Trish Hammond: I’m here today with Dr. Ritu Gupta, whose a specialist dermatologist and she works from Platinum Dermatology in Ultimo New South Wales.
I’m sure a lot of you guys are just like me where you’re not really quite sure what a dermatologist does. We’re adding specialist dermatologists to our directory, so I thought we’d invite Dr. Gupta along, and just find out a little bit about what she does and I think you’ll be really nicely surprised.
Thank you so much for taking the time to talk to us, Dr. Gupta.
Dr Ritu Gupta: That’s a pleasure, Trish. I was going to say lovely to meet you, but lovely to talk to you. I feel like I’ve met you.
Trish Hammond: Lovely.
Now, for a start, just to help our listeners out there can you tell us a little bit about how long a dermatologist studies for and what they actually specialise in? Because I was a little bit surprised myself, because I always thought it was just if you had a skin disease you would go to see a dermatologist, but you guys cover a whole lot more.
Can you tell us a bit about what you do?
Dr Ritu Gupta: Yeah, absolutely. Don’t feel bad that it’s not that clear what a dermatologist does. I think there’s a lot of misconceptions in the general population and people don’t generally know. Why would you, basically? Unless you’re a medical practitioner.
A dermatologist is a doctor who has done basic undergraduate training, and then usually somewhere between three to four further years in the hospital system, and then they have applied and got onto the dermatology training program. They are a member of the Australasian College of Dermatologists.
That involves then a further four to five years of training, including an entrance examination and then a final, pretty rigorous, fellowship examination in your final year.
To get on to the dermatology training program in Australia is very, very competitive. It’s a great specialty to do; it has good hours, it’s varied, and as you mentioned yourself it encompasses a lot of things. Medical dermatology, so things like acne, psoriasis, eczema. Paediatric dermatology so in kids, babies. Surgical dermatology, so excision of melanomas, skin cancers, skin grafts flaps and repairs. Then, increasingly, cosmetic dermatology. Not only managing photo aging, or ageing from the sun, but also photo rejuvenation so improving people’s appearance.
The lovely thing that I love about dermatology is the fact that one can do a bit of everything. You never get bored.
Trish Hammond: Okay.
Dr Ritu Gupta: It also means that we’re really a one-stop shop for anything. We’re the only specialists in hair, skin, and nails. Most dermatologists have also done additional research to gain a position on the training program, so I for instance did a PhD in skin cells and Vitamin D, so I did a full PhD before I started the training.
When you asked about how long it was, God, it took 18 years to become a dermatologist.
Trish Hammond: Wow.
Dr Ritu Gupta: That’s going straight through from go to woe. That’s from finishing school, undergraduate, postgraduate, and then specialist training.
The way that you can tell someone is a dermatologist just for your listeners out there, is they will have the letters FACD after their name. If people have those letters after their names, you know that they are Fellows of the Australasian College of Dermatologists, and that they are specialists.
Skin cancer clinics are not dermatologists. They are GPs, who might have an interest in skin. Some of them might have only done sort of weekend courses. Obviously laser clinics and rejuvenation clinics, cosmetic surgery clinics, cosmetic physicians, are not dermatologists.
Trish Hammond: Wow, that’s so interesting. I had no idea.
Do we need a referral from a GP to see you?
Dr Ritu Gupta: Well, it sort of depends. Medicare does not give a rebate for any cosmetic concerns, basically. If the query is a purely cosmetic one, the cost is the same as a normal consultation in my practice, but you don’t get a Medicare rebate. That means there’s not a lot of point wasting your time and money going to see your GP.
If however you’re coming for a skin check for skin cancer, and then you also have cosmetic queries, then you would get a Medicare rebate. I suppose it really depends on the individual, and what they’re after and what they need.
Trish Hammond: Okay, got it. If it’s cosmetic, you don’t need a GP referral. If it’s something that’s non-cosmetic, get a referral and you get a rebate from Medicare?
Dr Ritu Gupta: Yeah. Look, to be honest, the rebate gives you $77 back so it’s not a whole lot. If people are not sure and they think, “I don’t know if I can be bothered to get a referral,” they’re only going to save $77-
Trish Hammond: No, that’s true.
You’ve told us a little bit about your practice, but you can tell us a bit more about your practice Platinum Dermatology and your philosophy for treating patients?
Dr Ritu Gupta: I started this practice with a colleague three years ago. We’re both female dermatologist, we’re both working women juggling life like you are Trish. The whole kind of struggle, juggle shebang.
Trish Hammond: Sure.
Dr Ritu Gupta: I work four days a week. The practice is … Look, I think it’s lovely. It’s purpose built, it has four consulting rooms, two laser rooms, two other treatment rooms, a sterilization suite.
We have a staff of specialist dermatology nurses, including a cosmetic dermatology nurse from Miami who’s done a lot of body sculpting with “fat freezing” or Cryolipolysis, which is a new device we have, and also a lot of ultrasound skin tightening.
That’s sort of the practice. My philosophy for treating patients; in fact I just told someone this today. I said, “The way I practice is I always try and treat someone the way I would like to be treated. I hope that doesn’t sound too mushy, but essentially I always put myself in the patient’s shoes and think, “What would I want done if this were me, or if this was my relative?”
Trish Hammond: Yep.
Dr Ritu Gupta: The reason that came up today was a patient of mine, he’s about 60 or 70, he followed me from another practice before I set up my own practice when I was just locuming. I had done a big skin cancer excision on his nose.
Anyway, I was seeing him in follow up today and he said, “I’ve got to say, I couldn’t even see the scar. It was fabulous!” I said, “Leon, this scar is amazing.” He said, “Yeah, I can’t believe I even asked you about seeing a plastic surgeon.”
I said, “That is absolutely fine that you asked me.” He said, “I only asked you because my wife wanted me to ask you.” I said, “Look, my approach to you was I know that I can do this. If I had felt that this was beyond me, I would have referred you to a plastic surgeon.”
Trish Hammond: Of course.
Dr Ritu Gupta: That’s what I said. That’s my philosophy. I think hopefully you don’t go too wrong. I always try and do my best for my patients, absolutely. I look after them. A lot of them I feel are almost like my friends; I care about them, I know their kids’ names, I know when they’ve gone on holidays. It’s what makes work interesting to me. It’s not so much the procedures, or the skin conditions or the diagnoses, but it’s the people themselves. It’s talking to people.
Trish Hammond: Yeah. It’s true as a consumer, once you find someone that’s going to be the person to look after you for your skin cancers or your skin, or acne or whatever, that person might be your doctor but they’re that little bit extra as well. Where you know that you can rely on them.
Dr Ritu Gupta: Yeah, for sure. I think the thing is, and this is another lovely thing about dermatology, our patients are mostly well. They’re not sick. Most of them … It’s not like being an oncologist or something where it’s all this terrible, bad news you’re giving day in day out, and people are really sick.
We’re fortunate in that most people are walking in the door, they’re healthy. A lot of what we do is primary prevention, which means that we are preventing things and diagnosing things before they get to a really serious stage. That’s a great thing too, because that’s really the way healthcare needs to move in Australia is prevention rather than just treatment. It’s prevention.
That actually goes for aging as well-
Trish Hammond: Of course.
Dr Ritu Gupta: Yes, our treatment modalities get better and better, but honestly what you need to tell your listeners is the best thing they can do is sun protection, sun avoidance, and not smoke.
That goes a long way to preventing anything. Also, of course, maintaining any results of any treatments that they choose to undergo.
Trish Hammond: Mm-hmm (affirmative).
I notice that a lot of your work concentrates on using the latest devices to treat skin and face concerns. Can you tell us, just getting into the actual procedures now, what do you recommend for example for laser face resurfacing and what results can patients expect from that?
Dr Ritu Gupta: Laser resurfacing, laser is a very rapidly moving field as you may well be aware. It changes all the time. The laser I use is a Sciton laser, which I think is excellent. It’s quite beloved with dermatologists and plastic surgeons. Made in the US. It’s what’s called a “multi-platform” laser, so it has a number of different hand pieces that do different things.
Your question was about resurfacing; so for resurfacing, it uses erbium. People may have heard of carbon dioxide. The carbon dioxide was the first resurfacing laser. There are still CO2 lasers around, but a lot of resurfacing has largely been taken over by erbium, because there’s less downtime, there’s less prolonged redness, there’s less risk of being left with permanent white areas, and there’s less of a demarcation zone, like a cut-off line, between the treated and untreated area.
Resurfacing laser, I think the simplest way to think about this and I do a lot of general practitioner education, I give talks to 1300 GPs at a time. The way I describe it is resurfacing laser can be delivered as a spot, so for nuisance lumps and bumps. People who have got one of those raised, sticking out moles that they don’t like, the hairy moles on the face or people who have the rough wisdom warts or age spots. That can just be peeled off, like peeling off the skin of an onion, in just a single spot.
Or, it can be delivered in a fractionated way, so in dots, where it’s not peeling off the whole layer, it’s not peeling off the skin of an onion, there’s little cores of normal tissue left behind. That means the downtime is less, so the downtime is typically four days and the skin barrier completely heals. That’s a useful technique I use a lot for acne scarring. This laser is now gold standard for acne scarring, and can be used on any skin type, even all the way to African American skin which is a grade above-
Trish Hammond: Nice.
Dr Ritu Gupta: It was never able to be done. That’s the fractionated erbium.
It can also be delivered then basically as a full resurfacing, so fully peeling off the skin of an onion. Say all over the face, I was treating a lady today. That can be done in superficial and deep levels-
Trish Hammond: Is that to get rid of lines and wrinkles? Is that what that’s for?
Dr Ritu Gupta: Yeah, that’s what I was treating her for. She hates the lines around her eyes. That crepey under-eye skin, really there is nothing that treats that other than resurfacing laser. Ultrasound skin tightening will help as well, but resurfacing laser is really the only thing. Eye creams and things really have limited use. Filler is not going to help. Filler will help for the trough under the eye, but it will not help for that crepey skin.
The lovely thing about this laser is it’s incredibly tuneable. I can dial up and down in a hundredth of a millimeter increments, so incredibly precise. Another patient rang me today that booked in for the deep resurfacing next week with a few questions, and she said, “Is it a standard depth that you use?” I said, “No, the depth is not standard. The depth is individual, it’s dependent upon the patient. Even within the patient’s face it’s dependent upon the site because it’s dependent upon the thickness of the skin.”
Trish Hammond: Mm-hmm (affirmative).
Dr Ritu Gupta: I can be going up and down and changing every time I pulse the laser. I think laser resurfacing is great. Deep laser resurfacing can only be done in very fair skinned people, though. It can’t be done in Italian background people-
Trish Hammond: Oh don’t say that!
Dr Ritu Gupta: People with Italian backgrounds and more Mediterranean can have more superficial resurfacing. They can also have the fractionated resurfacing, and they can have the ultrasound skin tightening. There are definitely modalities, but the full, deep one week at home, hide away from everyone resurfacing is really for what we call in dermatology “skin phototype one and two”.
Trish Hammond: Okay, that’s what I was going to ask you. Say, for example, if I did have skin type one or two which is quite fair, and I want to come and have a treatment how long would I be out of action for if I was to have a deep one?
Dr Ritu Gupta: Deep treatment is seven days at home. You need a consultation first and I obviously assess whether it’s-
Trish Hammond: Suitable?
Dr Ritu Gupta: A good option, a suitable option. Go through everything about it, the pros, cons, costs, et cetera. I show not only before and afters, but what’s really important is healing diaries. People really need to know what to expect.
It is a bit of a process, but it’s a week. It’s a week at home. The day of laser is Day zero, then it’s seven days. We typically see patients on the seventh day, that’s all part of the cost.
At the seventh day, they’re still bright pink, but they can cover it with makeup. We have a medical grade camouflage that the nurses are very expert in teaching patients how to apply.
Trish Hammond: Great.
Dr Ritu Gupta: Which they can use. Then that redness fades with time; the typical person would probably … A fast healer would be all back to flesh colored in four weeks. A slower healer, more average, would be six to eight. A really slow healer might be 12 weeks.
Trish Hammond: It’s like taking off the whole top layer of your skin, and just getting a new skin underneath?
Dr Ritu Gupta: Yeah. It’s basically peeling off the whole of what’s called the epidermis, which is the upper layer of skin that you can see, down to the upper papillary dermis, which is the upper layer of the deep part of the skin. You can’t go down to the very deep dermis, which is called the reticular dermis that’s where the hair bulbs lie, because if you go down to the reticular dermis that’s when scarring can occur.
We’re travelling to the depth of the papillary dermis. When I’m actually doing the procedure, I see clinical indications that tell me that I’m at that right depth-[crosstalk 00:14:29]
Trish Hammond: Stop or don’t stop.
Dr Ritu Gupta: Or go deeper or make it shallower.
Trish Hammond: How long does that procedure take?
Dr Ritu Gupta: Physically doing the laser, because laser is mere second pulses, the deep resurfacing probably actually having the procedure done probably takes about 20 minutes. Probably the patient is in the practice for about an hour. It feels like the worst sunburn you’ve ever had, but patients have Panadeine Forte, they’re prepped with … I give them a script for a really strong local anaesthetic cream which they put on two hours before hand.
Usually it’s not jump of the bed stuff for most people. They leave once they’re comfortable. They lie there with ice pads; we have a relaxation room and the nurses attend to them. Then we call them every day and check on them and see how they are.
Trish Hammond: That sounds great.
I really want it, but I know I can’t have it. That’s okay.
Dr Ritu Gupta: I’d just need to see you to make an assessment of your skin type and then a plan, but there’s certainly options. There are options for all skin types for wrinkling.
Even dark skinned people like me, I mean I’m Indian. I’m not super-dark Indian, but I’m skin type four. There are even options for people like me, and darker than me.
Trish Hammond: There’s a whole lot of talk around collagen stimulation; you can do this and it will stimulate your collagen. Can you kind of explain this concept to us and tell us why collagen stimulation is so effective for the aging phase?
Dr Ritu Gupta: Absolutely. Actually one of my other jobs to do after this, Trish, is I’m writing a text book chapter on the ageing face, and the variations in ageing with different ethnicities, in a new Australian cosmetic dermatology textbook.
I’ve been rereading a lot about this. The basic components of the deeper layer of skin, the dermis, are collagen so collagen fibers; elastic fibers or elastin; and then blood vessels, lymphatics, and nerves. Collagen is what gives our skin its plumpness, its thickness, its tone. Unfortunately, with age, with smoking, with pollution, with sun exposure is the biggest one in Australia, collagen degrades. The fibers all start beautifully lined up, lovely and thick. If you look at them down a microscope, they’re beautifully thick, pink fibers. They’re lined up like the scaffold outside a building; beautiful matrix, and the elastic fibres are in between.
What happens with ageing is those collagen fibres shrink, and they become all sort of higgledy-piggledy and squiggly. Same with the elastic fibers, start to break down and if you do collagen and elastic stains on younger versus aging skin, you can see that deterioration.
Trish Hammond: Mm-hmm (affirmative).
Dr Ritu Gupta: Collagen remodelling or collagen stimulation occurs from lots of different things and they’re a basically superficial and deep collagen remodelling modalities. The deepest way to remodel collagen that is purely just working on collagen is ultrasound skin tightening, which I alluded to before when I was talking about our specialists nurses.
We have a device called the Ultraformer-
Trish Hammond: I love that. I love the Ultraformer, yeah.
Dr Ritu Gupta: Yeah, so that’s high-frequency ultrasound that’s delivered in sort of three different levels; so it’s stimulating deep, medium, and superficial collagen remodelling. That’s stimulating your own collagen remodelling.
A second way collagen remodelling can occur is obviously with a deep laser resurfacing. Not only is that going to strip off your epidermis, so you reform lots of new beautiful skin that’s not wrinkled, but you’re also stimulating collagen remodelling. It’s like a controlled dermal wound.
That collagen remodelling that happens from any resurfacing procedure is ongoing for six months. We don’t take our final photographs until six months. In fact, even for the ultrasound skin tightening, the Ultraformer, initial results you see at three months but final results are at six months. I actually had that done myself, just because I thought I better have something done so I know what it feels like. I had the ultrasound skin tightening on the face and neck … About a month and a half ago? I haven’t had time to see results, but if you do have a bit of laxity … I fortunately don’t have too much yet, and also Indian skin tends not to age as much, but if you do have a bit of laxity then you will see some immediate results as well, some immediate tightening.
Trish Hammond: Did it hurt? Sorry. Did it hurt?
Dr Ritu Gupta: No. It’s literally … It’s a lunchtime procedure. You use some Emla which is an over-the-counter topical numbing cream. We have complementary consultations for both the ultrasound skin tightening and for the CLATUU which is the fat freezing or body sculpting. Those consultations are with our specialist nurses, so they go through all that with you.
No, it’s not painful at all. It’s minor. It takes about 40 minutes and you’re in and out. You’re not even pink afterwards-[crosstalk 00:19:21]
Trish Hammond: I know this because I’ve had one done myself, I’ve had a painful one and I’ve had the Ultraformer and I know that it doesn’t hurt. That’s why I couldn’t help but ask you that, because I couldn’t believe it.
Dr Ritu Gupta: The painful one is called Ultherapy, and it’s largely been superseded. People need injectable anaesthetics for that, you know. It’s really terrible.
Trish Hammond: Yep.
Dr Ritu Gupta: I think the Ultraformer is a great advance on that.
Other ways that collagen can be stimulated, I do a lot of what’s called Forever Young BBL, broad band light. That’s the Sciton on again, but that’s using a second generation intense pulse light. Far superior to the corner store IPL devices, and very, very tuneable again with lots of different filters for pigments, for blood vessels.
What that will do is not only does it treat the reds and the browns, but it also causes collagen remodelling up to about 30%. That is a good modality for darker skinned people who don’t want to have resurfacing, or for people who don’t really want to have resurfacing, they just want a bit of tightening but their main issue is the surface things rather than the textural issues.
What happens with that again is it takes probably about three months to start to see the results, but there have been some amazing studies out of Stanford University in the US. I’ve used earlier models of the Sciton for eight years in other practices, and in the past what I used to do was see my patients, treat them for their pigmentation or their broken capillaries, and then I’d see them again in a years time for their skin check or whatever. I never did maintenance treatments.
These studies have shown, and I’ve got them summarised at my work, these studies have shown they took a group of patients a whole lot, they’re randomized, double blinded control studies. That’s the best quality scientific study you can do. They got these patients to be assessed by a bunch of dermatologists who were blinded; they didn’t know what age these patients were. The dermatologists all made an assessment of their age, they were pretty accurate as dermatologists would be.
Then, those patients had skin biopsies taken. Little plugs of skin that were then looked at under the microscope. You know when I was talking about thickness of collagen and elastin?
Trish Hammond: Yep.
Dr Ritu Gupta: That was assessed. In addition to that the RNA, one of the building blocks of our genes, was extracted from that sample. They looked at the genes that controlled aging, and the genes that controlled youth. They looked at the expression of those genes. Then they treated these patients with the BBL, Broad Band Light for whatever problem there was.
Then they treated them on a regular basis. Some people were treated every three months, some every six months, some every 12 months. They followed them for a long time, they followed them for nine years.
At the end of the nine years, the same dermatologists reassessed the patients; same blinded, didn’t know how old they were. They assessed that they had only aged by one year.
Trish Hammond: Wow.
Dr Ritu Gupta: Nine years had passed.
Trish Hammond: Wow.
Dr Ritu Gupta: Amazing. Then this is even more amazing thing, and to my knowledge this is the only device for which this is ever been shown; they took repeat skin biopsies of these people and they looked at their collagen and elastin and saw beautiful new collagen fibres, all lovely and thick, lots more elastic tissue.
Then they looked at those same genes, they looked at the RNA of the genes that controlled aging and the genes that controlled youth. They found that there had been a down regulation of the genes that control aging, and an up regulation of the genes that controlled youth.
This actually really does turn back the clock. It’s amazing. If people have maintenance treatments … If they’ve got the funds, and the time, come every three months. I have a lot of patients that come every six months, I have some who come every 12, I have some who come every three. It’s never too young to start. Some of these people were 27, 25, 27.
In fact, the earlier you start with these things, the less there is to do. It’s a bit like injectable fillers I tell my patients, which also do stimulate collagen remodelling, by the way. The more you do, the more you have with fillers, the less you need.
Trish Hammond: Yeah. It’s all about maintenance, isn’t it?
Dr Ritu Gupta: Nothing is one and done. You can’t go to the gym once and walk out with a beautiful fit body. God, if only. I’d be there. Everything requires … At the very least, the maintenance is sun screen, sun protection, sun avoidance, no smoking.
If you really want to get good results, then you need repeat treatments.
Trish Hammond: Okay, so great.
Another question I wanted to ask you, Dr. Gupta, is apart from cosmetic concerns, as a specialist you must see a lot of skin issues like acne, and benign lumps. Can you tell us how you would treat these?
Dr Ritu Gupta: Yeah, that’s a big question.
Trish Hammond: Yeah, true.
Dr Ritu Gupta: They’re big topics. Acne … I treat lots of acne. Lots and lots of acne. Where I’m situated, which is very close to the city I think it’s 10 minutes in a bus, I’m surrounded by three universities. I do see a lot of uni students. I also see a lot of school kids and things who’ve got acne.
Acne is a multifactorial condition. It’s caused by a lot of different factors. We’ve also got some good information about acne on our website, Platinum Dermatology Skin Specialists. A lot of what I do in acne firstly is dispelling myths; there’s a lot of nonsense that people have been told and people believe. I spend a lot of the consultation explaining the causes of acne, and the things that actually don’t affect acne. It’s not to do with their diet, the fact that they’re washing their face too much or too little, or that they’re stressed, or that they’re exercising et cetera.
Then medical management of acne predominantly will comprise not just a single thing. Because it is a multifactorial disease, it will usually need a sort of multi-pronged approach. By the time someone’s come in to see a specialist, often they’re going to need a prescription cream, and possibly prescription anti-acne antibiotics. The people who are worse, or the people who keep rebounding despite other treatments, will need Roacutane or Isotroin, which is the strongest treatment we have for acne.
I’m actually just now introducing what’s called Forever Clear. I just talked about Forever Young with a Broad Band Light, there is a new method of treatment which has also been developed in the US, using different filters different wavelengths of light on the Broad Band Light that helps with acne that is not for the really severe nodulocystic acne that needs Roactutane, but for all the people in between. Particularly it’s useful because it’s using light rather than taking tablets. A lot of people these days would rather not take medication.
Forever Clear can be a really good answer for these people. They will get some collagen remodelling as well. The way that works is it’s particular wavelengths of light that are selectively absorbed by the acne bacteria. They kill the acne bacteria.
Acne’s a big part of my practice, and one of my favourite things to do is to see someone from go to woe. Diagnose, treat them, get them clear, and then if they’ve got scarring treat their scarring. It’s such a rewarding process to then have them walk out a happy patient with beautiful clear skin, self confidence, scarring diminished or gone. It’s really great. I find it to be a great privilege-
Trish Hammond: What sort of time frame? Say for example, I’ve got a teenage son who’s got some acne on his back. It’s actually better than it was before, but what sort of time frame if I was to say to him, “You need to go and see a dermatologist about this, I’m going to send you off.” Could you say like, three months?
Dr Ritu Gupta: To-
Trish Hammond: To get it clear?
Dr Ritu Gupta: Clear it?
Trish Hammond: Yeah.
Dr Ritu Gupta: It really depends on severity. I would say, mild to moderate acne would clear within three to six months, yes? The milder it is, the lower the time frame. Acne that requires Roacutane, it depends on the body weight of the patient and also depends on the severity, again.
People who are pretty light, pretty lean like 50 kilos might be on treatment from somewhere like six to seven months. Someone who is 90 kilos might be on treatment for 10 to 12 months.
Trish Hammond: Right.
Dr Ritu Gupta: It’s not a hard and fast rule. It’s really about clinical judgement. If I assess the patient, when they’re on that medication really we’re treating them until they are completely clear. Not a single pimple, not a white head or black head to see, and nothing for at least a month before. That’s the clinical end point.
Mild acne can certainly be treated by GPs, but I do find I see a lot of patients who have wasted an awful lot of time and money on things that don’t work. Often by the time they’ve come to see a specialist, they’re very disillusioned. Often they’ve got scarring, and it’s really sad because it could have all been avoided.
The prescription treatments are cheap. They’re a lot cheaper than all the facials and all that sort of stuff. They’re much cheaper and they’ve got more science behind them. Now with the new Forever Clear modality, if someone doesn’t want medical, sort of no tablets and things, there’s other options as well.
Benign lumps? I do see lots of nuisance lumps and bumps. Those, as long as obviously the first and most important thing is to be absolutely certain that they are benign. That’s important that a specialist be assessing that. You don’t want to be going to see someone who’s not a specialist, and they say to you, “Yeah, that’s benign.” Then they take it off with something or the other, or with a laser, and then years later it grows back to be a melanoma or a basal cell cancer or something.
I would never do laser to anything that I’m worried about. If I’m worried about it, I take a biopsy and I send it off to the pathologist because I need results. If I’m certain it’s benign, so nuisance as I mentioned before, the raised colourless moles, or the deeply coloured moles in fact, the raised nuisance moles, or wisdom warts are a very common thing I treat. They’re properly medically called seborrheic keratosis, so they’re spots that start to appear even in the mid to late 30s. They can look quite scary, and they look a bit warty, but they’re not actually viral warts. They’re not contagious. People hate them; there are no creams that work for them. You can pick them off, but they’ll grow straight back.
They are treated very effectively with spot erbium resurfacing laser. If you recall when I was talking before, it’s just basically pop, pop, pop and wipe it off. The size of the spot that will be left will be the same size as the spot that was removed, and it heals like a graze. On the face, typically that will heal in seven days. Then once the skin barrier has healed, you can put makeup and cover up on it. Until the skin barrier’s healed, we just get people to use a little bit of flesh coloured tape, so they can still go out and about and do their normal thing.
If it’s a spot on the body, it typically takes about two weeks to heal. That’s a very effective treatment, spot resurfacing laser.
Trish Hammond: Okay.
The last question I want to ask you, I want to ask you about pigment. This is a real thing for me as well, I had a treatment done years ago and it left me with pigmentation under my eyes and I’ve always struggled with it.
I know a lot of patients are worried about pigmentation and capillaries, so how would you actually treat those?
Dr Ritu Gupta: Let’s start with capillaries, because they’re probably a bit simpler. If people have broken capillaries where you can see the lines, that can be treated very effectively with vascular laser. I have a vascular laser which is an Nd:YAG laser, and I also have the vascular broad band light. It can be treated either way. Which modality I would use would really depend upon the patient and their vessels.
Typically with blood vessels, you get a fabulous result after one treatment. You think, “Oh my god, I should have had this done years ago. Why have I been waiting,” but blood vessels have elastic tissue in their walls. What happens is they slowly start to creep back. Typically, if someone is mild I would say they mostly would need three treatments, approximately a month apart. People who have really severe like train track blood vessels might need even five to six treatments.
People who have bad rosacea, who have blood vessels that are visible from two meters distance, actually get a Medicare rebate, but most people don’t fall into that category. For most people, there’s no Medicare rebate for it even if you do have rosacea.
Basically treatment of the capillaries involves vascular laser or vascular broad band light, and what that does is it selectively targets haemoglobin which is what makes blood red. It coagulates the blood within the vessel wall, and shuts the vessel wall down. These vessels are not serving any purpose anymore, so by shutting them down we’re not harming the skin’s nutrition. The skin has several layers of blood vessels, so there’s no issue there. What it is is just bringing people back from being ruddy and rosy and looking like they’re hitting the Schnapps, to being flesh coloured.
Trish Hammond: Right.
Dr Ritu Gupta: It’s actually a very common treatment I do in men, rather than women.
Trish Hammond: Yes.
Dr Ritu Gupta: I treat women as well, but men who couldn’t give a fig about how they really look, they’ve not cared about their wrinkles, but what they don’t want is for people to think they’re a boozer with a big red nose.
Trish Hammond: Yep, because it’s the first thing you think.
Dr Ritu Gupta: Yeah. It’s pretty unfair, because it’s actually caused by a whole multitude of factors, including family history, fair skin, and sun damage.
Trish Hammond: Mm-hmm (affirmative).
Thank you so much, that’s been so informative. I found it really useful-
Dr Ritu Gupta: Sorry, I don’t mean to interrupt. I was just going to say I didn’t talk about pigmentation. I’m happy to talk about that if you’d like me to?
Trish Hammond: Yeah, yeah.
Dr Ritu Gupta: Pigmentation, to an untrained eye I appreciate this, everything just looks brown. You can’t tell what brown is in the upper layer of skin in the epidermis, what brown is at the junction zone between the epidermis and dermis related to pigment cells melanocytes, or what pigment is in the deep derma.
The first step with pigmentation is making a diagnosis. I see a lot of people who’ve been treated by non-specialists, unfortunately, who have had melasma and have been treated with IPL devices. IPL is contraindicative in melasma. IPL makes melasma worse. If you have melasma, you need to see a dermatologist and you’ll be prescribed a cream which is much cheaper than any light device, and that will treat your melasma.
Melasma is a medical condition, it doesn’t need to be treated with light devices. Sometimes very, very resistant melasma can be treated at the end with fractionated laser just to help the pigment escape, but not IPL.
The other type of common pigmentation are the so-called liver spots, which people commonly say to me, “I’ve got these sun spots.” Sun spots are pre-cancerous. The sun spots are the sort of red scaly spots that are precursors to squamous cell cancer. That’s different. The brown marks are predominantly caused by Ultraviolet A.
Something that people may not know, is that Ultraviolet A comes through window glass. If you’re driving, you’re getting UVA on your driving side, you’re getting UVA on the backs of your hands. If you’re sitting next to a lovely glass window at work, you’re getting UVA all day. It’s very important because that UVA is a long range penetrating wavelength that really contributes to sun aging. That’s what causes the brown liver spots.
They are treated very effectively with either pigment laser or I tend to use mostly pigment broad band light, because it does such a great job. Essentially what happens is they go darker, over a period of about a week they scale off. In a fair skinned person, it’s usually two treatments a month apart. This device is much, much more powerful than the sort of Korean made corner store clinics have. It is much more expensive of course as well, in terms of the cost of the device, but it is much more powerful. It’s two treatments.
I see a lot of people say, “I was told I needed six treatments.” With the Sciton if you’re fair skinned it’s two treatments. If you’re olive, you might need three. If you’re Asian skinned or dark, you might need four but that’s uncommon. Typically, the treatment’s are three to four weeks apart. It can be done summer or winter, there’s no downtime with it because you can put your makeup on immediately afterwards. Most people are absolutely fine … A small percentage of people can get a little bit of swelling, but my process is that I treat, we take the patient next door to the resting room, and they have an ice pack on for about 10 minutes or so and then off they go.
Trish Hammond: Okay. I’ve also heard of these new little after-laser patches and things that you can put on, which have just come out as well. Next time I go to have a laser I’m taking them with me.
Dr Ritu Gupta: What are they supposed to do? I haven’t heard of those.
Trish Hammond: They’re soothing, I’ll flick you through an email.
Dr Ritu Gupta: Okay. We put a post-laser balm. At our practice we stock the Aspect Doctor range of skin care, which is only stocked by medical practices, so you have to be a doctor to prescribe it. That’s because it’s a range of active ingredients. It’s the same company that makes cosmetics and Aspect, but the Aspect Doctor is a step up again.
It’s a great range; it’s relatively inexpensive, it works very well. We looked around for a long time, I personally … We did a lot of investigation before deciding which line to stock because we knew we’re dermatologists, it’s got to work. Every patient asks me about skincare.
That’s important as well, just as I said we talked about maintenance earlier, Trish.
Trish Hammond: Totally.
Dr Ritu Gupta: Good quality skincare is also important.
Trish Hammond: Sun cream, skincare, don’t smoke, and drink lots of water and you’re pretty much done.
Dr Ritu Gupta: Yes, absolutely.
Trish Hammond: My daughter loves that skincare, she swears by it.
Dr Ritu Gupta: Does she? Yeah. My patients love it, they absolutely love it. We’ve had nothing but good reports and been very happy with it. We’ve been delighted, as I say, I’ve used the Sciton now for nine years and I’m very happy with it.
I’m constantly learning new things, and that’s the other wonderful thing in medicine; you’ve got to keep up to date and that’s part of why I enjoy doing GP education, general practitioner education. It means that you’ve got to go out and re-read things and writing textbooks and all that stuff just means that you can deliver the best and the most current and up to date results and treatments for your patients.
Trish Hammond: Of course. We all know that teaching is learning, hey?
Dr Ritu Gupta: Absolutely. For me it’s also part of giving back. I like it, I’m always happy to talk.
Trish Hammond: That’s wonderful. Look, thank you so much-
Dr Ritu Gupta: Please. Great pleasure.
Trish Hammond: For the time that you’ve taken today to chat to us about that.
If you’re looking for a dermatologist and you’re in the Sydney area, check out Platinum Dermatology at Ultimo. Their website is platinumdermatology.com.au.
Thank you so much, Dr. Ritu Gupta.
Dr Ritu Gupta: Thank you so much. Thanks, Trish.
Trish Hammond: Bye.
Dr Ritu Gupta: Bye, bye.
Trish Hammond: Great, so if you’d like to see Dr. Ritu Gupta, you can Google her or check out the website at platinumdermatology.com.au.
Thank you so much for taking the time to talk to us today.
Dr Ritu Gupta: You’re welcome, pleasure.
Trish Hammond: Bye.
Dr Ritu Gupta: Thanks Trish.
The material provided in this podcast is general information, and does not constitute medical advice. Nor is it a substitute for consultation and advice from your own practitioner. It should not be used to diagnose or treat any medical illness. Any medical or surgical decision should be made in consultation with your own doctor or practitioner and not based on the materials provided in this podcast.