skin you want.

Another question we often get is the higher the SPF the better, right? Not necessarily, our physician assistants recommend you use a minimum SPF of 30. No matter how high the SPF is, you should be reapplying sunscreen every 2 hours. Especially during activities like swimming, hiking, and playing sports… basically any outdoor activities! You should be reapplying regularly to ensure you are indeed covering your skin. If you‘re a forgetful person like me, you can always wear a hat which can also help with sun protection.

SPF, or sun protection factor, is a measure of how much sunscreen will protect you from the harmful rays of the sun. To give you a better idea, if you start to burn after being in the sun for 10 minutes without sunscreen, using SPF 30 increases that time to 300 minutes (10 minutes x 30 SPF). You will notice the greater the SPF results in a higher price, so you can always start with a 30 SPF and wear additional protection like a hat or shirt to help ensure your skin is covered and protected.

Do you have your sunscreen? Mention this blog and receive 10% off your in-store purchase of either Elta-MD or Epionce sunscreen product.

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Talking is the key to understanding

November 6, 2018Dr Levy Blog Cancer Elie Levy MD

They said he was supposed to be dead in 1970, due to a kidney condition–he is still alive! A patient came in for a growing lesion on his leg for the past few years. It finally started to bleed. My astute PA-C Jonathan immediately took a deep biopsy and sent it in for a stat pathology reading. It was the deepest basal cell carcinoma I had seen in years!!! This patient is a cynical, pessimistic gentleman. He did NOT want to have it treated. I explained that surgery was not needed. We could perform Electronic Brachytherapy, a light, in office, radiation treatment to melt it away without surgery. He thought about it for one second and said: “No!” He stated that his kidneys are in low function and that they are likely to get him first. After an hour on the phone, he finally agreed just to try one treatment. I told him it only takes 1.5 minutes per treatment! We met, marked out the area, answered all his questions and he is now on his way to a cure! Electronic Brachytherapy (eBX) is the way to go where surgery can be complicated or lead to complications. The moral of the story here is to take the time to explain all options and really speak to our patients to ensure they understand.

My AAD Conference

March 15, 2018Dr Levy Blog Elie Levy MD

I recently returned from my annual American Academy of Dermatology Conference. No fewer than 18,000 were in attendance from all over the world. The exchange of ideas and techniques with colleagues was exhilarating. Here is a summary of a few impressions I took away.

We are in a new age of treatment for melanoma and atopic dermatitis.

I can personally attest to such a case regarding a patient of mine. Mr. Smith finally came to the office with his daughter and son-in-law, they had pushed him for years. He was a decorated veteran of Pearl Harbor. He had a hard black knot on his bald head. When I saw it, I immediately became very sad. Tears came to my eyes, as I had such a nice time speaking to this jolly fellow. He also had many small dark dots near the area implying local spread.

Now, the prognosis of melanoma is judged by its thickness. More than 4 millimeters, about half the width of your fingernail, means a 90% death rate in a few years. His was more than 4mm just above the skin and there was more below! We took him back to the certified Surgery Center in our office and excised it. It was so deep even the pathologists cringed.

Indeed, it was a melanoma, and at this point, we sent him straight to the oncologist. They did all the studies and fortunately, he did not yet have any internal metastases. He was placed on a medicine called ipilimumab, part of a new cadre of immunotherapies for melanoma. He had weekly infusions of the medication for several months. A miracle! All the melanoma disappeared and has not returned.

There are many more such therapies now available called PD-1 inhibitors. They supercharge a person’s own immune cells to attack the cancer and they are being used now in many other forms of cancer. One brand name is Keytruda, but there are several others, and there are studies now using them in combination.

Atopic dermatitis has a first biologic therapy called Dupilumab. I have seen good results so far in one patient of mine, now 19 years old, who has had eczema since age 5. Side effects are eye irritation and diarrhea, both passing and controllable; better than itching all the time.

More to come in ensuing blogs.

To your health!

Learning about Eczema

August 24, 2017Dr Levy Blog Elie Levy MD

Given the following information, which of these people do you think is more likely to contract Eczema, a skin disease affecting primarily children, featuring rashes of dry, itchy, and scaly skin?

Child A:
Chad lives in the United States in the swanky section of a bustling city (Park Slope, Brooklyn, New York). His parents are wealthy and upper class, and his mother was 35 years old when she gave birth to Chad. Chad’s parents make sure that he is always clean and well-cared for.

Child B:
Rami is not named Chad, but he does live there, one of the poorer nations on Earth. His family is poor even by Chad (the country) standards and is, socioeconomically speaking, lower class. They cannot afford to live in a city, instead living on a small farm where they have two animals; a dog, and a goat. They drink the goat’s milk. Rami’s mother was 15 when she gave birth to him. They cannot afford to keep him clean or give him adequate medical care.

Obviously, you would say Rami is more at risk for eczema. Rami is poor and doesn’t have access to Chad’s standard of medical care, his parents can’t afford to keep him as clean as Chad’s parents do, and he’s obviously more at risk of disease and infection. On top of his poverty, he lives in an undeveloped nation, putting him more at risk. Living around animals probably doesn’t help, and neither does drinking unpasteurized milk. Not to mention the fact that Rami’s mother had him as a teenager probably means that Rami’s even more at a disadvantage, having a mother who may not be as equipped to properly take care of him.

In fact, however, Rami is much, much less likely to develop eczema. Every single detail of Chad’s situation is actually correlated with higher incidence of eczema: Living in a city, in the developed world, in a high social class, with an older than average mother and a high standard of hygiene is in fact linked to increased incidence of eczema. And, on the other hand, every detail of Rami’s case is linked with a lower incidence of eczema: living in an undeveloped country, in a lower social class, with lower standards of hygiene, around animals, drinking unpasteurized milk, and with a younger than average mother are all in fact linked with lower incidence of eczema. Chad may have a better life than Rami in innumerable ways, but he’s more likely to have eczema than Rami.

This is all quite counter-intuitive and puzzling. Generally, better living conditions make you more at risk of eczema?

What it does mean, first of all, is that eczema is not a bacterial or viral disease that can spread in unhygienic conditions, because unhygienic conditions actually make it less likely. Secondly, and more importantly, it means that environmental factors play a large role in eczema, those factors being the stuff we enumerated: Better living conditions, better hygiene, and maybe exposure to animals and milk and the age of the mother. Why those particular factors are the ones triggering eczema is poorly understood. It is hypothesized that in our hygienic and clean societies, our children aren’t exposed to certain allergens, don’t develop a resistance, and are thus vulnerable later on to the sorts of allergic reactions that cause the rashes that constitute eczema. This may or may not be true, and should not cause you to forsake hygiene for your child (Chad may have more risk for eczema, but Rami has a higher risk for West Nile Virus).

It’s not just environmental factors, though. Genetics also seem to play a large role. Firstly, If a child’s parent had eczema as a kid, the kid is much more likely to get eczema as well. But not just that. A family history of Asthma or Hay Fever also seems to correlate highly with risk of eczema.

All of these facts, taken together, give us an idea of what eczema is and what it isn’t. It is not a bacterial or viral disease, it is not contagious, and it is not the result of a lack of hygiene or poor living conditions (if anything, just the opposite). Rather, it’s a condition caused by environmental and genetic factors interacting in ways we don’t quite understand to produce a certain set of symptoms.

Those symptoms manifest differently for different age groups. As we have mentioned, eczema primarily affects children. Between 10 and 20 percent of children get eczema, compared to 1-3% of adults. 90% of cases occur before the 5th birthday.

Infants (defined for our purposes as ages 0-2) often get eczema around 2-3 months old and break out in dry, scaly rashes on their scalp, forehead, or face, especially the cheeks. Because infants do not have the ability to verbally express how itchy they feel, a telltale sign of eczema may be the infant in question rubbing itself against bedding or carpeting, trying to scratch themselves, which you might find adorable for half a second before realizing your infant is doing that because they’re in pain. They also might have trouble sleeping, which makes sense; you’d have trouble sleeping too if you had an itchy rash and no fine motor skills. These rashes may bubble up and ooze or weep fluid or can become infected because of the aforementioned rubbing and scratching.

Children (from ages 2 and up until puberty) have different symptoms than infants. Their dry, itchy, and scaly rashes appear mostly in the creases of the elbows and knees, the creases between the legs and buttocks, neck, wrists, or ankles. In time, these rashes can become bumpy looking (like permanent goosebumps), lighten or darken, thicken in response to constant scratching and develop knots. They can even become itchier over time.

Adults, who, to reiterate, make up a tiny fraction of eczema cases, manifests as very dry, very scaly (scalier than children’s eczema) rashes that appears in the creases of the elbows or knees, the nape of the neck, or just all over the body, and can be especially noticeable around the face, particularly near the eyes. It can itch non-stop, can thicken, and can become infected.

What do you do about eczema?

As we have mentioned, eczema is a condition that results from a certain set of environmental and genetic factors that interact in ways that are still poorly understood. That means that unlike other skin diseases, where we can try and get rid of the thing that causes the disease, whether it’s a bacteria or a virus or oil build-up or what have you, with eczema, we don’t have that option, because changing one’s genetic makeup is still considered unethical and changing their entire living circumstances is impractical. So when treating eczema, we don’t so much address the causes of the symptoms than the symptoms themselves.

There’s one exception to this, which is allergic reactions. Skin reactions to allergens and eczema are very similar. You might even say that eczema is best defined as “the skin’s allergic reaction to something we don’t know about”. So the first response to a case of eczema, particularly if it’s in an adult, is to try and figure out whether it’s eczema or just an allergic reaction. People have allergic reactions to all sorts of things; certain laundry detergents, gold jewelry, fake jewelry, certain fragrances. If the rash only appears in a certain area touched by something that might be an allergen, try removing the allergen from the equation. That would be the easiest and most straightforward way of dealing with the problem.

If that doesn’t work, we’re back on symptom management. That means, primarily, two goals:

Get rid of the rash
Prevent infection

To get rid of the rash, and reduce dryness and itchiness, use moisturizer. Which moisturizer? Pick one. Just go down the aisle at your local pharmacy and pick one. Different brands work best for different people, and some trial and error may be necessary for determining which brand is best for you or your child. For a cheaper and fragrance-free option, consider using petroleum jelly. Apply the moisturizer at least twice a day, or when you or your child’s skin seems dry.

To prevent infection, really try your best to keep from scratching. When you scratch, you create holes in your skin that bacteria can get inside of, particularly when your skin is damaged as it is. This is a hard job for adults, to say nothing of children, so with children, some tricks may be necessary. Make sure their fingernails are short and smooth, to limit scratch damage. At night, putting cotton gloves on your child may prevent them from scratching during sleep.

The good thing is, eczema usually goes away on its own, even if it can be frustrating and painful while it’s present. If it’s any comfort, bear in mind that if you or your child has eczema, because of the environmental factors we mentioned at the beginning of this article, your life is in all likelihood pretty good in all the other areas besides “not having a dry, itchy, scaly rash”.

A Sad Story

June 12, 2017Dr Levy Blog

There is an Australian instrument called a didgeridoo. It is about a 5 inch wide, very long tube made out of wood and usually some sort of wax or plastic, covering up the top for a mouthpiece. It is played by breathing in and out almost simultaneously.

An Australian patient of mine, who married an American woman and settled close to the clinic, developed skin cancer two years ago on his left ear. It was squamous cell carcinoma. He adamantly refused to have surgery and “did not want to look like Van Gogh!” We have the option of a very light form of radiation therapy in our clinic that can be done in eight treatments, about only two minutes each. It was originally new technology called high dose rate brachytherapy that is now able to be done with minimal shielding, in the office setting, without having to go to the hospital in a very thick walled, leaded room. We have treated thousands of times and fortunately have had no recurrences of any cancer to date.

Similarly, six months ago a gentleman came to the clinic with an ulcer in the upper left portion of the year and the very same area we performed the radiation therapy. The cartilage was exposed and it was painful. After two months of wound care and dressings, he finally decided it was time to perform a skin graft. We performed a porcine skin graft and he eventually healed after a few weeks.

Both the Australian patient and I have a passion for playing musical instruments and I told him that I sing as well. He said that he would come to the office and play the didgeridoo instrument for me. He did so and it was quite a scene. People outside were wondering what was going on in the exam room. So, I explained to them the nature of this very unique instrument and how I was getting a lovely free concert as part of our follow up!

My wife is the one who comes to work every day and opens up the mail and helps out around the office in any way possible. When she sees a handwritten letter from a patient or typed letter for the patient she immediately brings it to my attention. A letter came informing me that her husband suddenly died. Her husband was this Australian gentleman who plays this instrument for me. I was in shock. He was in relatively good health. I immediately called her up as soon as possible after the clinic day ended to express my condolences. In speaking with her, he did have a history of high cholesterol but he wasn’t feeling well that morning when she went out she came back to find him on the kitchen floor. She was broken and really affected by the sudden tragedy. I attempted to use my pastoral skills to allay her concerns.

We must be vigilant about our health.

Thinking Outside the Box

May 22, 2017Dr Levy Blog Cancer Elie Levy MD

A nice internal medicine physician, originally Canadian, refers patients to me often from afar. I am very honored and humbled at the same time. Recently, he referred a patient in his early 60s. This patient had seen two dermatologists prior, in addition to his internal medicine physician, one who prescribed a corticosteroid and the other blew him off.

He complained about redness in his forehead, it was not very itchy. It mostly bothered him cosmetically and he wanted laser treatment to remove it.
In a seated position, I examined him from multiple angles. I pressed on it and it blanched. There was no pain whatsoever. It was growing and it had an interesting brownish border and looked like simple chronic sun damage.
Something about this struck me and I recalled photographs that looked almost identical to the gentleman that was sitting in front of me from residency over 20 years ago.

I told him I wanted to make sure he did not have a very rare disease and I needed to do not one but two punch biopsies, even if it left a scar on his face. Mind you, the patient was very cosmetically conscious and the furthest thing from his mind was to add more scars to an area that was already very reddened. To avoid cosmetic damage, he would pay good money to expunge!

I put down one and only one diagnosis: Angiosarcoma.
About 10 days later, I got the pathology report and after special testing the diagnosis is: angiosarcoma. The prognosis is very poor and there’s a 50% recurrence rate even after all measures taken.

I spoke to the patient as soon as I possibly could to explain that he will need a team of physicians including the radiation oncologist, a medical oncologist, and a surgeon to address this issue.

I referred him to the University of Washington.

The ironic twist in the story is that he and the referring doctor are in-laws, expecting their first grandchild.

Mohs Surgery and the Lady…

May 3, 2017Dr Levy Blog

It was a typical Tuesday afternoon and we started our second set of Mohs surgery patients. Emma had a squamous cell carcinoma on her left temple. After the initial excision, she already had a dime-sized hole in her head! Fortunately, her lesion cleared after two stages of surgery.

We took her back to our ambulatory surgery center, where we listened to her heart and lungs, measured her oxygen level, and took her blood pressure.
While listening to her heart, I noted that the heartbeats were not steady. I asked her about this and she stated that her heart rate was normal and that she was not on any medication to regularize her heart rate. We went ahead and proceeded with the closure which went very well. I felt her pulse again after the procedure. The rate was irregular, typical of Atrial fibrillation.

I asked who her general doctor was and put in a call to him myself. After two phone calls, I reached the triage nurse who asked if it was necessary that she be seen today or if it could wait till tomorrow. I responded: “if you want to take responsibility for this patient having a stroke tonight she can wait till tomorrow otherwise she has to get into see her physician or go into the emergency room immediately.” The nurse clearly heard where I was coming from and scheduled an appointment with her doctor within one hour. I informed my medical assistant to relay the news to the patient Emma and she was to be there at 4:30 PM.

I thought about her the next day and asked my medical assistant to give her a call in order to obtain information on her visit the afternoon prior. She stated she was feeling fine, and that the MD put her on warfarin and is very very comfortable, without any pain from her incision.

Lesson to be learned: The two extra years I spent in an internal medicine residency paid off again, as well as being astute to details and taking action. I’m not just a dermatologist or dermatologic surgeon, I care about my patients as a whole.

A Patient Who Cried

April 6, 2017Dr Levy Blog

One routine Monday morning, I came into Examination Room 5 to perform a full skin exam on Bob, the father of a young former patient I treated a decade ago for Morphea – a skin hardening condition. Prior to beginning, Bob thanked me for diagnosing his daughter’s condition, and I expressed my appreciation for his gratitude.

During the exam, we discovered a few suspicious moles, but thankfully, no skin cancers were detected. Nevertheless, he did request removal of a fatty skin deposit that had grown and become more painful, so my nurse scheduled him for that procedure.

At the conclusion of the appointment, I intended to rush out to see the next patient. However, before I could leave the examination room, Bob became noticeably emotional and began to cry, reiterating his thankfulness over my accurate diagnosis of his daughter’s condition. He also appreciated my referral to have his daughter treated at the Department of Dermatology at Seattle Children’s Hospital where she was put on methotrexate shots weekly (instead of pills, which she threw back up due to a reflux issue).

This appointment was a reminder to me and my staff that we must always do our best for our clients because of the possible long-term impact we can make in their lives.

Selfies help

December 28, 2016Dr Levy Blog

As physicians, we hear it time and time again – “By the time I came in to see you, my rash disappeared!” Well, no longer. More and more patients come into our clinic, showing us photos of their skin ailment on their mobile devices taken over a few days or even weeks at a time. This activity is extremely helpful in making a more precise diagnosis.

A recent example of how your photos can assist us is in the case of a young woman from Montreal, Quebec, Canada. She had a few little red marks here and there, but nothing compared to the way the area looked on the selfie she showed me from a week prior.

Due largely to her photo, we were able to determine she had a more serious form of Rosacea – Granulomatous Rosacea, which requires us to treat the mites heavily infecting the skin (possibly causing scaring). Thankfully, there’s a new topical agent that helps with this condition called Ivermectin. I have used one oral dose of Ivermectin over the years very successfully to treat this type of Rosacea.

Kudos to all of you who take photographs of yourselves and bring them into your dermatologist!

Happy Holidays!

Dr. Levy

The Patient Without the Earpiece

November 28, 2016Dr Levy Blog

Prior to every surgery in our clinic, we conduct a final examination consisting of a patient assessment, an infusion of local anesthetic, and a marking of the surgical area.

It was during a recent examination of this type that I encountered a young man who was to have a scalp cyst removed. Normally, while waiting for the anesthetic to fully take effect, I engage our patients in small conversation to help make them feel more comfortable. But, this young man was different. He wasn’t very talkative and just kept looking down at the floor. In fact, he looked quite depressed.

This procedure was observed by another physician, as part of the criteria for maintaining our ambulatory surgery center certification. He was greatly impressed when he saw that I used the incision technique for my young patient (so that no hair would be lost). He admitted to never having seen it before and decided to begin using it, as opposed to his current technique.

As I examined him more closely, I noticed his glasses were missing the left earpiece, and I wondered why he hadn’t replaced it. So, after the surgery, I sat him right up and asked him directly, “Why don’t you get a new pair of glasses or replace your earpiece?” He simply replied, “I cannot afford it”.

He mentioned he had been working at McDonald’s and only just started a new job. When I asked him where he went in the past for his eye care, he indicated he had gone to Walmart. Immediately, I asked my nurse to call the Walmart optical department to set an appointment for him to get a new pair of glasses.

Later, I called him to find out how he was feeling and to make sure he was going to obtain the new glasses. However, when his wife answered the phone, she informed me that he hadn’t had an eye exam in years and would need a new prescription. So, I told her that I would cover both his eye exam and the glasses. She was very overjoyed and promised he would make an appointment for the exam.

Conclusion: I find it very fulfilling to look beyond the reasons my patients come to our clinic to see if I can make a difference in their lives. They are more than just “cases” to me.