What is the Vortex Pore Cleaner (VPC)?
Our VPC is a medical/aesthetic device that uses cleansers, mild salicylic acids and hydrating solutions to simultaneously wash, vacuum, and hydrate your skin and pores.

What is the purpose of this treatment?
Dr. Cohen recommends this treatment for individuals with pesky “clogged pores” (comedones), “buried whiteheads” (milia) and stubborn acne. When combined with the judicious use of manual extractions and topical acne medications, it is a great way to enhance your complexion. For those people who are bothered by enlarged pores, keeping your pores clean will help.

Please explain the procedure in more detail.
Think of this treatment as a turbo-charged, 30-minute facial. First, we prepare your skin with a mild salicylic acid cleanser and warm, moist towels. We then use the VPC applicator tips in a three step process to deep clean, exfoliate/extract and hydrate the skin. This device uses simultaneous rinsing and suction and the blockages are collected in a disposal container. We know it sounds gross, but it’s better for this junk to be in the container than in your pores. We finish with manual extractions of particularly stubborn comedones and milia.

How much does this treatment cost?
Our fee is $150 for this treatment, which includes the manual extraction of up to five milia. If you request removal of more than five milia, there is an additional $75 charge. Dr. Cohen suggests returning for additional treatments on an as needed basis and we will recommend appropriate skincare to help maintain your complexion.

Do I need any special skin care for this treatment?
Topical retinoids such as prescription tretinoin (Retin A), over the counter Differin, or retinaldehyde (Avène RetrinAl) both before and after treatment are helpful for reducing comedones and improving results. These topical medications may have side effects, so do your homework or talk with Dr. Cohen first.

Did you know that, on average, you lose 50-100 strands of hair each day? The most common reason for hair loss is familial or male/female pattern hair loss. Both topical and oral medications have been shown to help, especially when combined with platelet-rich plasma (PRP). PRP is a treatment for hair loss that is derived from your own blood. The process involves drawing two tubes of your blood, spinning it in a centrifuge, withdrawing the platelet rich concentrate with a needle and injecting it back into the scalp at the level of the hair follicle.

How does PRP work?
There are no great controlled studies, but overall data indicates efficacy ranging roughly between a 10%-30% increase in hair counts and hair shaft thickness. Variations in results are likely to be related to variations in methods. Some studies showed no statistical increase in hair counts or density, but most do. Topical minoxidil seems to provide more synergy when used with PRP than oral finasteride. Monthly injections of PRP for three months seem to be more effective than less frequent schedule. Patient satisfaction is relatively high.

Will PRP work for me?
PRP has been used primarily for common pattern hair thinning in men and women. For people with other scalp conditions, treatment is best directed at the underlying cause.

Is PRP risky?
Not really. Since PRP is derived from your own blood, there really should not be any significant side effects.

Does it hurt?
It does hurt a little, but Dr. Cohen uses a vibrating anesthetic device and a superfine, German made multineedle injector system. You may experience some bruising, tenderness or swelling at the injection site for a few days after the injection. Results are typically seen within 4 to 6 months.

Narrowband UVB (nUVB) is simply using light to treat inflammatory skin diseases such as eczema and psoriasis.  In a sense, it is an “organic” treatment because it does not require any topical or systemic medications.  nUVB is ultraviolet B light in the 311-312 nm wavelength. This wavelength improves effectiveness while limiting collateral skin damage.  People with atopic dermatitis/eczema or psoriasis may experience symptoms ranging from itching to rashes anywhere on the body, scalp, palms or soles.  Fortunately, most cases are mild and are treated with proper skin care and the judicious use of topical medications.  Some cases are very severe and may require oral or injectable medications to help symptoms.  nUVB is a perfect way to bridge the gap for patients with more severe disease who do not want to be treated with shots and pills.

What is involved in nUVB?

Hendersonville Dermatology has a “light box”, which is a walk-in/stand up booth with 24 nUVB bulbs.  We also have a specialized sit-down unit for treating the palms and soles.  Treatments are administered three days weekly for one to two months.  Patients apply an emollient prior to treatment to improve light transmission to the skin.  Initially, each treatment lasts from 20-30 seconds and exposure time is gradually increased to seven or eight minutes.  After the skin has cleared, treatments may be continued once every week or two for maintenance.  This is not a cosmetic treatment and it is covered by insurance.

Are there risks?

The primary risks to nUVB are “sunburning” and the potential problems associated with UV exposure over time.  Patients are provided protective eyewear and uninvolved areas such as the face are protected too.  Finally, people taking photo-sensitizing medications, or who have photo-sensitivity diseases, are not candidates for nUVB.


nUVB is an effective treatment for atopic dermatitis and psoriasis that bridges the gab between topical skin care regimens and complex, potentially risky systemic medications.  It is especially useful for patients with severe skin disease and other medical issues who are poor candidates for more medications.


Seeking a quick, minimally invasive approach to reducing some of the signs of age?   Learn about soft tissue fillers.  Between the advancements in the safety of these products as well as our improved understanding of their use, fillers may be a good option for maintaining a more youthful appearance.

Soft tissue fillers comprise a large group of products of differing chemical composition.  This discussion is limited to hyaluronic acid (HA) fillers, which are based on a normal component of our extracellular matrix.  HA fillers have the advantage of being reversible, if needed, with the use of the enzyme hyaluronidase.  HA fillers are not permanent which, in my opinion, is an advantage in the event of an undesirable result.

Hyaluronic Acid (HA) Fillers

Currently, the following families of HA fillers are available in the United States:

  1.  Allergan’s products:  Juvéderm Voluma®, Juvéderm Ultra® and Ultra Plus®, Juvéderm Volbella® and Juvéderm Vollure™.
  2. Galderma’s products:  Restylane® Lyft, Restylane®, Restylane® Silk, Restylane® Refyne, Restylane® Defyne
  3. Merz Aesthetics’ Belotero Balance®.

While these products all contain hyaluronic acid, they differ in some alterations to the molecules and concentrations which affect their viscosity, “stickiness,” “thickness” and longevity.  Essentially, the thicker, more viscous products are used in the deeper areas of the upper cheeks to restore volume and provide lift.  The thinner, less viscous products are used to deal with subtle lines and deficiencies in the areas in and around the lips.  Middle-of-the-road products are typically used for prominent creases between the nose and mouth (nasolabial folds) and between the south and chin (“marionette” lines).

Juvéderm Vollure™, Restylane® Refyne, and Restylane® Define have only recently been released in the United States.  Consequently, specific information regarding the concentration, viscosity, thickness, etc. for these products is not immediately available.  Based on the information currently available, I rank these product families as follows (starting with the thinnest and less viscous products and ending with the thickest most viscous products):


  1. Restylane® Silk
  2. Restylane®
  3. Restylane® Refyne
  4. Restylane® Defyne
  5. Restylane® Lyft


  1.  Juvéderm Volbella®
  2. Juvéderm Vollure™
  3. Juvéderm Ultra®
  4. Juvéderm Ultra Plus®
  5. Juvéderm Voluma®

I have not listed the Merz products as they currently have a limited line of FDA approved products available in the Untied States.

In terms of cost, the Galderma products are generally somewhat less expensive than the Allergan products.  In terms of duration of effect, the Allergan products have generally been approved by the FDA for longer lasting periods of time.

Potential Risks

While there are many aesthetic benefits to the use of HA fillers, there are also some potential risks.  These risks range from minor issues such as temporary bruising to uncommon, but potentially catastrophic problems, such as scarring or blindness.  Other potential problems include skin discoloration, small blebs or bumps in the skin, aesthetically displeasing results and, uncommonly, nodule and abscess formation.  Your physician should be familiar with the underlying anatomy of the face, proper product selection, and how to inject to achieve aesthetically pleasing results.

Toenail fungus, otherwise known as onychomycosis, is an extremely common and persistent problem.  Certain people seem to have a unique pre-disposition to this toenail infection which makes it difficult to achieve a permanent cure.  Permanently curing this condition requires determination, persistence and know-how.  Often, a more realistic approach is palliative treatment instead of permanent cure.

Treatment of Toenail Fungus

The gold standard for the treatment of onychomycosis is systemic terbinafine.  This treatment usually requires at least 3 to 4 months of ongoing daily medication.  Care must be taken for individuals who have certain pre-existing conditions or who are taking other medications that may interact with this drug.  After approximately 6 to 12 months, the majority of individuals will improve.  However, without some type of ongoing maintenance, relapse is almost certain.

There are numerous recommendations floating around for the topical treatment of onychomycosis.  These range from various formulations of vinegar to the use of Vicks VapoRub.  Topical antifungal creams, sprays and powders fail because of lack of penetration into the nail tissue.  Even complete removal of the affected nail usually results in relapse.

Prescription Options

There are three topical prescription products available in the United States specifically for the treatment of nail fungus.  Listed below are their names, approximate effectiveness and approximate cost.

  1. Ciclopirox 8% nail lacquer, in one large study was shown to clear about 40% of cases.  In my clinical experience, the number is significantly less.  The price of this medication is approximately $60 for 6.6 ml of the generic.  As a point of reference, a teaspoon holds 5 ml.
  2. Jublia, in studies provided by the drug manufacturer, gave 20 to 30% clearance rates after 48 weeks of treatment.  This medication costs approximately $645 for 4 ml.
  3. Kerydin, in company provided information, gave response rates of a little below 20% at one year.  This drug is also priced at approximately $645 for 4 ml.

Over the Counter Treatment Options and Plan

Due to the lack of cost effectiveness of current prescription topical treatments, my preferred topical treatment for onychomycosis is the following:

  1. Apply over the counter terbinafine cream ($15.99/30 gm) to both feet, toes, web spaces and nails once daily.  Most people will have coexisting athlete’s foot and this strategy will help contain infection.
  2. Apply 47% urea gel (KERA Nail Gel $30/30 ml) thoroughly over and under the affected nails nightly.  If possible, work some of the terbinafine cream under the nail while applying the urea gel.  This concentration of urea will help dissolve away the infected nail, thus allowing the terbinafine to penetrate more effectively.

This treatment should be continued for 3 to 6 months and then reassessed.  While I do not have any research data on the effectiveness of this treatment, it is my clinical experience that many patients show improvement comparable to the much higher priced prescription topical medications.

Prescription Treatment Plan

For those highly motivated individuals in good health and not taking any other medications, I recommend the following approach for a complete and permanent cure:

  1. Systemic prescription terbinafine daily for 3 to 4 months.
  2. 47% urea gel nightly for 3 to 4 months.

Upon completion of this treatment program, it is essential to continue preventative maintenance indefinitely.  This is best accomplished with terbinafine cream applied to the feet, toes and nails daily after bathing.

This article on skin brighteners is a follow up to my blog on topical retinoids for skin restoration.  The primary focus will be the treatment of solar lentigenes (“liver spots,” “freckles”), melasma and post inflammatory hyperpigmentation.  This article is not intended to address other pigmented lesions such as moles, seborrheic keratoses, or anything that could be cancerous.  It is always best to seek the advice of a board certified dermatologist for the proper initial diagnosis and treatment plan.


Unwanted brown freckles or splotches typically appear in sun-exposed areas such as the face, upper chest, arms and hands.  The foundation of any treatment program for unwanted skin pigmentation includes sun protection, and usually a topical retinoid.  In addition to these, hydroquinone is the gold standard for treating brown spots.  While hydroquinone is the subject of controversy regarding its safety, this article will not address these issues because it has a long-term record of safe use in the United States.  Hydroquinone is available over-the-counter in a 2% formulation and by prescription in a 4% formulation.  It can also be compounded in higher strengths by some compounding pharmacies.  Adverse reactions to hydroquinone include skin rash in approximately 5% of users and exogenous ochronisis, a permanent idiosyncratic darkening of the skin.

Azelaic Acid

Azelaic acid is another useful treatment for unwanted pigmentation.  This naturally-derived substance has been shown to be beneficial for the treatment of acne vulgaris, acne rosacea, and melasma.  The only FDA approved topical prescription formulations are Azelex (20% Azelaic acid cream, $413/30 gm) for the treatment of acne vulgaris, and Finacea (15% Azelaic acid gel, $330.49/50 gm) for the treatment of acne rosacea.

Azelaic acid is also useful for hyperpigmentation, although published information seems to favor its efficacy more for melasma and post inflammatory hyperpigmentation than for sun spots.  The FDA has not approved it for over-the-counter use in concentrations of 15% or greater and no claims can be made for over-the-counter azelaic acid products for the treatment of acne.  Glytone has a product, Glytone Enhance Brightening Complex, containing 12% azelaic acid with 3% glycolic acid which costs $70/oz.  This combination of azelaic acid and glycolic acid should provide synergy for the treatment of unwanted pigmentation.  The manufacturer cites internal studies showing benefit but does not permit dissemination of the details of this information.

Topical Vitamin C

Topical vitamin C is another treatment option.  There are several research studies showing the benefits of certain formulations of topical vitamin C for the treatment of hyperpigmentation, restoration of collagen and elastic tissue, and reduction of fine lines.  In my opinion, high-quality vitamin C products are less effective than topical retinoids for this purpose because of their high price (SkinCeuticals C E Ferulic 15% vitamin C $165/oz, Glytone Age-Defying Vitamin C + E Serum with 20% THD ascorbate $130/oz, Revision Vitamin C Lotion with 30% THD ascorbate $109/oz) relative to their efficacy.  Still, for those who wish to spend the money, they do have utility when used with topical retinoids.

Effectiveness and Use of Skin Brighteners

Here’s how I rank these compounds in terms of cost effectiveness for skin brightening:

  1. Topical 4% hydroquinone
  2.  Revision Vitamin C lotion 30% or Glytone Enhance Brightening Complex with 12% azelaic and 3% glycolic acid

I recommend starting with 4% topical hydroquinone and a topical retinoid.  After a month or two, replace the hydroquinone with a topical vitamin C or an azelaic acid product.


Some of us remember the 1980’s Wendy’s advertisements where the customer looks at her fast food burger and asks “Where’s the beef?”  Well, that’s my question when it comes to topical products for skin restoration.  Does the product have ingredients with proven efficacy and safety to justify the cost?

Maintaining one’s best appearance starts with preventing sun-related problems.  For a discussion about preventing sun-related skin problems, please refer to my blog on sun protection.  My curent core list of proven effective compounds for skin restoration includes topical retinoids, hydroquinone, azelaic acid, alpha hydroxy acids and vitamin C.  Hydroquinone, azelaic acid, alpha hydroxy acids and vitamin C are the topic of Topical Treatments for Skin Restoration Part 2.  In my opinion, if tolerated, topical retinoids should be the foundation of any skincare program intended to restore skin quality.  They have been shown to help restore collagen and elastic tissue and to reduce fine lines and tan spots.  Additionally, they provide synergy when used in conjunction with other topical skin care products such as skin lighteners.   It should be emphasized that oral retinoids result in severe birth defects if taken during pregnancy.  Variable quantities of topical retinoids are absorbed through the skin into the bloodstream.  Consequently, women contemplating pregnancy, or who are pregnant, should not use topical retinoids.

Topical Retinoids

Topical retinoids include over the counter retinol (vitamin A), retinaldehyde, Differin (adapalene 0.1% gel) and prescription tretinoin and tazarotene.

Currently, I am aware of only three FDA approved prescription topical retinoids for skin restoration:

  1. Renova (0.02% tretinoin), approximately $290.22/40 gm, for the “palliation of fine wrinkles.”
  2. Refissa (0.05% tretinoin), approximately $106.91/20 gm, for the “palliation of fine wrinkles, mottled hyperpigmentation and tactile roughness of facial skin”
  3. Avage (0.1% tazarotene), approximately $387.73/30 gm, for the “mitigation of fine wrinkles, mottled hyperpigmentation and lentigenes”

Most other formulations of topical retinoids can be sold with no claims other than that they “reduce the appearance of fine lines and brown spots.”  Differin 0.1% gel (adapalene) was recently approved by the FDA for the over the counter treatment of acne and became available at approximately $30/30 gm tube in January 2017.  The availability and price of this medication is a game changer in terms of topical retinoid treatment, not only for its approved use in the treatment of acne but also the non approved use for the treatment of sun damaged skin.  There is a large, prospective, randomized, controlled study showing improvement in actinic keratoses, solar lentigenes and photoaged skin with adapalene.  Refissa, if available at $106.91/20 gm, with its FDA indications for skin restoration is also a strong option.

From most evidence to least evidence for efficacy in the treatment of sun damaged skin, I rank the topical retinoids as follows:

  1.  Tretinoin and tazarotene
  2. Adapalene and retinaldehyde (Avene Retrinal 0.1%, $70/30 ml)
  3. Retinol

From least irritating to most irritating, I rank these products as follows:

  1.  Retinol
  2.  Adapalene and retinaldehyde
  3.   Tretinoin
  4.   Tazarotene

In terms of cost effectiveness, I rank them as follows:

  1.  Adapalene
  2.  Refissa or retinaldehyde
  3.  Tretinoin
  4.  Tazarotene

How to Use

To reduce skin irritation, and for maximum effect, I recommend the following:

  1.  Start using the product every other night for two weeks, then nightly if tolerated.  If necessary, take periodic breaks in the treatment.
  2.  Use gentle skin cleanser.
  3.  Use a moisturizer in the evenings and a facial moisturizer with sunscreen in the morning.  Simple unscented skin cleansers and moisturizers are best.
  4.  Apply the products lightly and evenly over the entire face, except around the eyes.

Topical retinoids will intensify the effects of chemical peels, microdermabrasion, or laser treatments and should be stopped at least one week prior to these procedures.





It continues to surprise me how many people don’t realize that they have athlete’s foot.  This common fungal infection, known as tinea pedis, is frequently mistaken simply as “dry skin.”   The name “athlete’s foot” is a misnomer as the problem is not limited to athletes.  It is reported to affect between 30% to 70% of the population.  There are a variety of responsible fungi, but trichophyton rubrum is the most common.  These fungi are common in the environment and grow in the dead “keratinized” layer of the skin, known as the stratum corneum.  Genetics, climate and occlusive footwear predispose individuals to tinea pedis and it is much more common in adults than children.

Signs of Athlete’s Foot

Tinea pedis is frequently asymptomatic but the signs may include dry, scaly skin with or without tiny bubbles around the sides and along the bottom of the feet.  The skin between the toes may have a white, pasty appearance and often there is an accompanying toenail fungus.  Other common or more serious conditions such as psoriasis, eczema, allergic skin reactions, cellulitis and callused skin could be confused with tinea pedis.  A physician should be consulted if there is any redness, swelling, bleeding, inflammation, pain or if there are open sores or other complicating factors such as diabetes, vascular insufficiency, advanced age, cancer or immunosuppression.

Topical Antifungals

There are many effective antifungal topical products available for treating tinea pedis.  In recent years, prescription antifungal creams have undergone substantial price increases, but economical and excellent over the counter products are available such as generic terbinafine cream or butenafine cream (Lotrimin Ultra).  I do not recommend antifungal powders or sprays.  For maximum benefit, it is just as important to use the medicine properly as it is to choose the right medicine.  Apply the cream to both feet in a thin layer from the ankle down covering the entire foot surface.  It should be applied every morning after showering for two to four weeks.  Recurrences are likely, so be prepared to start treatment early for any signs of flare-ups.  While all medications may have the potential for adverse reactions, problems with over the counter topical antifungal medications are unusual.  The most likely problem would be an allergic rash, in which case the medication should be stopped immediately.  If your problem is not improving within two weeks (or certainly if it is worsening), see your physician for evaluation.


In addition to using a topical antifungal cream in the mornings, applying a “keratolytic” exfoliating cream or lotion at bedtime will increase the effectiveness of the antifungal cream.  These products work by helping to remove the dead keratinized layer of skin inhabited by the fungus.  They also by allowing better penetration of the antifungal cream.  Keratolytic products contain various concentrations of urea (10%-20%), salicylic acid (3%), or alpha hydroxy acids (12%).  They may be used indefinitely to keep the feet smoother, softer and to prevent recurrences.  A warning, keratolytics should not be applied to sensitive, irritated, inflamed or open skin.

Now that we all know that the sun is bad for our skin, what are we doing about it?  Brown spots, lines, scaly growths, precancerous skin lesions and skin cancers frequently appear on sun exposed surfaces and, once established, these changes are difficult to reverse.   While skin cancer can appear at any age, it usually starts appearing in the 50’s or 60’s after significant damage has been done.  Some simple precautions are the best way to keep your skin looking young and cancer free.

Sun Protective Clothing

Proper clothing is the first line of defense.  Unlike sunblock and sunscreen, clothing is essentially chemical free and provides all day protection.  Broad rimmed hats, long sleeve shirts, long pants and special swim wear protect most of the skin surface. Broad rimmed hats are superior to ball caps and visors because they help protect the neck and ears.  Long sleeved crew neck shirts prevent sun damage on the arms and the “V” area of the chest. Cotton is a good fabric for fall through spring and synthetic blends work well in summer.  As with long sleeved shirts, long pants come in a variety of fabrics suited for each season.  Finally, swim shirts are an excellent option for water sports.

Sunblocks and Sunscreens

Physical sunblocks are the next best choice after sun protective clothing.  These products contain zinc and titanium dioxide.  Zinc and titanium are opaque, and together, work by reflecting both UVA and UVB.  These compounds are relatively inert and, because they have fewer and simpler chemicals, they are better than chemical sunscreens for people with sensitive skin.  Physical sunblocks complement protective clothing by protecting exposed areas such as the face, neck and hands.

Chemical sunscreens contain various UV screening chemicals such as octocrylene (UVB), ethylhexyl methoxcinnamate (UVB), oxybenzone (UVA2/UVB), avobenzone (UVA1/UVA2), and homosalate (UVB).  Combinations of these compounds may absorb ultraviolet radiation in the form of UVA1, UVA2, UVB, or all three and dissipate this energy as heat.  In this group, select a sunscreen that effectively protects against both UVA and UVB.  Protecting only against the sunburning UVB permits excessive exposure to the carcinogenic and skin damaging effects of UVA.

There have been reports that not all sunscreens or sunblocks have been living up to the manufacturers SPF ratings.  Check the labels on your sunscreen and verify that it contains the ingredients needed to protect your skin against UVA1, UVA2 and UVB.  Remember that a face or body moisturizer with sunscreen will not resist water and sweat.  Additionally, sunscreens are not as effective if not enough is applied.  The average sized person should apply 30 ml (two tablespoons) of sunscreen for maximum effect.

Vitamin D

It is likely that lack of exposure to sunlight will result in low levels of vitamin D.  Vitamin D is needed for proper bone maintenance and may have other beneficial effects.  How much supplemental vitamin D is needed is a subject of uncertainty but can easily be determined by a blood test.  While the current minimum daily guidelines recommend about 600-800 IU of vitamin D daily, the actual amount may be closer to 1000-2000 IU daily or more.  As vitamin D is a fat soluble vitamin, too much vitamin D can accumulate in the body tissues and could theoretically be harmful as well.

What is SPF?

What is SPF?  The SPF number stands for the number of hours of sun exposure with the sunscreen that would equal the amount of sun exposure obtained after one hour of exposure without any sunscreen.  In other words, staying in the sun for 30 hours with an SPF 30 sunscreen is equivalent to staying in the sun for one hour without any sunscreen.  I recommend looking for the highest SPF sunblock or sunscreen with the simplest necessary ingredients, proven effectiveness, reasonable cost and cosmetic elegance.