I am often asked this question and my answer is “what do you want to accomplish, how much improvement do you want, and how much time and money do you want to devote to it?” You can start at either end—want do you want or what are you willing to do to get it, but you have to start somewhere. Cosmetic skin resurfacing procedures that are more aggressive give more results. They cost more, usually because of the technology involved.

If you expect a lot of improvement, but don’t have the time or money to get there, you are going to be disappointed. Sometimes this is a hard pill for patients to swallow. They want the kind of results that the procedures that they can afford won’t give them. I try to be honest and explain the real world results that they can expect, and then the choice is to do the less expensive, less aggressive treatments and get some improvement, do financing and pay it off over time, or save up until you can afford what you need. On the other hand, if you don’t need or want more aggressive results, then the less aggressive procedures are right for you. That’s why the prevention strategies we discussed previously are so important. But if the horse is already out of the barn, you have to do what it takes to get him back in.

Remember if you are not my patient don’t pay attention to what I tell you. Pay attention to what your doctor tells you.

If you have these changes, then these are your options:

Dull skin:

• Home treatment: exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: light chemical peels, microdermabrasion (SilkPeel), LED (GentleWaves)
• More aggressive office treatment: not needed

Flat brown spots:

• Home treatment: some improvement if mild*—exfoliants, glycolic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), skin bleach
• Less aggressive office treatment: light chemical peels, microdermabrasion, LED (GentleWaves)
• More aggressive office treatment: Intense Pulsed Light (IPL)

Raised brown spots:

• Home treatment: won’t work
• Less aggressive office treatment: lesions destruction with liquid nitrogen or electocautery
• More aggressive office treatment: lesion destruction + laser resurfacing

Fine lines

• Home treatment: glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: LED (GentleWaves), Botox, light chemical peels, microdermabrasion (SilkPeel)
• More aggressive office treatment: laser resurfacing

Skin colored bumps (milia cysts, moles, syringomas, fibromas, etc)

• Home treatment: milia only—exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin
• Less aggressive office treatment: milia only—light chemical peels. All others—lesion destruction with shaving, electrocautery
• More aggressive office treatment: laser resurfacing

Broken blood vessels

• Home treatment: won’t work
• Less aggressive office treatment: electrocautery to isolated veins
• More aggressive office treatment: Intense Pulsed Light (IPL)

Non-etched wrinkles (go away when you stretch the skin)

• Home treatment: some improvement if mild*—glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing,dermal fillers and/or Botox + laser resurfacing

Etched wrinkles (don’t go away when you stretch the skin)

• Home treatment: some improvement if mild*—tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: dermal fillers (Juvederm, Restylane etc), Botox
• More aggressive office treatment: laser resurfacing, dermal fillers and/or Botox + laser resurfacing

Rough spots (pre-cancerous actinic keratosis)

• Home treatment: some improvement if mild*—tretinoin, more improvement with—prescription topical fluorouracil, imiquimod, diclofenac
• Less aggressive office treatment: liquid nitrogen
• More aggressive office treatment: photodynamic therapy (IPL/PDT)

Enlarged pores

• Home treatment: if plugged only—exfoliants, glycolic, salicylic or multi-fruit acids, tretinoin (Retin-A, Renova, Refissa), tazarotene (Tazorac), and adapalene (Differin)
• Less aggressive office treatment: if plugged only—light chemical peels, microdermabrasion.
• More aggressive office treatment: if permanently enlarged—laser resurfacing

Scars

• Home treatment: some improvement in acne scars if mild*—tazarotene (Tazorac)
• Less aggressive office treatment: some improvement in acne scars if mild*—light chemical peels, microdermabrasion, dermal fillers (Juvederm, Restylane etc)
• More aggressive office treatment: laser resurfacing, surgical removal

Loss of elasticity

• Home treatment: some improvement if mild*—glycolic, multi-fruit acids, peptides, growth factors, tretinoin (Retin-A, Renova, Refissa)
• Less aggressive office treatment: some improvement if mild*—light chemical peels, microdermabrasion.
• More aggressive office treatment: laser resurfacing

Elastosis (yellowish, stiff, bumpy, permanently creased or cross-hatched change from long term sun damage)

• Home treatment: won’t work
• Less aggressive office treatment: won’t work
• More aggressive office treatment: laser resurfacing

Note: “some improvement if mild*”—your definition and my definition of mild may not be the same.

Next: What’s it gonna take?