man ipl before 2

man ipl after 2

Men are great candidates for rejuvenation with IPL (intense pulsed light or photo facial).   A lifetime of sun exposure has the same effect on their  skin as it does on us ladies.  Using the broad band of wavelengths available with an IPL we can target numerous skin conditions.

The above individual had 1 IPL to treat the hyperpigmentation and capillaries and saw dramatic improvement. He is a candidate to further clear the  remaining pigment and visible blood vessels.  He had minimal cosmetic downtime with this treatment and was able to conduct his professional and personal obligations without missing a beat.  The normal pigmentation darkening occurred and was gone in a week.

With IPL we are able customize a treatment based on the clients concerns and our assessment.  IPL is typically used to treat hyperpigmentation and redness.   Different filters are selected during the treatment to target a variety of skin discolorations.  Often a number of passes are completed in order to treat all the targets.

Hyperpigmentation (the brown pigment, most often from uva/uvb exposure) typically ‘peppers’, or darkens.   This peppering usually flakes off  by days 5-7.  There is minimal discomfort.  Patients are encouraged not to pick or remove the peppered areas, as this can lead to scarring.  The pigmentation, in some cases, is gone after the peppering resolves.  In other cases the pigmentation is lighter than before, but may need additional treatments.

Redness, either diffuse or individual capillaries, is treated effectively with IPL as well.  In some cases, if the capillaries are larger and dilated, there can be bruising following a treatment.  This is not common, but can occur.  Nasal veins are frequently stubborn and need to be treated more than once, as larger vessels lower in the skin keep those vessels dilated and “fed”.

Encouraging skin care that can compliment these treatments, and help protect the results, is important.  At the very least a topical antioxidant (such as vitamin c) and a sunscreen with zinc should be used on a daily basis.  There are other products that can be introduced depending on the individual and their primary concerns.   A retinol/retinoid can be helpful.  There are situations where there is remaining pigmentation that the IPL is not effectively treating.  A topical combination of a retinoid/hydriquinone/kojic acid/fluocinolone (a steroid)  can be compounded to resolve remaining skin discoloration.  This combination is frequently referred to as Kligman’s Formula.

This is a great time of year to have an IPL, or series of IPL’s, as sun exposure is not as prevalent in the winter months.  Sun avoidance is an important pre and  post care instruction to follow.

man ipl before

man ipl after

I look forward to helping this client further resolve his discoloration.

Fellas, don’t hesitate to seek professional aesthetic treatments if you are noticing changes you are unhappy with.

And, we do everything we can to make it as comfortable as possible!





We are now offering the Avya Skincare line at TOC Medical Spa.  This line is close to us as one of the creators of the line, Dr. Tanuj Nakra, is one of our physicians.

Avya, “first rays of sun”, in Sanskrit, is a skin care line combining beneficial botanical extracts with medical grade active ingredients.  The line is specifically formulated to help manage pigment and melanin production.  It is appropriate and can be efficacious for all skin tones/types.

Avya contains antioxidants and anti-inflammatories from Peony, Turmeric and Neem.  The Curcumin in the Turmeric is colorless and odorless. (rather than the dark yellow we associate with this extract)

The Avya Skincare line has 5 products: a cleanser, day moisture, night moisture, eye cream, and serum.  The line utilizes Qusome™ technology, which allows the active ingredients to slowly release over time once it has been applied to the skin.

Gentle Cleanser (non foaming)

  • cleanses without stripping skin of natural oils
  • contains Peony essential oil which has a lovely fragrance
  • contains salicylic acid to minimize skin congestion

Day Moisture SPF 20

  • contains chemical free sun protection (zinc) for broad spectrum protection
  • snow mushroom extract for hydration
  • niacinamide (B3) to help brighten and clarify skin
  • Peptides for collagen stimulation and support
  • anti inflammatories from botanical extracts
  • Peony, Turmeric, Neem

Night Moisture (with Vit A)

  • Retinyl Palmitate (Vit A), increasing cellular turnover and collagen support
  • decreases inflammation utilizing botanical extracts
  • Vitamin C
  • Vitamin E
  • Peony, Turmeric, Neem
  • Niacinamide
  • Beta Carotene

Anti-Aging Power Serum (with Vitamin C)

  • Antioxidants
  • anti-inflammatory properties from botanical extracts
  • Antibacterial and antimicrobial effects from Neem
  • Turmeric/Curcumin which  is a potent anti inflammatory and stimulates bodies own antioxidant enzymes
  • Vitamin C in Qusome technology, protecting the fragile antioxidant molecule until application
  • Retinyl
  • Peony, Turmeric, Neem
  • Peptides

Eye Bright Cream- with caffeine

  • minimizes under eye puffiness
  • minimizes under eye dark circles
  • Cassava matrix technology which works like “shrink wrap” for the under eye
  • Retinyl
  • Peony, Turmeric, Neem
  • hydration
  • recognized by Allure® Magazine as a favorite new product May 2018!

This line is efficacious while being cosmetically elegant.  The products have a pleasant smell and lovely texure.  This line does not test on animals, is Dermatologist and Ophthalmologist tested, and does not contain a lot of the ingredients consumers tend to want to avoid.  (for example, parabens)


My HALO Journey

As I mentioned in my last post, we now are offering Halo™ by Sciton at TOC Medical Spa.  I had my treatment March 19th and took a series of photos and took notes about my experience to better inform our patients.

immediate before halo

Before Halo/March 19th

immediate post halo

Immediately after Halo™

The days after treatment:


Day One

March 20th

Day Two     March 21st

Day Three      March 22nd

Day Four      March 23rd

By day five and six most of the brown had detached and sloughed off.  Unfortunately my photos from these days were lost:-(

Day Eight

March 28th

(still a small amount of malar swelling)

I wore topical numbing for approximately 45 minutes before the treatment.  The treatment itself felt like prickly heat.  The heat accumulates and becomes more uncomfortable with repeat passes with the laser.   A cool chiller is utilized along with the laser and helps to alleviate some of the sting.   The face is treated in 5 zones: each cheek, each side of the forehead and then the nose.  The perioral area is treated with the cheek zones.  I thought the most uncomfortable areas were the forehead and upper lip.  I think we all experience the sensation a bit differently so 4 people could have slightly different descriptions.  Post treatment, my face felt very hot for 45 minutes.  This seems to be consistent with everyone we have treated.  I drove home with the AC blasting on my face for most of that time.

At TOC we are recommending very gentle products post treatment for up to 5 days.  We are providing our patients Cetaphil Gentle Cleanser, Cetaphil Moisturizing Lotion and Aquaphor.

As you can see in the photos there is redness and swelling after the treatment for up to 5 days.  By day 2 a bronzing appearance and rough (sandpaper like) texture evolve.   This is the microscopic necrotic skin cells coming to the surface.    These slough off, in most cases, by day 5.  It is not unusual to have a few acne blemishes post Halo™, which I did.

I had swelling in the periocular and malar (cheek) area for a solid 7-8 days.  This is not typical, however.  Most patients have resolution of swelling by day 5.

Halo™ by Sciton helps with pigmentation, texture and the appearance of pores.  Improvement will continue to be seen over the coming months as the collagen stimulation triggered by the treatment can take months to be fully realized.

This is me today, 2 1/2 weeks post treatment.

April 5th

The treatment definitely lifted hyperpigmentation and brightened my complexion.  The results are impressive for one treatment with minimal downtime.  (mind you, I felt unsightly for a few days due to the swelling!)

Sun avoidance is very important after a Halo™, so sunscreen and big hats should be at the ready.   Most patients can return to their normal skincare routine at day 5-7, which will always include a sunscreen 🙂  We treat everyone prophylactically with antiviral medication (Valtrex) as the treatment can trigger a outbreak of cold sores.

Hope this helps and that my series of mug shots aren’t too much!

Have a great weekend!





We make a considerable effort to protect and care for the skin on our faces but can neglect the skin on our neck, décolleté and hands.  As we officially enter in to these summer months, I wanted to remind everyone to also pay attention to other commonly exposed areas.

Sun screen and antioxidants are the best defense.  Avoiding the high sun hours between 10-2 or even 10-4 is helpful. (although tough to accomplish if you love the outdoors!)

But what if there already is damage?  What can be done?

Pretty much anything that can be done to the face can also be done off face.


chest # 1

IPL (Intense Pulsed Light) is very effective at removing sun spots (hyperpigmentation).  The hands and chest are commonly treated with this modality.  The pigment will return if the area is not protected from the sun though, so invest in a sunscreen with zinc!  Additionally, consider protective clothing if your will be out during hours of the day when the sun is intense.

For those fellas out there (or even women with very thin hair) make sure to protect your scalp as well.  Since I am adding to the list, let me also include ears!  This is not only about hyperpigmentation, skin cancer commonly occurs in all of these areas!

Enjoy these warm summer days!  Safely!




Niacinamide is an ingredient receiving some well earned attention lately in skin care.  Studies have been conclusive that niacinamide has numerous skin benefits.  If your skin care does not include a product with niacinamide, you might consider adding one.

Niacinamide, vitamin B3, can be applied topically (ideally at least a 5% concentration) to skin once or twice a day for the following benefits:

  • Decrease moisture loss by increasing barrier function
  • Improve cellular communication
  • Fade hyperpigmentation
  • Increase Collagen
  • Increase skins elasticity
  • Decrease acne
  • Decrease inflammation
  • Fade the skin discoloration acne blemishes can leave behind
  • Decrease redness associated with Rosacea
  • Decrease oxidative damage (similar to an anti-oxidant)
  • Increase cellular turnover

A house favorite here at TOC Medical Spa is Skinceuticals® Metacell Renewal B3.  This daily corrective moisturizer has 5% niacinamide, 2.5% tri-peptide concentrate and 15% glycerin.  I can safely say that every staff member here is using this at least once a day if not twice a day.  Most of us are on our 3rd and 4th bottles.  It is emollient without being heavy feeling at all and works well under makeup during the day.

You will likely see niacinamide popping up more and more in skin care products, and hopefully this review will help you understand why 🙂


vi peel

Entering the fall months is a good time to undo some of the damage done over the summer months.  No matter how much sun screen we wear (although it is immensely helpful) if we have active lifestyles that take us outdoors a lot we end up with some sun damage.

We tend to have less and less sun exposure in the fall and winter months so it is a good time to target pigmentation with combination treatments.   Myself and several of my coworkers all agree upon a series of 2-3 IPL’s (or photofacials) combined with skin peels.  I personally like to do an IPL followed by a peel within 1-2 weeks once a month for 3 months.  This is very effective at lifting the pigmentation that developed over the summer.  There is some “downtime” with these treatments, although it is minimal.

The IPL creates what we commonly refer to as “peppering” which literally looks like pepper flakes on the skin.  These tend to develop over the first 12-24 hours and then flake off in 7-14 days.   These “pepper flakes” are pigmentation that has been brought to the surface leaving behind either faded pigmentation or complete clearance of the pigmented lesion.

A peel is a controlled surface burn of the skin using a combination of acids.  The peel helps lift pigmentation, shrink the appearance of pores, minimize fine-medium lines, firm and improve overall texture.  When a peel is done about a week after an IPL it helps to lift any of the peppering that is hanging on to the skin.  There are lots of peels on the market, from very light peels to deep peels.  We tend to use medium depth peels and find the results to be predictable and well tolerated.  The “real” peeling with these types of peels tends to occur on days 3-5 and then flaking can last 7-10 days.  The “real” peeling does create cosmetic and social downtime as the skin peels noticeably and one  looks like they are molting for 2-3 days.

We use SkinMedica Peels and VI Peels at Toccare.  I am a huge fan of the VI Peels.  They are well tolerated on most skin types and seem to go just a little deeper than the other medium depth peels I have used.  Additionally, VI peels can help minimize acne outbreaks and treat melasma.

So if you ended up getting a little too much sun and are unhappy with how it has left your skin color and texture consider the above treatment plan.  Here’s to beautiful healthy skin!


Hyperpigmentation is a condition affecting both men and women of all skin types.  I want to break it down for you and offer a few viable solutions.

Let’s start with how pigmentation is formed.  Our melanocytes deep in our skin are the source of melanin. Melanin is what shows up as pigment in our skin.  There is a whole cascade of events leading to the appearance of that melanin on the surface of the skin.  Essentially (and slightly simplified)  a trigger stimulates tyrosinase (an enzyme) within the melanosome and converts the amino acid tyrosine into melanin.  Then melanogenisis occurs where the melanin migrates to other cells and shows up towards the surface as a brown spot or hyperpigmentation.  There are different types of hyperpigmentation, including;

  • Solar Lentigines (age or liver spots)
  • Ephelides (good old fashion freckles)
  • Melasma (mask like, mostly affecting women and the most difficult to treat)
  • Chloasma (the mask of pregnancy, can also occur on abdomen, similar to Melasma)
  • PIH (post inflammatory hyperpigmentation)

The key to treating hyperpigmentation is a combination of prevention and correction.

There are multiple triggers for hyperpigmentation and pinning down the triggers is key.  The biggest culprit is UVA/UVB exposure. (sun exposure) But there are other culprits as well, including;

  • Medications (such as BCP, HRT, antibiotics and certain seizure medications)
  • Genetics
  • Skin injury leading to PIH (post inflammatory hyperpigmentation)
  • Thyroid dysfunction
  • Excessive picking at skin
  • Hormone imbalances

Identifying if any of the above are contributing to your hyperpigmentation is helpful.

So now let’s talk about how to treat it once it is there.  There are numerous approaches and  combination therapy works best.  Treatments and key ingredients can work synergistically together.

  • Topical antioxidants
  • Wearing a hat when prolonged exposure is unavoidable
  • IPL (or photofacial)
  • Peels
  • Laser resurfacing (for example Fraxel Dual)
  • Microdermabrasion
  • Topicals that are tyrosinase inhibitors or interrupt the formation of melanin

Let’s talk about that last one a bit.  There are numerous ingredients which inhibit tyrosinase (remember that enzyme converts the amino acid tyrosine into melanin)or interrupt somewhere else on the pathway leading to pigmentation.  There are both over the counter and prescription options.

  • Hydroquinone (this is a tyrosinase inhibitor) is available both OTC in a 2% solution or as a Rx, 4% or higher.  It is a proven ingredient that has been successfully used for years.
  • Tretinoins-  These Vit A derivatives help to turn over the skin cells and hyperpigmentation fades as the skin exfoliates. (Retinoids/Retinols)
  • Kojic Acid- also helps inhibit tyrosinase and helps other products penetrate deeper.
  • Niacinamide- Stops melanosomes from transferring melanin to surrounding cells. (melanogenisis)
  • Arbutin- An alternative to hydroquinone.  It is derived from bearberry plants.
  • Antioxidants- Vit C (ascorbic acid), Vit E (tocopherol), Green Tea, Resveratrol
  • Glycolic Acid- also helps with cellular turnover.
  • Licorice Root- A chemical called galbridin inhibits tyrosinase.
  • Kligman’s Solution- This is a very effective prescription combining hydroquinone, Tretinoin and a steroid.  Your provider can determine what % of each active ingredient would be appropriate for you.
HP Products
A few product options to target your hyperpigmentation – available at Toccare Medical Spa.

A popular line carried in doctor offices for pigmentation is the Obagi line.  In most states the line includes several products with 4% Hydroquinone and a Tretinoin cream.  This is a very effective and popular line for fading pigment and renewing the skin.  Here in Texas, however, we are unable to sell prescription strength Hydroquinone or Tretinoin OTC so we carry the Fx version of the Obagi line which utilizes a high percentage of arbutin in place of Hydroquinone.

OTC products include Neocutis Perle and Nouvelle which have their Melaplex non-hydroquinone skin brighteners  Melaplex is a proprietary blend of four ingredients which help fade pigmentation (Phenylethy Resorcinol, Leucine, Undecylenoyl Phenylalanine and Sodium Glycerophosphate).  The Skinceuticals line has Phyto + which utilizes arbutin and kojic acid to help with pigmentation.  Additionally, they have the Metacell Renewal B3 with a high percentage of niacinamide (one of my current faves!)  which also assists with the fading of pigment.  These are just a few of the OTC products available for pigment. Always look for the key ingredients to help choose products to fade pigment.

When a patient comes in wanting to address their hyperpigmentation we often prescribe a combination of therapies. A common combination is a series of IPL’s, peels or microdermabrasions with topical therapy to maintain the results.  It really depends on the individual and how much downtime they can afford and how much they want to invest in their treatment.

I hope this helps give you an idea of how hyperpigmentation can be addressed.

Please feel free to ask any questions:-)