Asthma Diary

From Kathleen MacNaughton, R.N.,
Your Guide to Asthma.
FREE Newsletter. Sign Up Now!

A Tool for Tracking SymptomsHere is a tool you can use to track your asthma symptoms. You can also record and identify your asthma triggers, which are the things that set off asthma symptoms or asthma attacks.

You can use this page as a reference for the types of information you can keep track of in your own asthma diary or notebook. Or, if you prefer, print our PDF version and make copies you can write on each week.

Asthma Treatment: Overview of Current Asthma Treatment, Asthma Medicines & More

From Kathleen MacNaughton, R.N.,
Your Guide to Asthma.
FREE Newsletter. Sign Up Now!

About.com Health's Disease and Condition content is reviewed by Sanja Jelic, MD

INTRODUCTION: The National Asthma Education and Prevention Program (NAEPP) has set five goals for asthma treatment:

• Control your asthma
• Prevent asthma symptoms
• Decrease the number of asthma attacks
• Help you use quick-relief medicines less often
• Do normal activities without having symptoms

Your asthma treatment should be part of an overall asthma management plan that you develop with your asthma doctor. Your doctor is guided by current asthma treatment guidelines published by the US National Institutes of Health and / or the Global Initiative for Asthma (GINA).

Learn More About Asthma Treatment Guidelines:

• National Asthma Education Program (NIH) Treatment Guidelines
• GINA Guidelines for Asthma

THREE APPROACHES TO ASTHMA TREATMENT:

There are 3 main approaches to asthma treatment:

1. Asessement and monitoring
2. Avoidance of asthma triggers
3. Asthma medication therapy

Each of these areas is an important component of asthma management and control.

1. Assessing and Monitoring Your Asthma

To manage asthma effectively, you and your doctor need to monitor your health. This can be accomplished by:

• Tracking asthma signs and symptoms and asthma attacks
• Monitoring pulmonary function via a peak flow monitor
• Assessing how much asthma is interfering with daily life
• Tracking your response to medication

Help With Monitoring:

• How to Track Asthma Symptoms
• How to Use a Peak Flow Meter

2. Avoiding Asthma Triggers:

Asthma is your body's response to something it perceives as a threat to your health. These "threatening" substances or events are known as asthma triggers.

A Tool for Tracking SymptomsHere is a tool you can use to track your asthma symptoms. You can also record and identify your asthma triggers, which are the things that set off asthma symptoms or asthma attacks.

You can use this page as a reference for the types of information you can keep track of in your own asthma diary or notebook. Or, if you prefer, print our PDF version and make copies you can write on each week.

What Is Asthma? - An Overview of Asthma Facts and Asthma Information

From Kathleen MacNaughton, R.N.,
Your Guide to Asthma.
FREE Newsletter. Sign Up Now!

About.com Health's Disease and Condition content is reviewed by Sanja Jelic, MD

Introduction: What is asthma? When you first get a diagnosis of asthma for yourself or your child, you may be wondering just what is asthma exactly? Or maybe you haven't been diagnosed yet and you're wondering if your symptoms might be asthma.

You won't get a diagnosis here. The information on this site is just that, general information. We can't speak to your condition personally. But if you are concerned about breathing problems, then it's a good idea to talk with your doctor or your child's doctor as soon as you can.

Even though asthma has become a worldwide health problem, it is not well understood by many of the people who have it or who are parents of those with asthma. Get the asthma facts and information you need to understand what asthma is all about.

Getting Started:

• Tips for Talking With Your Doctor About Asthma
• Common Asthma Symptoms
• How Asthma Is Diagnosed
• Asthma in Kids

Definition: Let's start with a simple definition of asthma:

Asthma is a chronic disease that affects your breathing. What happens is that your airways become inflamed and irritated in reaction to some kind of substance or situation, which is called a trigger. Your airways are the tubes that carry air and oxygen into and out of your body.

Your respiratory system includes your lungs and small tubes that branch out, called airways. These tubes become smaller and smaller until they form tiny sacs at the end called alveoli. Bands of muscle cover the bronchial tubes all the way down through the alveoli.

Hair restoration

Reviewed By: Mary Ellen Luchetti, M.D., AAD Kimberly Bazar, M.D., AAD

About hair restoration Hair restoration is the general term for the numerous methods of restoring hair to areas that are balding. Some patients may benefit from medications designed to slow or stop hair loss (e.g., minoxidil, finasteride). However, surgical hair restoration is more effective for most patients. In some cases, a combination of medication and surgery is used to achieve the best results. Hair restoration is performed to restore portions of hair to a person who has experienced hair loss, usually due to heredity. It may also be performed to restore hair lost because of injury (e.g., burns) or disease (e.g., alopecia areata). Regardless of the success of the method used for hair restoration, it is important to note that a patient will never have the same degree of coverage prior to the beginning of hair loss. However, hair regrowth from medication or surgical techniques may give a fuller appearance and minimize the appearance of thin or bald areas. Hair has long been recognized as an important characteristic of a person’s physical appearance. In addition to other physical features (e.g., size, body frame), hair may influence socioeconomic status and occupation, and it distinguishes facial features (“frame the face”). Men and women who experience abnormal hair loss (alopecia) often undergo hair restoration to restore hair to areas where it has been lost. Although treatment is not usually necessary, patients who are emotionally impacted by hair loss may benefit from seeking treatment. Patients with mild-to-moderate pattern hair loss (androgenetic alopecia) are often good candidates for hair restoration using medication. Currently, minoxidil and finasteride are the only two medications approved for hair loss by the U.S. Food and Drug Administration (FDA), and finasteride is only approved for use in men. Each works to slow or reverse the shrinking of hair follicles (tiny, tubular structure in the skin through which hair grows) by interfering with the conversion of the hormone testosterone into dihydrotestosterone, the androgen (male sex hormone) that causes pattern hair loss. However, these medications do not work for everyone. Furthermore, any hair that grows as a result of their use usually occurs gradually over a period of several months or years. Hair usually grows in pairs, though it may grow in groups of up to five or more. Understanding these hair growth patterns has helped lead to significant improvements in surgical hair restoration. Hair density following a transplant procedure often appears natural, and scarring is typically minimal and unnoticeable. The most commonly utilized surgical hair restoration technique is hair transplantation. It involves transplanting healthy follicles from another site of the scalp (donor site) to a bald or thinning area. All surgical techniques use existing hair from the patient. The purpose of these techniques is to blend hair in the most efficient and natural way possible. Criteria used to determine if a candidate is qualified for surgical hair restoration include: Degree of baldness. Perhaps the most important criteria for selecting a candidate. Individuals with baldness in the front portion of the scalp as opposed to the top of the head are preferable as candidates. Age. It is generally more difficult to gauge the amount of hair loss patients younger than age 25 will experience. As a result, the preferred candidate is usually age 25 or older. Hair shaft caliber. Individuals with thick hair shafts achieve greater coverage than those with thinner hair. Very small increases in the volume of hair diameter can make a tremendous difference in surface area coverage. Donor hair. Hair at the donor site must be dense enough for transplanting and sufficient in quantity to conceal the removed portions. Hair color. Individuals with hair that is red, blonde or “salt and pepper” colored tend to be preferred to those with black hair. People with black hair may still receive hair transplants, but require a grafting method that transplants only one or two hairs per follicle. Lifestyle issues and patient expectations of hair restoration also factor heavily into the type of treatment chosen. For example, men with pattern hair loss that begins in the late teens or early 20s (premature male pattern baldness) may have unrealistic expectations of hair restoration surgery and do not typically make good candidates for surgical hair restoration. Because balding will likely continue to progress following surgery in the surrounding areas of the scalp, an unnatural or patchy appearance will probably develop. Furthermore, patients with this condition require an unusually large amount of donor follicles, making scarring at donor sites particularly difficult to conceal. It is important to note that women with female pattern hair loss lose hair in different patterns than men. Mild forms of this condition are often only noticeable as a minor widening of the central hair part, whereas severe forms may appear as severe thinning across most of the scalp (diffuse unpatterned hair loss). In general, women in either category make poor candidates for transplantation. Female patients that are ideal candidates for hair restoration have high hair density in the donor site with thinning or hair loss largely confined to the front of the scalp. Hair transplant patients may also take medications to slow or stop further hair loss both before and after hair restoration surgery. This typically results in less donor site harvesting, less hair loss over time and a more natural overall appearance. Not all forms of hair loss can be treated with hair restoration. Patients who are poor candidates for medical treatment may effectively disguise their hair loss with wigs, hairpieces and weaves. In some cases, hairstyle changes can also help disguise the condition. However, these methods do not slow or stop the progression of further hair loss. Types and differences of hair restoration Patients with mild-to-moderate pattern hair loss (androgenetic alopecia) are often good candidates for hair restoration using medication. The effectiveness of medication in restoring hair growth also depends on the cause of hair loss and the patient’s response to treatment. Some patients experience hair regrowth or a slowing or stopping of hair loss. However, others receive no benefit from the use of these drugs. The following medications are approved by the U.S. Food and Drug Administration (FDA) to regrow hair: Minoxidil (Rogaine). An-over-the-counter topical liquid or foam designed to regrow hair and/or stop hair loss associated with androgenetic alopecia and alopecia areata (patchy baldness). Applied to the scalp twice a day, it is available in both a 2 percent and a 5 percent solution. Some evidence suggests the 5 percent solution may be more effective at treating cases of pattern hair loss, particularly in men. However, the 5 percent solution may cause side effects in women (e.g., facial hair growth) and is only specifically approved for use in men. Applied twice daily to the scalp, the use of minoxidil may produce longer, thicker hairs by reversing, stopping or slowing the shrinking of hair follicles (tiny, tubular structures in the skin through which hair grows) associated with pattern hair loss. New hairs grown by minoxidil treatment may be thinner and shorter than previous hairs, though they are often produced in sufficient amounts to successfully blend with existing hair and at least partially cover bald spots. Minoxidil must be used continuously to remain effective, as any hair grown as a result of use usually falls out once treatment is stopped. Not all patients grow hair with minoxidil. When it is effective, it may take six months to a year for the drug to begin working. A physician may recommend discontinuing use of minoxidil if no results or minimal results are achieved within about nine to 12 months. Finasteride (Propecia, Proscar). A prescription medication used to treat male androgenic alopecia. Taken daily in pill form, finasteride often slows the rate of hair loss and, in some cases, may initiate new hair growth. It works by inhibiting the conversion of the hormone testosterone into dihydrotestosterone (DHT), a hair follicle shrinking hormone that contributes to hair loss in men. Like minoxidil, any hair that is regrown or maintained while using finasteride is likely to fall out after the drug is discontinued. It may also take one year or longer before results are noticeable. Patients with mild alopecia areata may benefit from corticosteroid scalp injections and those with more extensive hair loss may require oral corticosteroids. Corticosteroids are a group of anti-inflammatory drugs similar to hormones produced by the body. Ointments and creams may also be used less frequently, though they tend to be less effective than corticosteroids. In addition, the medication anthralin may provide some benefit for patients with alopecia areata. Usually used to treat psoriasis (a chronic condition marked by frequent episodes where the skin becomes itchy and red and develops thick, dry, silvery scales), anthralin is a tar-like substance applied daily to the scalp for 20 to 60 minutes and then washed off. Anthralin may also be used along with other hair medications (e.g., minoxidil) for better results. Other treatments that may be used for alopecia areata include topical sensitizers (drugs that provoke an allergic reaction that eventually leads to hair growth) and phototherapy (controlled exposure to ultraviolet radiation). Patients who are not considered good candidates for medical hair restoration may benefit from hair restoration surgery. These popular treatment methods are often effective at creating a hairline that appears natural. However, hair restoration techniques have limited potential to transplant hair to areas other than hairlines. People with diffuse or extensively thinning hair across large areas of the scalp do not typically make good candidates. Recent technological improvements have helped create safer and easier hair restoration techniques than in years past. In some cases, a combination of techniques may be used to accomplish the best possible results. In addition to other factors (e.g., cause of hair loss, patient lifestyle), the patient’s extent and pattern of hair loss will determine which hair restoration surgery will be performed. The most commonly used surgical method of hair restoration is hair transplantation. It involves the removal of small pieces of hair-growing scalp (grafts) from a “donor site” (usually the lower back or sides of the scalp) and moving them to a bald or balding area. Multiple surgeries over an extended period may be necessary to achieve an appearance the patient feels is satisfactory, with each surgery usually separated by a healing time of several months. Hair color and texture may play a role in determining how much coverage is necessary. Light-colored or coarse hair typically covers better than hair that is fine or dark-colored. The number of hairs moved varies according to the type of grafting method utilized: Micro-graft. About one to two hairs. Mini-graft. About two to four hairs. Slit graft. Roughly four to 10 hairs each. Slit grafts are inserted into slits created in the scalp. Punch graft. Typically round-shaped and contain about 10 to15 hairs. Strip graft. About 30 to 40 hairs each. Strip grafts are done in sections that are long and thin. Different names or descriptions of grafting techniques may be used at different facilities. Nevertheless, all hair transplant procedures involve one or a combination of these grafting techniques. The use of mini-grafts or micro-grafts, particularly in more noticeable areas such as the hairline has become increasingly popular in recent years. Transplanting hair in small amounts creates an appearance that is more natural. Mini-grafts and micro-grafts tend to grow out like normal hair and are often undetectable. Larger grafts may be used for greater coverage behind the hairline, but may also be more noticeable. Other hair restoration surgeries include: Tissue expansion. Commonly used to treat burns and injuries that cause skin loss. A balloon-like device (tissue expander) is inserted beneath hair-growing scalp next to a bald area and inflated with salt water for several weeks. This causes the skin to expand, creating new skin cells. After skin beneath the hair has been adequately expanded, an additional procedure stretches the expanded skin over the bald area where it is stitched closed. Flap surgery. A section of bald scalp is removed and hair-growing scalp is stretched and sewn in its place, with hair growing to the edge of the incision. The size and placement of the flap depends on the individual patient. Flap surgery is designed to cover large areas of baldness, with one flap providing roughly the same coverage as several hundred punch grafts. In some cases, it may also be combined with other restoration surgeries (e.g., tissue expansion) to provide better coverage. Scalp reduction. Bald scalp is removed and sections of hair-growing scalp are pulled forward to fill in a bald crown area. Scalp reduction surgery may be used to cover areas at the top and back of the head, but is generally inappropriate for covering the frontal hairline. A section of bald scalp is first anesthetized (numbed) and then removed. The pattern of the scalp removed may vary according to the extent of baldness and the goals of the patient. The skin immediately surrounding the removed scalp is loosened, pulled together and closed with stitches. In some cases, medication may be used in conjunction with hair restoration surgery. Before hair restoration Prior to starting treatment, a physician will obtain the patient’s complete medical history, review any family history of hair loss and ask if prior attempts at hair restoration have been made. In addition, the physician will evaluate the patient’s hair loss patterns during a physical examination. An assessment of these factors will help determine the best available hair restoration method. If surgery is deemed appropriate for restoring lost hair, a physician will provide specific instructions (e.g., eating and drinking guidelines) about how to prepare beforehand. All medical conditions (e.g., high blood pressure, blood-clotting disorders), current medications (e.g., anticoagulants, aspirin) and lifestyle factors (e.g., smoking) that could potentially complicate treatment will need to be brought to the operating physician’s attention. Important concepts of hair restoration that will be discussed prior to surgery include: The ongoing nature of hair loss. Hair loss occurs throughout the lifetime of someone with the condition. This will need to be clearly understood by the patient prior to surgery. Framing of the face. The goal of hair restoration surgery is to deflect attention from the hairline and make the central face the focus of attention. Appearance. Modern hair replacement techniques should produce a look that does not seem odd or artificial. When performed correctly, hair restoration can put forth the illusion that no surgery has taken place. Similarly, the physician will determine which areas of hair loss the patient finds most troubling. Hairline. The creation of a permanent hairline must continue to be acceptable by the patient as they age. Rounded or youthful hairlines often look artificial later in life. In addition, the type of anesthesia (numbing agent) that will be used during hair restoration surgery and its effects may be discussed to alleviate patient concerns about pain and expected recovery time. The location of the procedure, the procedures to be used as well as the associated risks and costs will all need to be clearly explained by the physician well in advance. Transportation home for the patient after the procedure will also need to be arranged beforehand. During hair restoration Patients using medications as a means of hair restoration (e.g., minoxidil, finasteride) will need to apply the product daily as recommended by their physician to ensure the best possible results. Medications may or may not be successful in stopping hair loss and/or stimulating hair regrowth. When effective, improvement in appearance is generally noticeable within several months. Hair restoration surgeries are performed on an outpatient basis, usually under local anesthesia while the patient is awake. The patient may be placed under general anesthesia (asleep during the procedure) during more extensive surgeries. Patients under anesthesia will be insensitive to pain, although those under local anesthesia may feel pressure or a tugging sensation during the procedure. Hair transplantation involves the removal of small pieces of hair-growing scalp (grafts) from a donor site (usually the back or sides of the head) and implanting them in a bald or balding area. It is the most popular surgical hair restoration method. At the beginning of the surgery, the hair at the donor site will be trimmed short to facilitate easy access and removal of the skin. Both the recipient and donor sites are sterilized to help prevent infection. Different tools may be used depending on the size of the graft and where it is to be relocated. An average donor site rarely produces more than 100 follicles (tiny, tubular structures in the skin through which hair grows) per square centimeter. The size of the total area removed depends on hair density at the donor site. After grafts are removed from the donor site, they are then separated into smaller sections and transplanted into small holes or slits prepared in the scalp. Grafts are placed about one-eighth of an inch (approximately 30 millimeters) apart to maintain healthy circulation. Subsequent treatments with additional grafts may later be required to fill in any open spaces that remain or have since appeared. During the procedure, a saline (salt water) solution may be periodically injected into the scalp to help keep the skin strong and resilient. The donor site is then stitched shut, leaving a small scar that is usually covered by surrounding hair. The total process typically takes from five to 12 hours depending on the number of grafts taken and the number of staff required. Some differences in the technique may be incorporated for women who undergo hair transplantation. The use of minoxidil 2 percent may be advised for two weeks immediately before surgery and resumed five to seven days following the procedure. Larger grafts may be necessary behind the hairline to give a natural appearance. During a tissue expansion procedure, a balloon-shaped object called a tissue expander is placed beneath hair-growing scalp that borders a bald area. The tissue expander is then gradually inflated with salt water over a several week period during which time the patient can perform normal duties. This causes hair-growing skin to stretch and produce new hair-growing skin cells. When the tissue expander has stretched the skin sufficiently, an incision is made by a physician and the hair-growing scalp is stretched over the adjoining bald area and stitched closed. During a flap surgery, a section of bald scalp is first cut out. Then a section of adjoining, hair-growing scalp is lifted off the surface while it is still attached at one end. The hair-growing scalp is then stretched and sewn into place where the bald scalp was removed while remaining connected to its original blood supply at the other end. The size of the flap needed and the way it is placed will depend largely on the needs and expectations of the patient. During a scalp reduction, a portion of the scalp is removed. The skin surrounding the removed area is then loosened and sewn together with stitches. Scalp reductions provide coverage of bald areas at the top and back of the scalp. However, they are not effective for coverage of the frontal hairline. The size of incision may vary according to the extent of the procedure. Scalp may be removed in the shape of an inverted Y, U, pointed oval or other figure depending on the amount of coverage needed. After hair restoration Following hair restoration surgery, the scalp is cleansed, the “donor site” is typically covered with an adhesive bandage and the patient’s head is wrapped in a turban. The patient may be kept in the facility briefly after hair restoration surgery for monitoring before being accompanied home by a friend or relative. Bandages can usually be removed in about one day. Patients may resume wetting and washing hair approximately two days after surgery. If stitches have been used, they are typically removed about seven to 10 days afterward. The wound at the donor site is typically healed in a week to 10 days, leaving only a narrow scar. Infection may occur in rare cases. How quickly a patient is able to resume normal activities following surgical hair restoration depends upon the size and scope of the procedure, as well as the individual reaction and healing abilities of the patient. Any pain, tightness or throbbing experienced is usually temporary and manageable with over-the-counter medication (e.g., aspirin). Prescription pain medication may be needed during the first two days following the procedure. Swelling may develop two to three days after hair restoration surgery, and typically lasts three to 10 days, depending on its severity. Patients may also be advised to do the following: Avoid strenuous activity (e.g., exercise, sexual activity) for several days or weeks, as increased blood flow to the scalp may cause bleeding. Do not drink alcoholic beverages for at least two days following surgery. Sleep with the head elevated for the first one or two nights following surgery. After daily shampooing, apply antibiotic ointment to the graft and donor areas with a cotton swab or clean fingers. Do not pick or scratch scabs or crusts that may form at the transplant sites. They will naturally fall off within about two weeks. Wait at least two weeks before wearing a hairpiece. The operating physician may want to periodically check the scalp in the first month following surgery to make sure incisions are healing properly. It is not uncommon for “new” hair to fall out about six weeks after surgery. This is usually temporary, with hair growth resuming in approximately six weeks at the rate of about a half-inch (13 millimeters) per month. In some instances, follow-up procedures may be necessary after the incisions have healed. Blending or filling in the hairline using a combination of grafting techniques may be performed to create a more natural look if transplanted hairs do not grow or if hair loss progresses in other areas after surgery. Patients who have had a flap procedure performed may need to have small bumps of skin that remain visible on the scalp (“dog ears”) removed. A physician may prescribe the use of minoxidil or finasteride following hair restoration surgery to minimize further hair loss and ensure a patient’s new hairline retains a natural appearance. Patients using one or both of these drugs will need to continue their use indefinitely. Hair loss will most likely resume and any new hair grown as a result of these drugs will fall out once their use is discontinued. Potential risks and benefits of hair restoration The risks and benefits of hair restoration depend on the method used. When performed correctly, successful hair restoration can provide patients with hair that appears natural. Recent advances in hair transplantation make it possible for some patients to achieve this natural look in one session. Careful planning combined with the right candidate can produce lasting results. Recent advances in grafting technology have made surgical procedures much more effective and less noticeable, though they tend to be expensive and may be painful. Hair replacement surgery is usually safe when performed by a qualified physician. However, side effects can occur and may include: Nausea or vomiting caused by medication Postoperative bleeding or infection (rare) Excessive sweating (hyperhidrosis) Headache Numbness of the scalp Scarring Poor growth of grafts (transplanted tissue) Hair replacement surgery is not generally recommended for people without sufficient quantities of donor hair, such as men with premature pattern baldness (androgenetic alopecia) or extensive balding. Further progression of hair loss following surgery may result in a “patchy” appearance, particularly if new hair loss occurs next to patches of transplanted hair. Additional procedures may be required for some patients to achieve a look that is cosmetically acceptable. The medications minoxidil and finasteride are normally safe methods of hair restoration that cause only occasional minor side effects when used as directed (e.g., skin irritation). However, finasteride is not approved for use in women. In addition, women of child bearing age should not ingest or handle finasteride due to a risk of serious side effects in male fetuses. Continued use of finasteride and/or minoxidil may regrow hair and/or stop hair loss after several months in some individuals, though these medications do not work for everyone. Furthermore, any hair grown or maintained because of the medication is usually lost within several months after treatment stops.

What is " Botox "

Reviewed By:
Mary Ellen Luchetti, M.D., AAD
Sandeep Singla, DDS, MD

Botox (Botulinum Toxin Type A) is the brand name for a cosmetic treatment that temporary improves facial lines (wrinkles) between the eyebrows and in other areas. It is a sterile, purified form of the Clostridium botulinum, a bacterium that contains the toxin responsible for food poisoning. Saline is added to Botox to dilute its potency before use, in varying amounts according to the physician.

Normally, the brain sends electrochemical messages to the muscles, causing them to contract and move. These messages are sent from a nerve to the muscle by a substance called acetylcholine. The cosmetic use of Botox works by producing a protein that blocks nerve signals to muscle, causing paralysis of the injected muscle. It stops the release of acetylcholine from the nerve which relaxes the muscle. This greatly reduces, and in some cases prevents, movement of the muscles.

It takes 24 to 48 hours for the muscle weakness or paralysis to develop. The results, however, are not permanent. After about two to six months, the nerve will recover and start releasing acetylcholine again, causing the muscles to become active. At this point, the patient will require a new injection of Botox.

Botox was originally used to treat muscle disorders, including facial dystonias, uncontrolled blinking and lazy eye. In addition, fewer units per injection of Botox may be used to treat hyperhidrosis (a disorder characterized by excessive sweating) by paralyzing sweat glands in the underarms, hands and feet. Botox was approved for cosmetic use in the United States by the U.S. Food and Drug Administration (FDA) in 2002.

Studies have suggested that Botox can be effectively used as a treatment for a number of other conditions, including migraine headaches, overactive bladder, tennis elbow (lateral epicondylitis) and enlarged prostate. However, additional research is needed to determine the safety and effectiveness of using Botox to treat these conditions.

Wrinkles that appear across the forehead, between the eyebrows (glabellar lines), around the eyes (crow’s feet) and on the bridge of a person’s nose are the result of muscle movement (e.g., frowning, squinting) over time. Muscle bands on the neck may also become visible with age. When Botox is injected into these wrinkles, it temporarily reduces the contractions of the underlying muscles. This diminishes the appearance of wrinkles for up to 120 days, according to the FDA.

Improvement in the appearance of wrinkles will vary according to the practitioner performing the injections and the depth of the facial lines. Botox is not typically used for lines around the mouth because the underlying muscles in this region are needed for essential functions, such as talking and eating. It is important to note that Botox injections will not radically alter a patient’s facial appearance or affect their ability to make facial expressions.

There are some effects from aging that cannot be temporarily remedied with Botox. Excess fat around the face, loss of skin elasticity and decreased muscle tone will not respond to treatment with Botox.

According to the American Society for Aesthetic Plastic Surgery (ASAPS) 3,181,592 Botox injections were given in 2006. It was the leading cosmetic procedure (both surgical and nonsurgical) among both men and women. The treatment is indicated for use by adults between the ages of 18 and 65.

There is growing controversy in the medical community over the mass treatment of patients who attend “Botox parties.” During these gatherings, individuals socialize with one another, consult with a Botox practitioner and receive injections of the toxin. Some practitioners contend that Botox parties are a good way for patients to receive more affordable injections in a more relaxed atmosphere. However, critics claim that the bulk distribution of Botox is potentially dangerous because each vial of Botox is intended for a single patient during a single treatment session, and there is no preservative in Botox to prevent contamination if a single vial is used repeatedly. In addition, Botox parties often involve the consumption of alcoholic beverages, which may intensify bruising in some patients.

In addition, the FDA is growing concerned that there is a great potential for Botox abuse. Recent ASAPS reports indicate that Botox is being dispensed by unqualified people in home-based offices, hotel rooms, gyms, salons and other retail settings.

Currently, Botox is the only drug of its kind available for use in the United States. However, other similar drugs are presently awaiting FDA approval for use in the United States. One such drug, Myobloc (Botulinum toxin type B), has been approved for the treatment of cervical dystonia (muscle spasms in the neck) and patients may consent to “off-label use” of the drug for cosmetic purposes. The term “off-label” refers to the use of approved drugs for a purpose other than which it was originally intended, and that was not approved by the FDA.

Before, during and after the Botox procedure

Botox injections are increasingly being administered by non-medical practitioners. However, the U.S. Food and Drug Administration (FDA) recommends that patients interested in receiving Botox consult a qualified physician (often a dermatologist) because results may vary depending on who administers the injections. The physician will compile a complete medical history, including a list of current medications and allergies, to determine if the patient is a good candidate for Botox injections (e.g., does not have droopy eyelids, neurological, muscular disease). If the patient is deemed an appropriate candidate, the physician will describe the procedure in detail. It is important that the physician inform patients about the capabilities of Botox so they do not have unrealistic expectations going into the procedure. Although Botox can temporarily relax certain facial lines (wrinkles), it cannot actually erase them. This means that superficial facial lines will practically disappear, and deeper facial lines will appear shallower after treatment. Botox may also help prevent new facial lines from forming. A photograph may be taken at this time for comparison after the procedure. Before Botox injections are administered, the patient is placed in an upright position on an examination table. The patient may be asked to contract the muscles in the area being treated. This enables the physician to determine the correct location for the injection. The future injection sites are cleansed with a nonalcoholic solution, and a topical anesthetic may be applied to the skin. In some cases, the area to be injected can be iced to decrease the discomfort associated with skin penetration by the needle. The physician then injects the Botox directly into the muscles that cause the facial lines. Typical patterns of Botox injection include two or three areas around each eye and four to five areas on both sides of the patient’s forehead. Depending on the skill of the physician, the type of wrinkles present and the desired effect, additional areas may be injected. If a site appears to bleed after injection, pressure may be applied to the affected area. Discomfort during Botox injection is typically brief and minimal, and the entire procedure normally takes approximately 10 minutes. After the procedure, the patient will usually be instructed to lay semiupright or upright on the examination table for approximately two to five minutes to ensure that the injections did not produce any ill effects. It is recommended that patients avoid lying down for up to four hours after Botox injections have been administered. There is no downtime required after the procedure and patients can immediately return to work and resume normal daily activities. To avoid or reduce bruising, patients should refrain from using aspirin and related products (e.g., ibuprofen), clopidogrel and warfarin after the procedure. They should also avoid manipulation in the treated area for several hours. This reduces the movement of Botox, which can cause ptosis (eyelid droop). Patients can apply make-up to the area after treatment. Some physicians recommend that patients work the injected area several times in the days that follow the procedure, whereas others instruct patients to avoid using the affected muscles for several days after the injections. To date, no studies have been conducted to determine which course of action produces the most desirable results. Potential benefits and risks of Botox Benefits of Botox injections include a reduction in facial lines (wrinkles) and a more youthful appearance. Botox may also effectively treat certain medical conditions. For example, individuals who receive Botox injections to treat hyperhidrosis (a disorder characterized by excessive sweating) may experience a decrease in sweating. Very few risks are associated with Botox injections administered by a qualified physician. Though uncommon, tenderness, burning, numbness and mild bruising may occur around the site of injection. The procedure may also result in pain, headache, flu-like illness, nausea and rash. Rarely, drooping of the eyebrow area or eyelid or dry eye may occur. Risk of severe eyelid drooping (ptosis) or ectropion (condition in which the eyelid turns outward) is minimal. Individuals may experience double vision (diplopia) in very rare instances. When Botox is injected into the neck, patients may experience drooling, bruising, weakness of neck muscles, drooping of the corner of the mouth and difficulty swallowing (dysphagia). Injections into the lower portion of a patient’s face may result in lip drooping or asymmetry of the mouth. Pain, temporary muscle weakness and coughing may occur when Botox is used to treat hyperhidrosis. Patients are urged to report these and any other unusual symptoms to their physician. There are a number of medications that may interact with Botox. These include antibiotics, heart medicines and those used to treat Alzheimer’s disease. Patients are advised to fully inform the physician of all medications or supplements (e.g., vitamins) that are used before exposure to Botox. Because Botox is prepared with an egg (albumin) base, it is not indicated for individuals who are allergic to eggs. Patients with immune system disorders should also avoid the treatment. In addition, Botox is not recommended for women who are or may be pregnant or those who are breastfeeding. It is unknown whether Botox can negatively affect the fetus or whether it is found in breast milk. The effects of Botox on children and the elderly are also not known. Patients should notify their physician if they have any of the following: Neurological or muscular disease Heart problems Infection, swelling or muscle weakness in the injection site Previous allergic reaction to Botox History of botulism infection Swallowing problems

Facial skin rejuvenation

Reviewed By:
Rana Rofagha Sajjadian, M.D., AAD
Mary Ellen Luchetti, M.D., AAD

Facial skin rejuvenation is the use of techniques designed to restore damaged skin to a youthful, healthier-looking appearance. It may involve medications, procedures, surgery or a combination of these treatments, and is used to repair damage caused by factors such as illness, aging and exposure to the sun.
The skin is the largest organ in the body. Over time, the skin fibers that keep the skin taut – collagen and elastin – weaken as a combination of gravity and internal and external factors pull the skin downward. In addition, years of exposure to the sun can create superficial blemishes that become more pronounced with time, and disorders such as acne can cause scarring that is cosmetically unappealing.

Dermatologists and dermatologic surgeons use facial skin rejuvenation to combat this deterioration and improve the skin’s general appearance. Different techniques may be performed depending on the condition to be treated. A person’s skin type is a critical factor in determining which procedure can best restore facial skin health.

Facial skin rejuvenation can help reduce wrinkles and sun spots, tighten loose skin, improve skin texture and color, remove blotches or damaged blood vessels, and lessen the appearance of minor scars. Over the years, advances have helped make such procedures less invasive and safer.

Types and differences of facial rejuvenation

There are several main categories of facial skin rejuvenation, including: Topical products. These are drugs or cosmetics that are applied to the skin. They usually are used to treat fine lines, superficial wrinkles and other milder signs of aging. Some topicals can also be used to prevent skin damage or to reduce or delay the need for other procedures. Topical medications include tretinoin (a substance within the vitamin A family), alpha-hydroxy acids (derived from fruit and dairy products) and topical antioxidants (including vitamins C and E). Fillers. Soft tissue fillers are used to elevate facial furrows and hollows, reduce wrinkles and give the skin a smoother appearance. They are especially effective when used around the lips and mouth and for correcting depressions and scars. Substances used for this purpose include bovine collagen (fibrous protein substance derived from cows), fat removed from another part of the patient’s body, hyaluronic acid derivatives, hydroxyapatite, poly-L-lactic acid (PLLA), and silicone and polymer implants. Botulinum toxin. This agent – a purified version of the bacteria that cause botulism food poisoning – can be safely injected in tiny amounts into individual muscles to create a nerve block that relaxes that muscle’s movement. Botulinum toxin is used to treat lines and wrinkles associated with facial expression. The Food and Drug Administration (FDA) approved use of this product for glabellar wrinkles, or wrinkles between the eyebrows. However, many dermatologists and plastic surgeons also routinely treat other areas, such as forehead lines or crow’s feet around the eyes, safely. Botulinum toxin also may be used to relax muscle bands that may be visible in the neck. Treatment results typically last for three to four months. Chemical peels. Chemical solutions such as alpha-hydroxy acids, trichloroacetic acid and carbolic acid may be applied to remove outer layers of aged, discolored or irregular skin. Depending on the specific type and concentration of the acid used, the skin exfoliates or peels over a period of days, leaving behind new skin that is smoother, has fewer wrinkles and is more even in color. Chemical peels are often used to treat wrinkles around the eyes and mouth, skin discoloration, age spots, mild acne scars and dull skin. They may range from mild peels (for fine lines and wrinkles) to medium-depth peels (for moderate skin damage, such as age spots, freckles and precancerous growths such as actinic keratoses). Chemical peels cannot remove deeper scars. Dermabrasion. Resurfacing procedure in which skin is mechanically “sanded” with an abrasive instrument, such as a rapidly rotating brush. This removes outer skin layers and smoothes the skin overall. It is used to treat significant scarring, pigmentation and sun damage. Although healing time may take several weeks, results are often impressive and long-lasting. Microdermabrasion. A technique similar to dermabrasion that uses either micro-particles or a diamond-tipped wand to remove part of the top skin layer (epidermis). This helps stimulate proteins involved in cell differentiation and growth. Key adventages of microdermabrasion are that it is noninvasive, does not require anesthesia and creates little or no discomfort. In addition, it does not require significant recovery time. It is usually performed in several treatment sessions, two or three weeks apart. Lasers. Used to remove layers of skin with laser light energy. Lasers work by creating an intense beam of light that travels in one direction. They may be either ablative (remove the top layer of skin) or nonablative (treat layers beneath the surface layer). Lasers are used to vaporize or improve wrinkles, scars, skin discoloration, broken blood vessels and precancerous skin growth. Lasers also may be used to treat lines and blemishes on the neck and to improve folds and creases by tightening loose skin. Finally, lasers often enhance other treatments, such as chemical peels, liposuction of the face and neck, and blepharoplasty (eyelid surgery). Intense pulse light (IPL). Makes use of broad spectrum light that filters out harmful wavelengths. It is used to treat vascular (blood vessels) lesions and problems involving texture, pigmentation and pore size. IPL is often combined with techniques such as microdermabrasion or botulinum toxin. Light-emitting devices (LED). Makes use of light, delivered through light emitting diodes (LEDs), to activate skin cell receptors stimulating them to produce new collagen and elastin. It is used to treat fine lines, hyperpigmented lesions (brown spots and freckles) and other skin problems associated with sun damage. LED is often combined with other facial rejuvenation treatments such as botulinum toxin, dermal fillers and nonablative laser, IPL and photodynamic therapies. Radiofrequency technology. Using radiofrequency waves, these non-invasive techniques result in skin contraction and tightening that can lead to lifting of the face, brow and cheeks without surgery or a prolonged recovery time. Photodynamic therapy. Involves the application of a topical medication called 5-aminolevulinic acid (ALA) to the skin. ALA is left on the skin for a specified period of time. The area is then treated with colored light (blue, yellow or red) using LED, IPL or a pulsated dye laser. Photodynamic therapy also can effectively treat early precancerous changes of the skin. Surgical excision. Removal of tissue using a scalpel or other sharp instrument. Excision may be used to remove moles, scars and benign (noncancerous) skin growths that enlarge with aging. Surgical excision may also be used to treat droopy eyelids by removing excess fat pads and skin (blepharoplasty), reduce severe lines in the forehead, raise the eyebrows (browlift) and tighten and trim excess skin on the cheeks, chin, neck and around the mouth (rhytidectomy, or facelift). Liposuction. Surgical removal of local fat deposits by applying suction through a small tube inserted into the body. Liposuction can be used to remove excess fat and improve the contour of the face and neck areas. Local anesthetic is often used in liposuction procedures. Neck and jowl treatments. Many different techniques may be used alone or in combination to treat problems such as sagging jowls or double chins. Techniques include chemical peels, botulinum toxin therapy, laser resurfacing, liposuction, radiofrequency procedures and neck lifting. The choice of technique used to treat a patient may vary depending on several factors. A patient’s skin type and treatment goals are important factors in determining which technique is best. In some cases, a combination of techniques may produce improved results. Before, during and after facial rejuvenation Patients who are considering facial skin rejuvenation will consult with a physician to discuss various aspects of the procedure. It is important to search for a qualified dermatologist who has experience performing facial skin rejuvenation. Dermatologists are skilled in the use of a wide variety of surgical and nonsurgical methods of treating skin conditions. As a result, they will be able to recommend a procedure based on: Type of skin condition being treated Location of the skin being treated Degree of damage Patient’s skin type Patient’s treatment goals Time required for recovery Patient’s age Patient’s medical history Prior to the procedure, patients should follow any preparatory advice recommended by their physician. This may include dietary restrictions and changes in medication regimen. The choice of technique will dictate how the procedure unfolds. Some procedures – such as botulinum toxin injections and others that may take place in a physician’s office – can be completed in as little as 30 minutes without the use of anesthetics. However, more invasive surgical procedures (e.g., eyelid surgery) may require use of anesthetics and a brief hospital stay. Recovery time for facial skin rejuvenation varies significantly, depending on the technique used to treat patients. Many techniques – such as soft tissue filler and botulinum toxin injections, microdermabrasion and some laser and intense pulse light (IPL) treatments – require no recovery time. More invasive procedures may require between three and 10 days of recovery time. In most cases, patients will feel no significant pain as a result of the procedure. Minor discomfort may occur, however, in addition to mild redness and swelling. In many cases, repeat procedures will be necessary at some point to maintain the restorative effect achieved during the initial procedure. Potential risks with facial skin rejuvenation Facial skin rejuvenation is generally safe, and new surgical techniques and technological advances have made surgical procedures less risky. However, there are risks associated with any type of treatment, especially surgery. Side effects may include: Mild redness Inflammation Minor discomfort Sun sensitivity months or years after treatment More significant side effects also may occur, especially when more invasive procedures are used. These may include: Scarring Persistent redness Permanent pigment changes Processes such as chemical peels and dermabrasion sometimes cause reddening and peeling of the face that is similar to a sunburn. This typically lasts from a few days to several weeks, depending on the strength of the solution used and the depth of the skin peel in chemical peels, or the amount of skin surface removed in dermabrasion. Medications may be prescribed to reduce discomfort or prevent infection, and patients will be advised to remain out of the sun until the new skin is ready for such exposure.

Aging & the Skin

Reviewed By: Kimberly Bazar, M.D., AAD Aging has many effects on a person’s skin, from wrinkles and sags to increased risk of certain skin conditions, such as skin cancer. As people age, their skin begins to change due to environmental factors, genetic makeup, nutrition and other factors. Covering the entire outside of the body, the skin is the body’s largest organ and consists of three layers: the epidermis (composed of skin cells, pigment and protein), the dermis (composed of blood vessels, nerves, hair follicles and oil glands) and the subcutaneous tissue (composed of sweat glands, hair follicles, blood vessels and fat). Each layer also contains connective tissue, collagen fibers for support and elastin fibers to provide flexibility. Hair and nails are modified versions of skin. Hair maintains warmth in the body by preserving heat. Hair located around the eyes and in the nose and ears protects these areas from small particles such as dust. It also cushions the body against injury. Nails sprout from deep folds in the fingers and toes. They provide protection and support for the sensitive fingertips and toes. The skin serves many roles in an individual's body. It protects a person from the environment, helps maintain fluid and electrolyte balance and provides receptors that help the body feel sensations such as pain, vibration and pressure. It grows faster than any other organ in the body, and people continuously renew their skin throughout their lifetime. From the moment a person is born, the skin begins a process of constant change. A baby’s skin tends to be soft and smooth and has a thicker layer of fat and thinner layer of keratin, a protein that is the chief component of hair and nails. As a person enters the young adult years, the skin becomes stronger and suppler. As people age, many changes affect their skin. The outer skin layers (dermis and epidermis) begin to thin and the number of cells containing pigment (melanocytes) begins to decrease, even as the remaining melanocytes increase in size. Connective tissue begins to change, reducing the skin’s strength and elasticity (elastosis) and causing it to take on a leathery appearance. The skin also dries out and begins to lose underlying fat (except in the abdomen and thighs), and fine wrinkles increasingly appear. Causes of aging-related skin changes Sun exposure (photodamage) is the chief source of aging-related skin damage, including blotchy pigmentation, wrinkling and scaling. The more skin is exposed to the sun without protection, the greater the likelihood of developing signs of aging. A person’s skin type plays a significant role in how damage manifests. For example, people with blue eyes and light skin are much more likely to show aging skin changes than those with darker eyes and skin. In addition, skin becomes even more vulnerable to sun damage as it ages and the number of cells containing pigment (melanocytes) begins to decrease. Because older people have a reduced inflammatory response, they are less likely to develop sunburn than younger people. However, this lack of sunburn masks the fact that older people with fewer melanocytes are actually more likely to suffer significant ultraviolet radiation damage than younger people. Long-term exposure to the sun has been linked to many aging-related skin changes, including loss of elasticity (elastosis), skin growths (keratoacanthomas), thinning of the skin, pigment changes (such as age spots), actinic keratosis (precancerous skin changes) and skin cancers. People who spend a lot of time outdoors may develop solar elastosis due to sun exposure, which causes the leathery appearance to become even more pronounced. Other environmental factors that may contribute to skin damage include climate, exposure to chemicals and allergies. Genetics also play a role in the development of aging-related skin changes. A person's tendency to develop wrinkles, for instance, may be inherited from their parents. Additional aging-related changes that impact the appearance of the skin include: Weakening of blood vessels in the skin’s middle layer (dermis). As these vessels become more fragile, bruising, bleeding under the skin (purpura) and cherry angiomas (small red spots on the skin) may occur. Thinning of the subcutaneous fat layer. This layer of skin provides insulation and padding and absorbs some medications. As the subcutaneous layer thins, a person becomes more susceptible to skin injury and medications may work differently in the person’s system. The subcutaneous fat layer also helps the body to maintain proper body temperature. The thinning of this layer leaves the body with less natural insulation, increasing the risk of hypothermia during exposure to cold. Decreased sweat glands. Both the sweat glands and blood vessels in the skin begin to decrease. This makes it more difficult for patients to keep cool, putting them at increased risk for overheating or suffering heat stroke. Drying out of the skin. This condition – known as xerosis – occurs in a majority of older people and may result in itchiness (pruritus) and a roughness to the skin’s texture. It is particularly likely during the winter. The exact cause of this drying out is unknown, although a reduction of oil production from the sebaceous glands may be at least partially responsible. Women produce less oil after menopause, which causes dry skin and itchiness. Men experience a lesser decrease, usually after age 80. As people age, they also become more vulnerable to diseases and disorders that may cause skin conditions. Diseases that can impact the skin include diabetes, liver disease, heart disease and arteriosclerosis (a blood vessel disease). Shingles (a viral infection caused by the same virus that causes chickenpox) is also more common and painful in people older than 50, although it can occur in people of any age. Other factors that may impact the skin include stress, medication reactions, obesity and lack of adequate nutrition. Symptoms of aging-related skin changes As the skin begins to slowly deteriorate during the aging process, a number of symptoms may appear. The skin often appears thinner, paler and more translucent. People may look increasingly gaunt, with hollowed cheeks and eye sockets. “Laugh lines” may appear around the mouth, and crow’s feet may appear around the eyes. Sleep lines – which are temporary marks on the face that appear after sleeping on a pillow all night – may become etched into the face. As gravity takes its toll on the skin, the eyelids begin to fall, jowls form, the nose tip droops downward, the upper lip recedes while the lower lip protrudes and the ears grow longer. The skin dries out and begins to lose elasticity. Areas that are exposed to sun may develop into brown patches known as age spots or liver spots. These most often appear on the face, hands, arms, back and feet of people with fair skin. Skin is more vulnerable to injury as the subcutaneous fat layer breaks down and a person’s sense of touch becomes reduced (due to a decrease in the number of nerve endings in the skin). Simple rubbing or pulling of the skin can result in tearing of the skin and blood vessels are more easily broken. Even minor injuries can result in bruises, flat collections of blood (purpuras) or raised collections of blood (hematomas). Such injuries most frequently appear on the outside of the forearms. Not only is aging skin more susceptible to injury, but it also heals more slowly. The slow healing process may result in ulcers or skin infections. In addition, the aging process makes people more susceptible to growths such as warts, skin tags (small, fleshy, noncancerous skin growths attached to a stem-like base), seborrheic keratoses (benign, gray/brown rough-surfaced growths) and cherry angiomas (benign skin growths that appear as small, smooth, cherry-red bumps). Generally, skin disorders are more common in older people. Aging also increases the presence of spider veins, blood vessels located just beneath the skin surface that grow larger and appear red or blue when they weaken and become clogged. They most often appear in “sunburst” patterns on the face and legs, but can affect other areas of the body. Finally, aging impacts other types of skin such as hair and nails. Hair begins to go gray as hair follicles produce less of the pigment (melanin) that gives hair its color. This occurs first on the scalp and then on other areas of the body. Over time, gray hair eventually turns white. People may also experience hair loss on the scalp or grow unwanted hair in other regions. Nails may grow slower and become dull, brittle, yellowed and opaque. Toenails may become hard and thick over time. Prevention of age-related skin changes It is impossible to prevent all of the changes that occur to the skin as a person ages. However, older individuals can take steps to slow the pace of these changes, or to treat symptoms that result from these changes. Tips include: Avoid sun exposure. Sun damage (photodamage) is the leading cause of wear and tear to the skin ranging from wrinkles to skin cancer. For this reason, people should always wear sunscreen with a sun protection factor (SPF) of 15 or higher when outdoors, even during the winter. Protective clothing, such as wide brimmed hats, long-sleeved shirts and long pants can also help protect the body from the harmful effects of the sun. If possible, avoid exposure to the sun during the peak sun hours of 10 a.m. to 4 p.m. Avoiding sun exposure is especially important for those living in warmer climates – with every four degrees of closeness to the equator, the incidence of skin cancer doubles. Use moisturizers and emollients. Simple, inexpensive versions of these products can be effective in restoring moisture to dry skin. Moisturizers that contain lactic acid or urea may be more effective in relieving the severe dryness associated with aging skin. These products are intended to alleviate the actual cause of dryness rather than to just treat the symptoms. Maintain a healthy diet and consume adequate fluids. Poor nutrition increases the risk of skin rashes, lesions and other skin changes. Foods that are recommended for good skin health include fruits, vegetables, whole grains and “good” fat, such as that found in vegetable oil, fish and nuts. Foods containing sugar, cholesterol, and sodium should be avoided or consumed in moderation. Dehydration increases the risk of injury to skin tissues. Consuming a minimum of eight 8-ounce servings of water throughout the day can help prevent the body from dehydrating. Talk with a physician about additional medications or treatments. The effects of skin damage can often be treated, slowed or prevented through the use of certain medications (such as tretinoin or alpha hydroxy acids) or procedures (such as cryotherapy, chemical peels, microdermabrasion, Botox, facial skin rejuvenation, soft tissue augmentation, laser resurfacing and blepharoplasty).