Dr. Dosal weighs in on the best shampoos

Ever wonder if you are using the best shampoo for your hair?  Well check out this comprehensive review from Reviews.com on some of the best shampoos on the market.

Their methodology is intense, and in the process, Reviews.com does a remarkably thorough and well thought-out attempt to pare down the enormous choice that consumers have when buying shampoos.  Their top pick for Normal to Dry Hair is a really nice product (Davine’s Oi shampoo).

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In my opinion, the most important factor when choosing a shampoo is to not remove ALL of the oil from your scalp.  The natural oils on your scalp are lubricating and good for the hair, so finding the right balance between not looking greasy or too dry (and with it, itchy and flaky scalp) is very important.  Reviews.com took a close look at all the surfactants (the ingredients that removed oil) and found products that were kind to the hair and scalp.  This article has great picks for oily hair (Living Proof Perfect Hair Day) and even cheaper drug store picks.

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I have been pleasantly surprised with the quality of articles on Reviews.com.  Check them out – they review everything, not just beauty products (some examples include the best dog food, mattress, probiotic supplement, electric toothbrush, and cell phone plans!).

Note: I have no conflict of interest with the website, other than being quoted in this article.

Enjoy your good hair day!

Dr. Dosal’s Favorite Things – for 2017

OK, so it’s a little too late for gifting, but never too late for giving yourself a fresh start to 2017!

If you are looking for a few new fresh ways to get your skin glowing, look no further!  I’ve got some of my favorite new discoveries that anyone can use!

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Heeere are some of my faaaavorite things!!! (Did that sound like Oprah?)

Eye cream with SPF
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It seems to be as much of an catch-22 as one might think.  The eye area is very sensitive so most people don’t put SPF around the eye due to stinging and irritation. Yet, the skin around the eye is the most delicate and vulnerable to UV damage.  Many women complain about crepiness around the eye area, much of which can be contributed to UV damage.  So why are we leaving the thinnest skin on our body completely defenseless against the sun?

Not anymore.  I’m so happy to be using Supergoop! Advanced Anti-Aging Eye Cream with SPF 47 every morning.  It has a cold metal roller that decreases early morning puffiness as well as some minerals that reflect light and make the eye area appear brighter.

Now, I’m definitely a product junkie, so, embarrassingly this is only 1 of 3 eye creams I use on a daily basis!  I also use  Teamine concealer that contains peptides, vitamin C, and licorice extract as my underage concealer (layered over Supergoop!).  At night I can’t live without my Neocutis Micro Eye cream (find Neocutis at our new Skin Associates Apothecary in Coral Gables!) – I recommend it to everyone!

Harness the power of nature – SNAILS! 🐌🐌🐌

biopelle-tensage50_largeIt’s all the rage in Korea.  Finally the US is starting to catch on.  Snails have the ability to easily heal themselves after encountering many injuries from the hazards of snail life – rocks, bacteria, etc.  Extract from snails contains growth factors, hyaluronic acid, peptides, glycolic acid, and other cell regenerating properties.  Snail extract has been reported to have anti-aging benefits, fade brown spots, tighten the skin, and increase “radiance,” a term that is difficult to define and measure.

I first tried Biopelle Tensage after receiving a sample at our annual dermatology meeting.  It looked like every other sample I had received, but this was the most impressive that I had ever used.  Within one week, I noticed a big difference.  I try so many products on a regular basis and it’s pretty hard to impress me, but the snails did!

If you are ever looking for a boost or a nice glow before a big event, use the potent Tensage 50 serum 1-2 times daily for a week, then once a week thereafter.  Tesage makes a daily serum that my patients also love!  Find them in our Skin Associates Apothecary!

Skin Detox

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Ever experience a skin freak-out?  Where your skin goes nuts for seemingly no apparent reason?  Usually it centers around travel, new skin-care products, or stress.  One in 5 people will experience an allergic reaction or irritation from a personal care product, so when these bad skin days/weeks occur, it’s best to strip down to only the basics… a skin “boot-camp!”  Rather than pitching all your products, check out this handy kit to get you through those rough days.  It is a kit that contains all your skin care products free of the 76 most common allergens, specially formulated for allergic people.  VMV Hypoallergenics is a leader in skin care for sensitive skin.  I refer all of my allergic patients to their website.  These products are also great for air travel, as they are small (TSA bonus points) and better than the fragrance-laiden soaps you’ll find in the hotel.

Anti-aging for your arms and legs

yj51czpn_201405022051428273Ever look at your grandmother’s arms or legs?  If she spent some time in the sun, then you might expect to see leathery texture to the skin, brown spots, dry skin.  Marketed as therapy for severely dry skin, DerMend’s Alpha + Beta Hydroxy Therapy is a one-two punch against both dry skin and aging skin.  It’s packaging is less glamorous than what can be found at the department store, but it’s an all-star treatment deserving of gold stars.  Alpha and beta hydroxy acids such as salicylic acid and glycolic acid help rejuvenate the top layer of the skin and also stimulate collagen growth with regular use, while simultaneously gently exfoliating off dry skin.  Note: be sure to wear sunscreen  when exposed to the sun while using this product and for four weeks afterwards.  Glycolic acid can make you more sensitive to the sun.  It’s well worth it (and you should be doing it anyway!) – my skin has honestly never felt so soft!

Ultherapy

before_after_ultherapy_results_full-face3As one of my nurses, Joan, puts it, Ulthera (Ultherapy) is the gift that keeps on giving.  Ultherapy uses ultrasound energy to lift and tighten the skin in a gradual process that gets better with time.  I experimented on myself (my neck) about 3 months ago.  While not overweight, I’ve always had a blunted angle from my chin to my neck, which has always bothered me.  Within a few months of having Ulthera done, I already appear thinner and have a more defined jawline.  It’s something I didn’t think was possible, and I’m thrilled!

Ulthera works best for normal weight individuals with good elasticity to their skin.  It does not replace surgery, but for those looking for a subtle lift, it does a great job!!  Check out http://www.ultherapy.com to learn more.

Clear and Brilliant

Clear and Brilliant (C&B) is a very light resurfacing laser treatment that almost anyone can have done.  Perfect for someone looking for a light treatment with almost no downtime, a series of Clear and Brilliant treatments can clear the complexion, lighten up dark spots, and give the skin a smoother appearance.  I find that sometimes people shy away from lasers because of the downtime needed.  C&B is perfect for the busy professional (or mom) who can’t take time off work (shuttling the kids) to recover from a laser treatment.

That’s all for now.  I’ll be sure to periodically update all of my favorite things!

 

 

 

Dr. Dosal Featured in Harper’s Bazaar

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Dr. Jacquelyn Dosal was featured in this month’s Harper’s Bazaar Australia.  Journalist Amy Molloy consults with Dr. Dosal about over-stretched concerns regarding sunscreen safety.

Molloy writes that women are skipping daily sunscreen use for fear of putting chemicals on their skin. This “chemophobia” is largely internet and celebrity driven, in contradiction to scientific studies that demonstrate safety and effectiveness of sunscreens.

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Dr. Dosal explains that the many of the assertions of toxicity come from lab animals that were fed sunscreen.  According to Dr. Dosal,

“There is a monstrous difference between eating super-high doses of sunscreen and applying it to your skin daily.”

To put it in perspective, it would take 200 years of daily sunscreen application to reach any amount of concern such as the scenarios found in the often cited rat studies.

If one has concerns, there are certain ingredients, such as zinc and titanium dioxide based, that are marketed as “chemical free,” (which really is a misnomer – everything is a chemical…. even water – remember H2O anyone?).

In summary, sunscreen not only prevents skin cancer, but it is also the best anti-aging ingredient on the market.  Don’t waste your time with fancy La Mer products if you aren’t wearing sunscreen every day!

Full article can be found here: harpars-bazaar-au-oct-16-health-sunscreen-new

Dr. Jacquelyn Dosal is a Board-Certified Dermatologist practicing dermatology in Miami, FL at Skin Associates of South Florida and is a voluntary Assistant Professor at the University of Miami.

 

My Homemade Sunscreen Experiment

Why, might you ask, did I attempt to try to make my own sunscreen?  Boredom on vacation?

I think many of us are attracted to do-it-yourself home remedies.  They seem cheaper and it might make sense to use things that are already in the cupboard. For instance, apple cider vinegar seems to be the internet/Facebook “cure-all” – it can fix everything!  Pretty soon I started noticing links for how to make your own sunscreen.  I haven’t tried apple cider vinegar yet, but had to try this one.

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My homemade sunscreen experiment.  Can anyone spot the most essential ingredient in the realization of this blog?  Hint – it’s in blue (baby monitor a.k.a nap time).
But does it really work?  In the case of sunscreen, I wanted to find out for myself.

Those looking for natural or organic solutions are particularly ripe for getting misinformation or potentially dangerous advice.  There are MANY excellent natural solutions, but usually those giving advice  (i.e. your friend on Facebook) don’t have any medical background, making it hard to vet what is SAFE and effective.

As many of you already know, I’m very passionate about sun protection, and wanted to make sure that people weren’t getting bad information.  I was optimistic, hoping to be surprised!  With this in mind, I set out to make my own sunscreen.

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Zinc oxide powder ready to be added to the base.
Here were the pros:

  • It was relatively easy and fast to make.
  • There were only a few ingredients, which should please simplistic and naturally oriented people. (Ingredients: coconut oil, shea butter, zinc oxide, pomegranate oil, and lavender oil).
  • I did not burn while wearing it for 2 hours in the noon Florida summer sun.

Here were the cons:

  • It cost me $57.70 to get all the materials!  
  • It was messy to apply.  Commercially formulated containers exist for a reason. Next time I would transfer it to a squeeze bottle.
  • Forget re-applying (one of the most common mistakes people make is not reapplying their sunscreen) – it would be way too messy to transport this DIY sunscreen.
  • I felt like a human version of “Slip-N-Slide” after applying.  The texture was way too greasy for my taste.
  • The true SPF of the concoction is unknown – a major no-no for me.
  • The stability and expiration date is unknown – I would guess that you could keep this mixture for 60 days, and then have to repeat the process. (I have absolutely no data to support this, which is the point… how do you know if it’s still good?)
  • The ingredients separated after mixing – not a big deal – just required mixing again before applying. A few days later the mixture was more consistent and paste like.
  • I would not recommend using this on your face if you are break-out prone. The oils might cause an acne flare.

My conclusions:

Save the $57.70, buy a $15 sunscreen with SPF 30+ and UVA protection, and use the rest of the $$ for a good sun shirt!  (Find my sun shirt picks here!)

And a last few words.  Some websites advocate using coconut oil alone as sunscreen – this is NOT OK!  Coconut oil has an SPF of about 4-6.  Would you ever consider buying a sunscreen with SPF 5?  No, so don’t consider it adequate protection for your skin.  The American Academy of Dermatology recommends a broad-spectrum sunscreen with an SPF of at least 30.  We are talking about a serious cancer risk (1 in 5 Americans will develop a skin cancer in their lifetime), as opposed to any hypothetical concerns about ingredients – see my in-depth post about sunscreen safety here.  The mixture above includes zinc oxide powder to beef up the SPF.  Even easier, you can also very easily find some simple commercial sunscreens with zinc oxide.

While my experiment “worked” in that I didn’t get burned, the practical aspects of the homemade sunscreen made it a no-go for me.  It was too expensive, too greasy, too messy, and in my humble dermatologist opinion, a little too risky for me.  I’m ok with using a homemade milk mask, but I don’t like risking DNA damage to my skin cells because I messed up the SPF formulation.  I’ll leave that to the experts.

It takes just two painful sunburns to increase your risk of melanoma, so for me, it’s really not ok to experiment with sun safety.  I did it for you, so that you won’t have to!

In the end, my main message is to use something that you know has an SPF of over 30, reapply every two hours, and practice sun safe behaviors.

Dr. Jacquelyn Dosal is a Board-Certified Dermatologist practicing dermatology in Miami, FL at Skin Associates of South Florida and is a voluntary Assistant Professor at the University of Miami.

Can you use diet to help protect against skin cancer?  

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Can you use diet to help prevent against skin cancer?

The answer is No.  

And Yes.

The reason why I say “no” first is that there are no superfoods in the world that can fully protect against any cancers, and NOTHING replaces sun-safe behavior as the single most effective strategy against skin cancer.  We are all looking to take back some control against the scariness and sometimes unfair nature of cancer.  Diet can seem like the most obvious choice, but let’s not let diet overshadow the most important factors in preventing skin cancer, in this order:

  1. Sun protection
  2. Sun protection
  3. Sun protection
  4. #4 through #100 – Sun protection 

    woman on beach

The use of sunscreen, sun clothes, sunglasses, wide brimmed hats, and seeking shade is far more important than what you eat.  Over 80% of skin cancers are due to UV radiation.  Just like quitting smoking is one of the best things you can do to prevent lung cancer and heart disease, sun protective measures will always trump nutrition as a cancer prevention strategy.

Now why, “yes?”

I’m fascinated by how our nutrition might affect the overall health of our body.   Apparently, so are a lot of other people.  You can find a nutrition study for just about any nutrient, and just about any disease state.  After reading Michael Pollan’s  In Defense of Food, I now understand how difficult it is to isolate a single nutrient with regards to health, since nutrition does not exist in a vacuum.  Nutrition is much more than the sum of its nutrient parts.  It depends on the human host that consumes it, vitamins and cofactors consumed simultaneously, the soil/environment in which it was grown, etc.  It is very difficult to prove causation (and not just association) in nutrition studies.

That being said, I am still very interested in what has been published with regards to skin health and skin cancer prevention.  At this point, evidence is still only suggestive of certain foods being beneficial in preventing skin cancer.  However, most of these foods are known to be beneficial for other reasons, such as preventing heart disease, diabetes, obesity, etc, so I see no difficulty recommending them– in addition to rigorous sun protection.

The Highlights…

mediterranean diet

  • The overall direction of the medical literature roughly supports something similar to the Mediterranean diet, with emphasis on vegetables and good fats.
  • Prudence should be taken with alcohol and possibly citrus fruits (while in the sun).
  • Supplements do not replace whole foods, and in my opinion should not be used as a substitute for getting the nutrient du jour.  See below for the dangers in “nutritionism.”
    • In some cases supplements might increase your risk of skin cancer.
    • There is also the issue of pervasive supplement contamination with “yucky stuff” (hormones, heavy metals, or undetectable levels of the actual product that is being sold).

So let’s look at the specific foods that can be helpful (and a few words about supplements):

    • Fish high in omega-3 fatty acids (sardines, anchovies, tuna, salmon, shellfish)
    • Regular tea drinking (green and white tea)
    • Veggies (especially dark leafy greens like kale, carrots, broccoli, cabbage, brussel sprouts)
    • Tomatoes
    • Herbs and spices – rosemary and turmeric
    • Olive oil
    • Coffee
    • Fruits
    • Soy

Foods to avoid (foods that are pro-inflammatory)

  • Trans-fats
  • High amounts of omega-6 polyunsaturated fatty acids
  • Pre-prepared meals or snacks in a package
  • Too much red meat
  • Controversial: dairy

This is the way I think of it…  Skin cancer generally happens for a combination of three reasons.

  1. Genetics – red haired, light skinned individuals have genetics that make them susceptible to skin cancer and UV damage, partly because of their lack of pigment leaves them vulnerable to the sun.
  2. DNA damage, predominantly from UV rays –  The sun actually damages our DNA – the tan and sunburn you see are your body’s reaction to all the bad stuff that is happening on a cellular level.  With enough DNA damage comes uncontrolled-immortal-damaged cells (a.k.a. – cancer).
  3. Bad luck – There are some instances where skin cancer develops in sun-protected areas or in dark-skinned individuals – this is a combo of a spontaneous mutation in their cells, maybe a genetic predisposition, but probably just bad luck!

The only factor in our control is to avoid #2 – seek sun protection to avoid DNA and oxidative damage that comes from UV rays.  However, unless you live under the ground, you will probably have your fair share of sunny indiscretions.

Nutrition comes in as a way to keep your bodily defense reserves high against DNA damage from UV radiation.  Think of it as ROTC (Reserve Officer Training Corps for the US Military) for your body.  You will have highly trained soldiers ready to come to action should there be some cellular stress on your body. By keeping those soldiers ready, you are more likely to protect against the waxing and waning onslaught of stressors on the body whenever needed.  It helps protect against damage from UV rays, smoke, environmental pollutants, even stress (and can help regulate stress response).

The key to this is keeping anti-inflammatory foods high, and pro-inflammatory foods low.  It is also helpful to keep a diet full of antioxidants.  By fighting inflammation and oxidative stress (hence the terms anti-inflammatory and antioxidant), you keep the body functioning at its best, ready to fight off any DNA-damage-causing forces.


 

Here is a little more detail for those interested:

grean tea bestGreen Tea – Frequent tea consumption was protective against melanoma in an Italian study (in a dose dependent relationship) (Fortes).  Green tea contains polyphenols (epigallocatechin-3-gallate or EGCG) and catechins. These antioxidants help prevent DNA damage from UV radiation, help repair DNA damage, prevent the progression of DNA damage into cancer, they block immune suppression that can allow cancer to grow.  Of note, there are studies that show no benefit of drinking tea in the prevention of skin cancer, so like almost everything, the data is mixed.

Tomatoes and carrots – Carrots and tomatoes contain carotenoids such as beta-carotene, lutein, and lycopene which are excellent antioxidants.  Increase beta-carotene intake has been associated with decreased risk of melanoma, as documented in a retrospective dietary analysis in a case control study of melanoma patients.  In a placebo-controlled clinical study, sunburn intensity after UV irradiation was lower in subjects receiving carotenoid supplements.  Of note, lycopene is better absorbed with olive oil, which is why tomatoes and olive oil pair so well, and is a hallmark of Mediterranean cooking.

Cruciferous and green leafy veggies – (broccoli, brussel sprouts, cauliflower, kale, spinach) – The same study done by Fortes et al showed a protective effect of high consumption of vegetables (>5 times weekly) and more than one fruit a day.  Cruciferous vegetables (cauliflower, broccoli, bok choy, brussel sprouts) and dark green vegetables are best on the list, as they are all rich in polyphenols, which have many anti-cancer properties including: photo-protection, protection from ROS (reactive oxygen species, a big promoter of oxidative damage), reducing sunburn, stimulation of the immune system, and cell regulation which is important in cancer prevention.

Herbs and spices (especially rosemary and turmeric), which are central to the Mediterranean diet.  Curcumin (turmeric and curry) strongly inhibits tumor production in mouse skin and inhibits inflammation in mice (Huang et al., 1991; Stoner & Mukhtar, 1995). Fortes et al found an inverse relationship between consumption of Mediterranean herbs such as rosemary, sage, parsley, and oregano and certain types of cancer.  Carnosol (extract from rosemary) has been evaluated with promising anti-cancer properties (Johnson, 2011).

Extra virgin olive oil, which is rich in phenolic antioxidants, squalene, and oleic acid, may help to protect against skin cancer and aging by inhibiting oxidative stress (Owen at al, 2000).

Soy – Recent research has illustrates the antioxidant and DNA-protective effects of soy isoflavones on the skin.  The antioxidant and phytoestrogen genistein found in soy is believed to block UV-induced cellular damage (Accorsi-Neto et al., 2009).

coffee happy faceCoffee – yes, coffee.  Higher consumption of coffee was associated with a lower risk of basal cell carcinoma, the most common type of skin cancer (Loftfield E, et al).  It may also have an effect at lowering the risk of melanoma as well.  It is believed to be related to the caffeine content, so decaf doesn’t cut it.  And the effects were seen at multiple cups (4 or greater) per day, so as long as your doctor says it’s OK, brew happy!

The complicated story of Polyunsaturated Fats (PUFAs): PUFAs stand for polyunsaturated fats.  Often thought of as an alternative to saturated fats, the modern American diet has adopted too many of PUFAs due to the industrial reliance on corn oils and soybean oils for cooking.  The story is complicated, and there is a good summary here.  Many of you might have heard about omega-3 polyunsaturated fatty acids as being good for the body.  It’s the new dietary fad, and omega-3s are the “good fats,” found in salmon, cod, avocados, and flax seeds, among others.  The most important part of the PUFA story is the ratio of omega-6 (O-6) to omega-3 (O-3) fatty acids.  The idea ratio is somewhere between 4-6:1 of O-6 to O-3.  The typical American diet has somewhere around 10:1 or 16:1 ratio, which is waaaay too in favor of the omega-6 fatty acids.  This is because of all the vegetable oils that are used in cooking and our processed foods (i.e. canola oil, soybean oil, vegetable oil, crisco) and because of our heavy red-meat consumption (omega-6s are also found in conventional, non-grass-fed red meats).   Omega-6s contain arachidonic acid, which has a pro-inflammatory effect on the body and skin (hint: aspirin inhibits arachidonic acid, which is a main contributor of pain, and why aspirin works on pain).  Fish oils rich in omega-3 fatty acids contain eicosapentaenoic (EPA) and docosahexaenoic acids (DHA) which inhibit the formation of inflammatory molecules and generates anti-inflammatory and anti-proliferative metabolites.  The data on skin cancer prevention and PUFAs is mixed, probably because the story of PUFAs is complicated.   Again, the Mediterranean diet, which emphasizes omega-3 PUFAs (fish) found positive benefits with diets high in PUFAs, while others have found even an increased risk of skin cancer.  The important question is: “what was the omega-6 to omega-3 ratio?”  Without that information, the discussion of PUFAs is too muddy. Of note, there was no effect of a low-fat diet on the risk of two of the most common types of skin cancer (basal cell and squamous cell carcinoma), therefore a fat restricted diet is not recommended for skin cancer prevention.

Foods that may INCREASE the risk of cancer

drunkA word about alcohol:  multiple studies have found an increased risk of skin cancer with higher consumption of alcohol, while others have not (Murzaku, et al).  Of course, the possible confounding factor here is that those who regularly consumed alcohol might be higher risk-takers, increasing the risk of sunburn behavior. An exception was found with the Mediterranean diet, where no increased risk was found with alcohol consumption, probably because the drink of choice was likely red wine.  Red wine is rich in polyphenols (similar to chocolate and green tea), which might neutralize the alcohol-induced oxidative stress.  Similar beneficial compounds are not found in beer or hard liquor, so choose your drink wisely!

citrus drinkOf note, citrus consumption was associated with slightly higher risk of skin cancer (Wu S, et al).  Citrus contains psoralens, which can make your skin more sensitive to the sun.  A large prospective study correlated citrus consumption with an increased risk of basal cell and squamous cell carcinoma risk of skin cancer, and another study found increased risk with melanoma.  Highest incidence of skin cancers associated with the highest consumption of citrus fruit, especially grapefruit, which has the highest concentration of psoralens.  Hold on… citrus has a lot of other beneficial components, including Vitamin C (an antioxidant), so it isn’t time to give up your OJ yet.  Just use caution when being in the sun and don’t skimp on sun protection, especially when accompanied by a tropical drink.  Also, think twice where you put that lime…. lime burns, also known as phytophotodermatitis (say that 3 times fast), can give a bad burn and leave a stain for many months.  If eating/drinking citrus, think sunscreen!!!

Supplements  

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Disclaimer:  This section on supplements is only in regards to the prevention of skin cancer, not any other disease state, and is meant as educational only.  Please consult with your doctor with any specific questions.

In general, I usually don’t  recommend taking a supplement over getting the nutrient in question from whole foods.  While there are some studies supporting benefits of supplements, there are also many others that show no benefit or actual harm being done to patients, including an increase in mortality!  Eat a diverse, colorful diet, and you won’t need to pop any pills!

BUT… I still like to know what’s out there… so here it is!

Aspirin, ibuprofen, naproxen – also known as non-steroidal anti-inflammatory drugs (NSAIDs). Epidemiological studies have shown a protective effect for the regular intake of NSAIDs on the development of melanoma (Harris, 2001). Of course, these medications should not be taken to prevent melanoma, but it feeds into the theory of “anti-inflammation” being helpful in fighting/preventing many diseases, including cancer.  NSAIDs have other serious side effects with prolonged use, including stomach ulcers, so again, you should not take this without your doctor’s oversight, and certainly not for skin cancer prevention until we get more data.

Selenium is an antioxidant.  Originally selenium supplementation was thought to be beneficial in preventing skin cancer, however, one study did find that selenium may increase the risk of certain types of skin cancer and a review from the JAAD concluded that selenium supplements should be avoided. (Murzaku EC, et al.).

Vitamin D: Data is conflicting (Reddy et al, Tong et al).  While Vitamin D shows excellent properties in the lab, clinical trials with 36,000 patients did not show any improvement in melanoma rates with modest vitamin D supplementation (calcium + 400 IU daily) compared to placebo.  There is some data that in high risk patients with a history of non-melanoma skin cancer, supplementation results in a significantly lower melanoma risk.  But for the average person, vitamin D does not seem to impact skin cancer risk.  It is important to note that these studies are looking at vitamin D supplements… getting vitamin D from the sun is automatically accompanied by DNA damage that can cause skin cancer, as shown by this study.  There is no safe way of getting vitamin D from the sun!

Vitamin E (and C): Topical vitamin E works well in combination with topical vitamin C as an antioxidant.  However, oral vitamin E studies are mixed.  Multiple studies show no association between vitamin E and melanoma risk.  The safety of vitamin E supplementation is also unclear, because increased all-cause mortality has been found in patients receiving high-dose >400 IU daily vitamin E (Bjelakovic G, et al, 2014).

red wine

Resveratrol is a naturally occurring polyphenolic compound in grapes, red wine, some berries, and peanuts.  While the purported benefits are large (photoprotective, antioxidant, anti-inflammatory, and anticarcinogenic), there are no good studies looking at oral supplementation with the exception of a study showing better skin outcomes after radiation for breast cancer in those taking a combination antioxidant supplement containing resveratrol (Murzaku EC, et al 2014).

Lycopene: is a carotenoid found in red fruits and vegetables.  Tomatoes and tomato paste are a great dietary source of lycopene.  Lycopene is a potent antioxidant and free radical scavenger that protects against UV photo-damage (Murzaku EC, et al 2014).  Topical application of lycopene before UV irradiation decreases the inflammatory response, diminishes the generation of enzymes that damage the skin (MMPs), decrease how fast the skin becomes red to UV, and preserves DNA integrity and normal cell proliferation.  Human studies of oral lycopene are conflicting.  When dietary lycopene was stratified into the highest 20% of consumption, one case control study found that these patients had a significantly lower melanoma risk. It was shown that it was possible to protect against UV light-induced erythema (sunburn) by 40% after eating 40 grams of tomato paste a day for 10 weeks (Stahl et al., 2007). However, 3 case control studies found no significant association between serum lycopene levels and risk of subsequent melanoma.

Two supplements that I think is worth highlighting in particular….

Heliocare (Polypodium leucotomos) – Heliocare is an oral dietary supplement derived from the fern species Polypodium leucotomos, which has been used for centuries in Central and South America to help protect the skin from the sun.  It is an excellent adjunctive to externally applied sun protective measures.  It takes more UV exposure to cause a sunburn in someone taking Heliocare than someone that does not.  Of note, a similar product has also come to market, called UVO, which instead of a pill, is a powder packet that also contains other antioxidants that you can dissolve in water and drink daily.  Polypodium leucotomos is never a replacement for sun protection, but I think they are an excellent adjunctive.  To date, no adverse events or side effects have been reported with this supplement to my knowledge.  The major caveat is that since it is not a medication, it has the same loose oversight (and lack of FDA oversight) as any other vitamin or nutritional supplement.

Nicotinamide – A randomized, double-blinded, controlled trial found that supplementation with twice daily 500 mg of nicotinamide significantly decreased the number of precancerous lesions and all types of skin cancer.  (Chen A et al, N Engl J Med 2015).


Again, as a reminder, I would like to reiterate that nutritional studies are notoriously fraught with research biases, making them difficult to interpret.  Many studies show a correlation, which is very different from causation.  Here’s a nice example of this error from Wikipedia:

Sleeping with one’s shoes on is strongly correlated with waking up with a headache.

Therefore, sleeping with one’s shoes on causes headache.

sleeping w shoes

The above example shows why one should not confuse correlation with causation.  This example prematurely concludes that sleeping with shoes causes a headache, rather than the more likely factor, which is going to bed drunk causes both the headache and sleeping with shoes on.

In summary, I think the most extreme example of how nutrition can be a form of sun protection would be when you’re on vacation. You are probably getting more sun exposure than usual, and maybe a little loose with your diet.  Now would be the time to pass on the cheeseburger – full of grease and lacking any beneficial antioxidants, and opt for a green salad and fruit, or a caprese salad with tomatoes and olive oil!  Keep your reserves of anti-inflammatory and antioxidant powers high, and no matter what, don’t forget your sunscreen!!

 


 

References

Accorsi-Neto A, et al.  Effects of isoflavones on the skin of postmenopausal women: a pilot study.  Clinics (Sao Paulo) 2009;64(6):505-10.

Aguilera P, et al.  Benefits of oral Polypodium Leucotomos extract in MM high-risk patients.  J Eur Acad Dermatol Venereol 2013;9:1095-100.  

Bjelakovic G, et al.  Antioxidant supplements and mortality.  Curr Opin Clin Nutr Metab Care 2014;12(1):40-4.  

Bronsnick T, et al.  Diet in dermatology: Part II. Melanoma, chronic urticaria, and psoriasis.  J Am Acad Dermatol 2014;71(6):1053

Chen AC, et al.  A phase 3 randomized trial of nicotinamide for skin-cancer chemoprevention.  N Engl J Med 2015;373(17):1618-26.  

Ferrucci LM, et al.  Tea, coffee, and caffeine and early-onset basal cell carcinoma in a case-control study.  Eur J Cancer Prev 2014; 23(4):293-302.

Fortes et al. A protective effect of the Mediterranean diet for cutaneous melanoma.  Int J Epidemiology; 2008: 37(5):1018-29.

Harris RE, et al.  Inverse association of non-steroidal anti-inflammatory drugs and malignant melanoma among women.  Oncol Rep 2001;8(3):655-7.

Huang MT, et al.  Inhibitory effects of curcumin on in vitro lipoxygenase and cyclooxygenase activities in mouse epidermis.  Cancer Res 1991 51(3):813-9.

Jensen JD et al.  Nutrition and melanoma prevention.  Clinics in Dermatology 2010;28:644-649.

Johnson JJ.  Carsonol: a promising anti-cancer and anti-inflammatory agent.  Cancer Lett 2011;305(1):1-7.  

Loftfield E, et al.  Coffee drinking and cutaneous melanoma risk in the NIH-AARP diet and health study.  J Natl Cancer Inst 2015;107(2).

Murzaku EC, et al.  Diet in dermatology: Part I.  Atopic dermatitis, acne, and nonmelanoma skin cancer.  J Am Acad Dermatol 2014:71(6):1039

Peterson B, et al.  Sun and ski holidays improve vitamin D status, but are associated with high levels of DNA damage.  J Invest Dermatol 2014;134(11):2806-13.  

Pollan M.  In Defense of Food.  2009 Penguin Books.

Reddy KK, et al.  The role of vitamin D in melanoma prevention: evidence and hyperbole.  J Am Acad Dermatol 2014;71(5):1004-5.

Smith SG.  How diet impacts your skin.  March 22, 2016 https://www.md.com/blog/how-diet-impacts-your-skin

Stahl W, et al.  Carotenoids and flavonoids contribute to nutritional protection against skin damage from sunlight.   Mol Biotechnol 2007;37(1):26-30.

Stoner GD, Mukhtar H.  Polyphenols as cancer chemopreventive agents.  J Cell Biochem Suppl.  1995; 22:169-80.

Tong LX, et al.  Nutrition: the future of melanoma prevention?  J Am Acad Dermatol 2014;71:151-60.

Wu S, et al.  Citrus consumption and risk of basal cell carcinoma and squamous cell carcinoma of the skin.  Carcinogenesis 2015;36:1162-1168.

Wu S, et al.  Citrus consumption and risk of cutaneous malignant melanoma.  J Clin Oncol 2015;33(23):2500-8.  

Zeng W, et al.  Tea consumption and cancer incidence in a prospective cohort study of postmenopausal women.  Am J Epidemiol 1996;144:175-82.

The Best Sun Protective Clothing – and why you should wear it!

After many years of battling with unpleasant sunscreens, I have finally come around to the notion that sun clothes (clothes that have built in SPF, or more technically, UPF) are much more convenient and more effective and protecting from UV damage.  And most surprisingly, I am MUCH COOLER in the sun when I wear a long sleeve sun shirt!  New technology has made sun protecting clothing the ultimate multi-taskers; protecting from UV rays, cooling down the skin, wicking away moisture, and ventilating at the same time.

I think it would have been tough if I was still a teenager, dealing with the peer pressure to sunbathe in an itty bitty bikini, to instead wear a full coverage sun shirt.  But I should give our society more credit.  More and more people are starting to realize that the sunbathing you do as a youngster to “look good,” or “have a base tan,” is passé.  Pale is beautiful, and the very sunbathing done for aesthetic purposes has very ugly consequences even as short as 15 years later (think sun spots, wrinkles, blotchy skin).

Here are some benefits of UV clothing:

  1. You feel COOLER in the sun!  Amazing, but true.
  2. You don’t need to reapply sunscreen!  Who wants to reapply every two hours?
  3. You won’t miss any spots and have awkward geometric burns on your back.
  4. Prevention of skin cancer and skin aging.

So, here are my reviews and recommendations of some of the best sun protecting clothes that are cute and fashionable.

Coolibar – the company performs vigorous testing on all lots of clothing to ensure excellent UV protection. These were my first sun shirts.

Columbia – OmniShade and Omni-Freeze Zero – One of my personal favorites.  The Omni-Freeze Zero technology cools down a person when exposed to sweat.  We find it most commonly in their Performance Fishing Gear.  Great for the beach or any hot day.  My family knows that if it’s hot out, my hubby will only be wearing this shirt.  It’s now a joke that he doesn’t own any other clothes.

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Good dermatology family!  We are covered up and cool (both temperature-wise and figuratively). My hubby is sporting his favorite Columbia shirt.

UV Skinz – nice selection of outerwear for the family (nice kids selection), plus sun “sleeves” which are great for driving, gardening, golfing, etc.  I just bought some of the sleeves for myself and my husband!  Plus I LOVE their May Skin Cancer Awareness campaign – any purchase comes with a free baby sun shirt!

banner-saveababysskin
UV Skinz Save a Baby’s Skin Campaign – free baby sun shirt with any purchase during Skin Cancer Awareness Month (May).

Lands’ End – I was surprised myself, but after seeing a tweet by Deborah Messing, I checked them out.  They have surprisingly cute swim wear!

SwimZip – As seen on Shark Tank.  This company makes it easy to find cute swimwear with zippers – we all know how hard it is to take off a wet bathing suit from a squirmy toddler!  SwimZip makes it super easy.

Mott50 Sun Protective Fashion – Co-founder Anne Reilly wanted to capitalize on the more noticeable trend of young ladies covering up.  Nice variety of casual and swim wear for women and kids.

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Dr. Dosal modeling a Bloxsun scarf at the Miami Open 2015

BloxSun – a local Miami company, offering beautiful UPF scarfs to cover you up in any occasion.  Check me out modeling my scarf at the Miami Open, where the sun can be unbearable.  This beauty kept me cool!  I also use their sun gloves while driving and gel manicure to keep my hands looking young.

Screen Shot 2016-02-08 at 1.14.25 PM

SunSoaked – Australian beach outwear line.  Designed to offer more fashionable, feminine, elegant sunwear.

Cover – Founded by the sister of a melanoma survivor and former investment banker, founder Lisa Moore offers luxury sun protective clothing that is runway worthy.

SanSoleil – makes golf, tennis, and other sports apparel out of Newport Beach, CA.

BloqUV – Excellent beach and sporting apparel. Great selections for golf, tennis, running, yoga, swim.

Any clothing with “Coldblack” – coldblack is a special dye added to clothing to reflect light and infrared heat.  Used to keep men cool in dark suits, it also provides a UPF factor of 30 to its clothing.  It can notably be found in Ermenegildo Zegna suits and in Under Armour golfing wear.

These retailers have earned the Skin Cancer Foundation’s Seal of Recommendation for sun protective clothing and hats.

  • Boys Scouts of America
  • Columbia Sportswear
  • Coolibar
  • J. Crew
  • Lands’ End
  • O’Neill Wetsuits
  • Quiksilver
  • Roxy
  • Specialized Bicycles
  • Sundrive
  • Wollaroo Hats Company (I like their hats a lot)
  • Whitworth Hats

I encourage you to pack (and wear) a sun shirt the next time you are going to be somewhere sunny.  I think you will be pleasantly surprised how much you like it!

References

The Skin Cancer Foundation Journal, Vol XXXII, 2014.  skincancer.org

Dr. Dosal is a practicing dermatologist at the Skin Associates of South Florida in Miami, FL.  She is also on voluntary faculty at the University of Miami.

I LOVE my Gel Manicures! But should I worry?

I LOVE my gel manicures!  Lasting at least two weeks, gel manicures have finally made my pincers look pretty!  Like many of you, I had been wondering about the safety about the UV lamps that are used to cure the gel manicures.  They seem fairly benign, but there has been some press questioning its safety. nail polish

When I read a recent issue of JAMA Dermatology, I was relieved to read that the authors concluded that the risk of skin cancer was very very low with gel/UV manicures, even with regular use.  This is what I suspected, so I stopped worrying.  Additionally, my salon recently introduced an LED nail lamp, which also seemingly solved the issue of the UV lamp.

Well, imagine my surprise when this topic came up again at the most recent American Academy of Dermatology Annual Meeting.  Nail expert Dr. Chris Adigun reopened my concerns about the safety of UV lights. She argued that the lamps are notoriously variable in their UV exposure, nail salons hardly ever follow manufacturer recommendations, and that the UV exposure is more than we previously thought.

This really left me conflicted, since I adore my gel manicures, and I really hadn’t prepared myself to abandon them anytime soon. So I took it upon myself to read through all the relevant articles on the subject (I hate taking someone else’s word for it).  Luckily, several groups have studied a variety of nail lamps, with a variety of hand positioning and exposure times.

Here’s the summary:

The amount of UV exposure is WAY below anything close to skin-cancer-causing levels.  

Here are a few other important take-away points:

  • Out of 72,709 women getting regular manicures for 60 years (assuming generous exposure times), only one woman would develop skin cancer who wouldn’t otherwise (in statistics, this is called the “number needed to harm”).
  • It would take 250 years of weekly gel manicures to equal that of a therapeutic phototherapy session that I commonly prescribe for psoriasis (15–30 treatments over 5–10 weeks).  (Yes, phototherapy is often UVB, rather than UVA, but this JID study measured UV dose in J/cm2, and gives a risk comparison to something we already know to be safe).

From a skin cancer perspective, the risk of skin cancer from nail curing lamps is very low.  However, it is important to note that ALL lamps used to cure gel manicures emit UVA radiation, even the LED lamps.  Despite the lack of “UV” in the name, LED lamps are actually more intense than UV lamps and emit more UVA.

As a quick review: UVB rays cause sunburn and skin cancer, while UVA rays penetrate deeper into the skin, causing skin aging, cell damage, sun spots, and wrinkles by breaking down collagen and elastin (and to a lesser degree than UVB, also contribute to skin cancer).

UVA UVB infographic
UVA penetrates deep into the skin to affect collagen and elastin, causing wrinkling, blotchiness, and poor skin tone.
UVA radiation is responsible for the brown spots (“liver” spots or “sun” spots) on your grandmother’s hands, as well as the wrinkles and crepiness of the skin.

There’s nothing worse than a youthful face that has been preserved with good skin care, but “old” looking hands.  

While the risk of skin cancer is much less than ambient exposure to natural sunlight, the cumulative effects of UVA exposure can result in discoloration and premature aging of the skin.

 

Aging hands
The typical appearance of a photoaged hand.  Note the blotchy appearance of the skin, brown spots, and thinned skin overlying the veins and tendons of the hand.  This occurs with regular exposure to UV light, especially UVA, which is emitted in all nail curing lamps and penetrates windows.
So your gel manicure won’t significantly increase your risk for skin cancer, but why risk any UV exposure?

For the very sake of preserving the youthful appearance of your hands, I recommend at least the application of a broad-spectrum sunscreen with an SPF of 30+ (see here for recommendations), or sun gloves while having your hands in the lamp.  My feeling is the gloves are better.

  • I use these sun gloves made by BloxSun– I wear them driving and bring them to the salon. 
  • Screen Shot 2016-02-08 at 1.14.25 PM
  • YouVee sunshields are currently crowdfunding – they are very cheap disposable hand protectors that block 99% of all UV radiation.  Wouldn’t it be great if salons started carrying these?
    2e0973_49bb9c8432144cb7809de96894bdcdf2

 

In summary, I’m going to keep getting my gel manicures (thank goodness)!

For many of us women on-the-go, the gel manicure is here to stay!  Just be sure to protect those hands! And as with anything, it’s good to take a break once in a while from manicures to give your nails a breather.

Dr. Jackie Dosal is a practicing dermatologist in Miami, FL at the University of Miami and Skin Associates of South Florida.  

 

References

Shipp et al.  Further investigation into the risk of skin cancer associated with the use of UV nail lamps.  JAMA Dermatology 2014;150(7):775-6.
Diffey BL.  The risk of squamous cell carcinoma in women from exposure to UVA lamps used in cosmetic nail treatment.  British Journal of Dermatology 2012;167:1175-1178.
Markova A, Weinstock MA.  Risk of skin cancer associated with the use of UV nail lamp.  Journal of Investigational Dermatology 2013;133:1097-1099.
Macfarlane DF, Alonso CA.  Occurrence of non melanoma skin cancers on the hands after UV nail light exposure.  JAMA Dermatology 2009;145(4):4479.
Curtis J, Tanner P, Judd C, Childs B, Hull C, Leachman S.  Acrylic nail curing UV lamps: High-intensity exposure warrants further research of skin cancer risk.  J Am Acad Dermatol 2013;69(6):1069-70.
Dowdy JC, Sayre RM.  Nail curing UV lamps: Trivial exposure not cause for public alarm.  J Am Acad Dermatol 2015;6(64):e185-6.

This is what I do… I daydream about the skin.

Recently I spent 3 days at a University of Miami Dermatology 60th Anniversary Conference learning from leaders in the field (most of which were UM alumni), my peers, and even our super smart current residents.  I’m a sucker for these meetings – I love to soak it all in.  I always learn so much from these meetings, and it’s learning that challenges me to constantly improve with the ever-changing science of medicine.  

Learning, I realize, is one of the favorite parts of my career.  I’m fortunate to be one of those people who absolutely loves what I chose for my profession. I’m also privileged to work part-time at the University of Miami, where I see challenging cases, as well as teach residents. I’m often referred cases that have seen 3+ dermatologists before seeing me, all without success.  It’s a great learning opportunity for our residents, whom I love having in my clinic. We feed off each other, challenge each other, and learn together from difficult cases.  I’m honored to be part of their education in one of the highest ranked dermatology programs in the country.

journals stack
Stacks and stacks of dermatology journals.

I have a little time off before my official start at Skin Associates of South Florida (SASF) on March 9, so those days that I’m not at the University of Miami, I’m spending quality time with my daughter. When she is asleep, I’m able read all of those dermatology journals that were stacking up in my office – the sight of which drives my neat-freak husband mad.  This “in-between-jobs” time (a phrase which is not quite accurate, I’m still at UM quite a bit) has been a refreshing chance to catch up, learn more, and have some time for self-betterment that was not possible in the hustle and bustle of a full time practice.

Having this extra time and space has also allowed my brain to get excited and wander (and wonder) into the depths of dermatology issues.  This is what I do… daydream about skin issues.  The skin is a wild puzzle piece of the body which tells a story of the body that no other organ can.  It’s complex, challenging, and it excites the heck out of me.  I’ve already come up with a few new research projects for 2016 that have me beyond excited this year!   Fortunately, both University of Miami and SASF are leaders in dermatologic research, so I’m in good company.

In medicine, there are always questions that need answers, there are always new targets for therapy, and the learning never ends… which is part of the fun! I suggest that everyone strive to make a clearing for some time to dedicate to what you love to learn about.  Whether it’s reading a book, journal article, blog (like mine!), a TED talk, an Audible book, or even just time outside. Create a space for daydreaming.

Dr. Jackie Dosal

Another Reason to Keep Your Resolutions…

Sticking to those New Years resolutions?  Need a little motivation?  Maybe I can help.  Many of the good things we do for our body and mind can have a positive effect on our skin.  What a nice bonus!  Don’t we all want glowing skin?

Let’s review below:

Move daily – Get that blood flowing and move daily!  Whether it’s a walk, a fitness class, yoga, or pilates, just move your body. Research shows that individuals over 65 who performed at least 3 hours of moderate to vigorous exercise a week were able to reverse the signs of aging. Compared to non-exercising seniors, skin biopsies from the buttocks of the exercising individuals showed features that looked more like a 30-year-old!  Exercise gets the blood flowing, brings nutrients to your cells, lowers stress, strengthens the immune system, and much more.

My husband and I recently got the FitBit fitness tracker, and it has been a great motivation to go for a walk rather than sit in front of the TV.  We challenge each other to who can walk the most steps in a day.  Depending on the day, the recommended 10,000 steps can be very easy or almost impossible to accomplish without some effort.  We have to consciously prioritize a walk or activity over TV or work.  Considering the modern lifestyle that leaves us sitting in front of the TV or computer for hours, the challenge to be more active is a welcome initiative.  The line “Sitting is the new smoking” has resonated with many folks, myself included.  Now that you know it’s also good for your skin, get moving!  

Avoid added sugar – I think most of us can agree that there is an over-abundance of sugar in the American diet.  Sugar is added to just about everything we encounter in the grocery store (which is why the advice of shopping the perimeter of the grocery store is so true).  And why wouldn’t manufacturers add sugar?  It makes everything taste better!  Sugar actually coats innumerous targets in the body, making them function subpar.  Most important to the skin, sugar also coats collagen (a process called glycation) and makes it stiffer, making our skin look sallow, aged, and stiff.  So think twice before that second helping of dessert… it may taste sweet but may be making your skin look sour!

glycation-of-collagen
Glycation of collagen makes it bulky and stiff.

 

Get more sleep.  This should be on everyone’s resolution list!  Sleep is the time when the body can repair itself.  Sleep deprivation means more stress and increased cortisol levels.  Increased cortisol levels can wreak havoc on the skin and cause acne breakouts, skin rashes, and worsening eczema or psoriasis.  Make sleep a priority.  Turn off the TV earlier than usual, make yourself a cup of tea, settle down with a good book (preferably paper and not on a screen like an ipad, as the light prevents the brain from knowing sleep is near), and try to start this routine 30-60 minutes earlier than usual.  You will be surprised how refreshing it can be.

This last resolution that may not have been on your list… but it’s an easy resolution to keep — and you can start it at any time, it doesn’t need to be New Years!  WEAR SUNSCREEN EVERY DAY, 365 DAYS A YEAR! Put one of my favorite sunscreens next to your toothbrush, and put it on every morning, rain or shine.  Do I need to show you the twins?  One wore sunscreen and the other didn’t.  

twins
Differences in lifestyle show how UV exposure ages one twin decades in comparison to the other twin.

While the photo may look exaggerated, all of us will eventually experience some of the tarnishing effects of the sun such as brown spots, dry skin, and/or wrinkles.  I got my first brown spots after only 5 years of living in the Miami sun!  

Damaging UV rays penetrate car and building windows, so it doesn’t matter if you “never go to the beach.”  

Unless you live in a windowless basement and never leave the house, you are always encountering damaging UV rays.   Love your skin and apply a sunscreen daily… you will thank me later!

And…. you have my permission to cheat once in a while…. but only with a glass of red wine and a piece of dark chocolate… both are great for the skin! Resveratrol and antioxidants, baby!

Cheers to 2016!

Dr. Jackie Dosal is a practicing board-certified dermatologist at South Florida Skin Associates and is on clinical faculty at the University of Miami Department of Dermatology.  

New Year, New Location

Happy 2016!  2015 was a spectacular year for me both professionally and personally.

Most importantly, 2015 was marked by my first year with my daughter Caroline, who turned one in November.  It’s been such a joy to see her grow and learn – more than I ever expected!  It’s been so fulfilling to be a “mommy” in addition to being a dermatologist – it gives me more depth to my overall perspective.  It has also helped ground my approach to both patient care and family life.

IMG_5417
Brian, Jackie, & Caroline Dosal at Moving Day Miami, a walk for the National Parkinson’s Foundation.

Looking ahead, 2016 marks a new and exciting chapter for me professionally!  I am thrilled to announce I will be joining the prestigious Skin Associates of South Florida, alongside the brilliant Dr. Joely Kaufman, Dr. Jeremy Green, Dr. Christopher O’Connell and Dr. Cynthia Golomb.

logo-skinassociates-top

Skin Associates of South Florida is one of the leading dermatology centers in the country, and pioneers many of the state-of-the-art dermatology and cosmetic services for non-invasive rejuvenation. I’m very excited to be joining this talented group of physicians.  My first appointments will be available in March 2016 – mark your calendar!

“A good beginning makes a good end” – English Proverb

Cheers to 2016!!

 

Dr. Jacquelyn Dosal practices general, cosmetic, surgical, and laser dermatology in Miami, FL.