Introduction

Despite your age, colour, and skin type, pigmentation may affect you at some point in your life. Everyone’s skin possesses a brown pigment – melanin, and it’s deposited by pigment-producing cells called melanocytes. Melanin is a natural protective mechanism of the skin and is largely dependent on ultraviolet (UV) or sun exposure.

When the production and deposition of melanin by these cells become abnormal, it causes an excess of skin pigmentation, hence the appearance of brown or darker spots that can be seen on the skin surface.

Undoubtedly, there are numerous skin pigmentation treatments out there in the market today, both invasive and non-invasive. However, most of these treatments are deemed to fail. Why is that the case?

Reason 1: Incorrect Diagnosis of the Pigmentation

The cause for excessive skin pigmentation or hyperpigmentation is generally due to exposure to UV rays from the sun. This form of radiation stimulates a rise in melanin production and can be focused on an area of the skin.

Sun Spots or Solar Lentigines in medical terms are brown spots of varying sizes that tend to occur on the sun-exposed parts of our skin. They usually first appear on the cheeks, sides of our face. The skin of our hands can be involved as well.

Melasma is another form of hyperpigmentation and is a result of a combination of factors including genetics, UV radiation, and hormonal aspects. Women tend to be more susceptible to this condition than men due to the overstimulation of melanocytes by the female hormone – estrogen. Pregnant women are generally more affected as well, especially when they are more exposed to sunlight on a daily basis.

Hori’s Nevus is an acquired pigmentation condition that tends to affect both sides of the face symmetrically. There are other types of acquired pigmentary conditions common in this part of the world. Interestingly, this pigmentation is NOT due to sun exposure. Nevertheless, the appearance of Hori’s Nevus can be quite distressing for the individual patient. It is often confused with melasma.

Freckles are also caused by UV radiation and can lighten or darken depending on the amount of sunlight one is exposed to. Its age of onset is much earlier, and patients usually start noticing the freckles in their teenage years.

Moles are not exactly a kind of pigmentation, but a form of pigmentated growth and are defined by an abnormal cluster of pigment-producing cells in the skin. Moles need to be monitored closely as they may evolve in colour and size over time.

The above are some of the common pigmentation conditions that are encountered in the clinical practice. Each of the condition requires different treatment approaches. I have seen patients with acquired pigmentation conditions like Hori’s Nevus and other types of acquired pigmentation conditions being diagnosed and treated as melasma!

Caveat: The most important step to a successful pigmentation treatment lies in the CORRECT DIAGNOSIS. Get this step wrong, and the appearance of the pigmentation may not ever improve.

Reason 2: Insufficient Knowledge of Other Treatment Options Besides Laser.

Yes, we have all heard about lasers. But do you know about the other treatment options that are available that can treat pigmentation as well? There are many that have been shown to work, and I will just list down some of them:

1. Hydroquinone. Hydroquinone is a compound that inhibits tyrosinase, the enzyme responsible for melanin synthesis. It is used as a topically applied cream to treat areas of uneven skin tone and pigmentation such as melasma, freckles, solar lentigines, and even post-inflammatory hyperpigmentation. Multiple studies have shown that the best results occur when using hydroquinone as a combination therapy together with retinoid and corticosteroid [1]. In Singapore, these combination creams require a doctor’s prescription. Usage of hydroquinone has to be under a doctor’s orders and the patient has to be followed up closely by a doctor during the course of hydroquinone usage. Adverse effects may include irritation, redness, stinging and even ochronosis, a grey-blue discolouration of the skin.
2. Cysteamine. This product is a natural molecule with a well-known anti-melanoma, anti-mutagenic, and anti-carcinogenic effects. Its application in pigmentation is quite new, only in the last few years, but has shown considerable promise. In some recent studies, cysteamine has been shown to be effective in decreasing melanin content of lesions, successfully treating patients with epidermal melasma and uneven skin tone [2]. Cysteamine is available in Singapore as a 5% cream, under the brand name Cyspera.
3. Vitamin C. There is considerable evidence that shows that this Vitamin C has skin lightening effects and antioxidant properties. It has demonstrated efficacy in reducing melanin synthesis, as well as counteracting the effects of UV-induced skin damage. Vitamin C is an unstable compound, and important characteristic to note in formulations, and also the reason why most Vitamin C products do not work as well as they claim [3]. They get oxidised even before being absorbed by the skin. Vitamin C serums that include compounds like Vitamin E in their formulations are more stable and are more effective in treating hyperpigmentation.

Caveat: Laser is NOT the only option you have to treat pigmentation, and sometimes it may not even be the best option. Your medical team should always provide a list of comprehensive treatment options and discuss with you the best-suited one for you.

Reason 3: Insufficient Pre-Laser Care

Some aesthetic treatments like high-concentration chemical peels and lasers for pigmentation are only performed in clinics for a reason: they can be strong to the skin and needs to be done under controlled environments. This also means that the patient’s skin must be able to go through the treatment without any complications. Let me give you an example. In our clinic, one central principle in all our laser treatment protocol is: “First do no harm”. Before performing any laser treatment on a patient, he or she has to be cleared of the following:

• Prolonged direct sun exposure (> 2 hours) in the last one week prior to treatment
• Visible sunburns
• Contact dermatitis or eczema flare
• Concurrent skin infections
• Light dermographism (a form of light allergy condition that affects the skin)
• No prior laser treatment in the last 7 days

Caveat: A safe treatment is an important factor of a successful treatment for pigmentation

Reason 4: Insufficient Post-Laser Care

The emphasis on sun protection must be highlighted even after treatment on a daily basis and it is essential that patients are educated on all forms of post-treatment care to avoid a recurrence or relapse.

In addition to sun protection through the use of sunscreens, doctors may prescribe other home-use topicals medications, and moisturisers to be applied by the patient after the laser procedure. These are usually part of the comprehensive treatment plan that can ensure effective clearance of pigmentation and in the meantime, reduce the rate of pigment recurrence, especially for UV-induced pigmentation.

However, it is not uncommon to see patients not abiding by sun avoidance advice. This is more so if the patient has a very active outdoor lifestyle and engage in sports like golf, tennis, fishing, or frequent overseas travels. Moreover, they may not have the discipline to stick with the topical regimen for medication and products, which lowers the success rates of pigmentation clearance or a longer treatment course.

Caveat: Lifestyle modifications can be one of the hardest to achieve, but if done well, it can lead to significant improvement in pigmentation clearance rates.

Reason 5: Inadequate Knowledge of Laser Operation

There are many laser clinics and even more laser machines out in the market, each with their own treatment protocol to treat pigmentation. When there are so many choices out there, two factors that differentiate these choices are price and efficacy. And the efficacy of the treatment is determined by the expertise and experience of the doctor.

Lasers, being highly effective in reducing dark spots, also generate certain risks. They work using a focused beam of light, targeting a specific pigmented area in the skin. There are many grades of heat generated at a session and it depends on each individual condition how much to vary. Moreover, each laser machine will have its own operating protocol. An experienced doctor should have substantial competency in operating different laser machines so that he/she customises a laser treatment plan for the patient.

If performed poorly, lasers can cause problems involving, but not limited to, the following:

• Post-injury hyperpigmentation (PIH)
• Hypopigmentation (white spots)
• Laser burns
• Failure of treatment
• Others

In some cases, one should only opt for laser treatments when other modalities have been proven unsuccessful, when an addition of a laser modality can increase the speed of pigmentation clearance, or when the patient is suffering from multiple types of pigmentation concurrently.

Caveat: Like a double-edged sword, laser treatments can enhance a pigmentation treatment, or can give its own set of problems. Please do seek out an experienced doctor and have your laser treatment done in a MOH-certified clinic.

Conclusion

With the explosion of medical and laser technology in recent years, there is a multitude of skin pigmentation treatments at our disposal yet it is still our responsibility as service providers to ensure the safety and success of these treatments before proceeding. The Ogee Clinic ensures that product standards and clinical safety processes are in place for each and every patient who walks through the door so consistency in treatment quality is maintained.

References

Pigmentation is defined as the darkening of patches of skin as compared to normal surrounding areas. The darkening occurs when an excess of melanin, the pigment that produces normal skin colour, forms deposits in the skin. Hence, besides age spots (or Solar Lentigo in medical terms), freckles and melasma are also termed as skin pigmentation.

These conditions are harmless by nature, yet it can cause some aesthetic distress to many women, especially when its appearance is unwarranted or unexpected. Thankfully, the best treatments for pigmentation are more widely accessible today than before.

The Asian Factor

While pigmentation can affect any skin colour, Asians tend to be more susceptible to conditions that are caused by sun exposure such as age spots, due to climatic factors. When the skin is exposed to UV rays, hormones are triggered to stimulate increased melanin production in the melanocytes and skin inflammation can cause an overactive production. When there is an overflow of the melanin pigment, your body’s inability to spread them out effectively will lead to clumping and the appearance of dark spots. Ageing will slow down the process, even more, leading to age spots.

Let’s talk briefly about the types of pigmentation that are common among Asians.

Age Spots (Solar Lentigo)

If you know someone who tends to get sunburn a lot or loves to tan, chances are they will have a higher susceptibility to developing age spots. According to Medical News Today, age spots often appear on the face, shoulders, back, arms, and tops of feet – areas that are usually exposed to the sun. While this condition is common among women aged 40 years and above, it can also happen to anyone of any age, especially those with a lighter skin tone.

Melasma

Melasma is distinctive by dark, discolored patches on one’s skin. This condition is also called chloasma, or ‘mask of pregnancy’, which means 90 percent of people who develop melasma are women, as researched and reported by the American Academy of Dermatology. These brownish patches often develop on the cheeks, forehead, bridge of nose, and chin. While melasma can be caused by hormonal changes, sun exposure is also a culprit in affecting the pigment cells.

So with UV exposure and hormones at play, can pigmentation be treated?

Good news is you can! There are some effective treatment methods out there, both that can be done by the individual herself at home, or treatments performed in a skin clinic. All of which are generally safe.

Effective Treatment 1: Adequate Sun Protection

Ultraviolet rays from the sun is the number one cause of pigmentation development. Sun protection is one of the most overlooked and underappreciated tools in our beauty arsenal that can be used to fight against pigmentation. Too much marketing hype and too many fancy cosmetic products graded with SPF values lead to many of us having inadequate sun protection.

The SPF value and PA grading of the sunscreen matters less than the frequency of daily sunscreen application. As a safe general rule, you can start using a sunscreen of SPF 20 PA ++ and above daily. Once you get into the habit of regular usage, you can then work your way up to consistent reapplication throughout the day.

Effective Treatment 2: Topical Skin Care and Medications

Every woman would have at least one anti-ageing product in her armour of cosmetics, whether it is sunscreen, a serum, or rejuvenating lotion. There are few common active ingredients that are used in some of these products, such as marine collagen extract, hyaluronate, and Vitamin C. These ingredients are touted to lighten and fade darkened skin patches by slowing the production of melanin as well as hydrate and replenish at the same time, allowing dark spots to gradually fade over time [1]. We have listed some of the more well-known compounds that have been shown to work:

1. Vitamin C. Vitamin C is an unstable compound, but there is considerable evidence that shows that this compound has skin lightening effects and antioxidant properties. It has demonstrated efficacy in reducing melanin synthesis, as well as counteracting the effects of UV-induced skin damage. Vitamin C is an unstable compound, and important characteristic to note in formulations, and also the reason why most Vitamin C products do not work as well as they claim [2]. They get oxidised even before being absorbed by the skin. Vitamin C serums that include compounds like Vitamin E in their formulations are more stable, and are more effective in treating hyperpigmentation.
2. Vitamin E. Vitamin E is a fat soluble antioxidant and has been used for more than 50 years in dermatology. It protects the skin from deleterious effects of solar radiation, and it inhibits tyrosinase [3], an enzyme responsible for production of melanin, as well as increases intracellular glutathione, which are strong evidence for its pigmentation reducing effects. [4]
3. Topical Retinoids. These are compounds derived from Vitamin A. Vitamin A has multi-functional effects on the skin: anti-pigmentation, anti-oxidant, and can even function as a low-grade ultraviolet (UV) filter to prevent photodamage [5].  Over-the-counter creams containing retinol and retinaldehyde can be obtained at pharmacies, while stronger formulations like Retin-A, Stieva-A, Tretinoin, etc, contain retinoic acid in various concentrations, and can be obtained only through a doctor’s prescription.
4. Hydroquinone. Hydroquinone is a compound that inhibits tyrosinase, the enzyme responsible for melanin synthesis. It is used as a topically applied cream to treat areas of uneven skin tone and pigmentation such as melasma, freckles, solar lentigines, and even post- inflammatory hyperpigmentation. Multiple studies have shown that the best results occur when using hydroquinone as a combination therapy together with retinoid and corticosteroid [6]. In Singapore, these combination creams require a doctor’s prescription. Usage of hydroquinone has to be under a doctor’s orders and the patient has to be followed up closely by a doctor during the course of hydroquinone usage. Adverse effects may include irritation, redness, stinging and even ochronosis, a grey-blue discoloration of the skin.
5. Cysteamine. This product is a natural molecule with a well known anti-melanoma, anti-mutagenic, and anti-carcinogenic effects. Its application in pigmentation is quite new, only in the last few years, but has shown considerable promise. In some recent studies, cysteamine has been shown to be effective in decreasing melanin content of lesions, successfully treating patients with epidermal melasma and uneven skin tone [7]. Cysteamine is available in Singapore as a 5% cream, under the brand name Cyspera.

Incorporating any of these products into your regular skincare routine makes it more convenient for you on-the-go, or if you are averse to aesthetic procedures that may seem invasive. While results may be more of a gradual progression and are slower to be seen, committing to a proper routine that protects your skin from environmental damage and the inevitable ageing process is still an important part of treating pigmentation

Effective Treatment 3: Medical Laser Treatments

If you are cringing at the mention of needles or are looking for extra treatment, try a laser machine. Depending on the clinic, laser devices are generally used to target and remove excess pigment within the skin, allowing a proper distribution of our natural melanin and improving overall skin tone. With the best technology out there today, laser treatments have been thoroughly tested in the market, bringing a combination of high peak power, short pulse duration, and deep levels of penetration.

Another perk from choosing this treatment method is that it can treat most forms of pigmentation including melasma, pigmentary marks from acne inflammation, freckles, sun spots, or just generally dull and dehydrated skin. However, proper consultation is necessary as some pigment conditions are situated on different layers of the skin, thus requiring the use of the right laser accordingly.

At The Ogee Clinic, you can be assured that a thorough consultation is conducted before the commencement of any laser treatment. The Glow and Radiance program offered is a multi-modal system that not only helps women achieve flawless, healthy skin, but a radiant complexion without any use of makeup.

The program is exclusively tailored to each individual pigmentary condition, as well as skin colour and tone. As the treatment is non-invasive by nature, one can walk in and walk out without any laser downtime. Over time, results such as a reduction of UV-induced damage, an even skin colour tone, smoother skin texture (reduction of fine lines), and a maintenance of glowing, healthy skin will be apparent.

Effective Treatment 4: Skin-Boosting Treatments

The name says it all. Basically the skin booster treatment is done with a fine needle through a series of micro-injections, depositing a product into the dermal layer of the skin. It’s a quick, lunch-time procedure, aimed at targeting the areas of concern with minimal bruising after. It has been shown to repair sun-damaged skin, slow down ageing at a cellular level, and improve acne scars by increasing the collagen content of damaged skin cells. It is also helpful to do some research on the various skin boosters that a clinic is subscribed to, especially if you have sensitive skin or have other existing skin conditions.

The most common skin booster in the market is made of hyaluronic acid and is used to provide hydration, increase moisture levels and subdermal collagen production. Small deposits of these liquid gold act as water reservoirs for the skin, hence retaining long lasting hydration for plump, dewy, and supple skin.

Source: Website

Rejuran is another skin booster that has become the latest craze in the aesthetic market. Instead of hyaluronic acid, it is made of PolyNucleotides (PNs). They are also administered via the regular injection method and is touted to be a skin healer, to repair cellular damage caused by external (sun exposure) and internal (scarring) factors. The Ogee Clinic is one of the few establishments that provide this treatment option.

Effective Treatment 5: Oral Supplements

Polypodium Leucotomos Extract (Oral Sunblock Under Heliocare)

Polypodium leucotomos is extracted from a South American fern and used for medicinal purposes. It was developed by Heliocare, pioneer of the Fernblock® Technology that has been proven effective in protecting one’s skin from the harmful effects of solar radiation. The extract is commonly used to treat eczema, sunburn, psoriasis, and many other skin conditions due to its antioxidant effect, which also prevents further damage caused by excessive sun exposure.

Crystal Tomato

Crystal Tomato® has been touted as a revolutionary oral health supplement to help you achieve even toned and healthier skin from within. Made from 100% natural ingredients after endless research, clinical trials, and testing, it’s a one-of-a-kind supplement that contains pure carotenoid extracts from a special breed of non-GMO white tomatoes and proven in their skin brightening benefits. Hence, it serves as an excellent sunscreen against UVA and UVB rays, contains anti-inflammatory properties, prevents melanin synthesis to prevent the formation of pigmentation, reduces melanin on a cellular level, acts as an antioxidant to shield one’s skin against free radicals and environmental toxins.

Conclusion

Ultimately, there is no one best way to treat pigmentation. It all depends on the severity of your condition, the time and budget you have, and the suitability of a particular treatment catered specifically towards your needs. The important thing is being comfortable in your skin and making sure you notice the changes in your skin condition and treat dark spots sooner than later to prevent further damage that may become irreversible.

Situated right in the heart of the CBD, The Ogee Clinic offers various treatment options, carefully sourcing products to provide the best quality for your skincare needs. Contact us at 6909 5370/+65 8816 2878 (Whatsapp) to book a consultation or pay us a visit at 1 Raffles Link to know more about our services.

References

If you have been hearing the word ‘Rejuran PDRN’ quite a fair bit recently, chances are you are not alone. This South Korea-originated treatment has been topping the aesthetic search list on Google for the past two years because of the amazing results that it supposedly gives.

It seems like everyone is riding on the Rejuran PDRN bandwagon, trying to get their hands on this popular treatment for fear of missing out on its purported skin benefits. However, it is not uncommon to hear of highly varying Rejuran PDRN results. Friends who have sat down together to discuss about their Rejuran treatments often find their personal experience and results very different from each other. On the one hand, some love the Rejuran result so much that they cannot wait for their next Rejuran treatment, while on the other hand some others absolutely hate the whole Rejuran experience of getting no results for the injection pain that they have to endure.

Why is this the case? What exactly is happening? There are many reasons why your friend’s Rejuran result is much better than yours. And in the rest of the article, I will be discussing some of the more important reasons. But first, let’s recap!

What is Rejuran PDRN and why is it so popular?

Rejuran PDRN is a popular skin treatment that contains purified salmon DNA fragments, also known as polydeoxyribonucleotide (PDRN). When injected, it helps in 1. Skin repair and healing, 2. Reduction and improvement of scars, 3. Restore elasticity and improve skin texture, 4. Reduce fine lines and wrinkles, and 5. Better skin hydration [1] [2]. These will then result in improved skin healing, texture, hydration, as well as the reduction of fine lines.

Its popularity can be attributed to its two main functions of repair and regeneration [3]. Rejuran PDRN in itself is a rejuvenating treatment that excels in improving skin quality, and in preparing the skin to respond better to other complementary treatments. In this sense, Rejuran PDRN is very versatile because of its ability to be combined with various treatments as a way to further boost results and to help the skin recover post-procedure. However, it is not uncommon to find that the results of the Rejuran treatment can vary from person to person.

Possible Reason 1: Your friend’s Rejuran is injected into the dermis layer, while yours is not.

Rejuran provides skin revitalization by promoting cell growth through fibroblast stimulation [4]. Fibroblast promotes the secretion of various dermis components such as collagen and other extra cellular matrix [5]. So where are the fibroblast located? It is in the dermis. Needless to say, to get the most out of your Rejuran PDRN treatment, the Rejuran PDRN should be injected and deposited at this layer of the skin. Above, I have shown a simple diagram as to where the dermis layer is.

Possible Reason 2: Your friend’s Rejuran is less painful, while yours is more painful.

As Rejuran PDRN is delivered through a series of micro-injections into the skin, pain control is an important factor in determining the Rejuran outcome. Nobody can sit through an injection treatment if it is too traumatic! The comfort level of the Rejuran PDRN procedure can and should be managed by the clinic and doctor before and during injection, such that Rejuran PDRN can be delivered without much pain to the patient. With the patient being comfortable for the whole duration of the treatment, the depth placement can be more precise and the overall treatment more detailed.

Possible Reason 3: Your friend’s Rejuran treatment is more detailed, while yours is less detailed

Rejuran PDRN injections are done with a micro-pomphous injection technique, with the following characteristics:

1. Depth: at the superficial dermis
2. Volume: 0.05 mls per injection points
3. Injection distance: 0.5-2cm between injection points

In addition, specific problem areas like mild pigmentation, acne, rough skin texture with open pores can be further targeted.

It is not uncommon to have multiple bumps in your treatment area after your Rejuran PDRN treatment. Some of my patients even say that they look like they just walked through a beehive! However, these bumps are part and parcel of the Rejuran PDRN treatment and should resolve completely over 24-30 hours. Generally, the more detailed your Rejuran treatment, the better your results will be.

Possible Reason 4: Your friend’s Rejuran treatment is done by Manual Injection, while yours is done by Injector Gun.

This is often overlooked but a very critical factor in determining the Rejuran outcome. The two main methods of delivering Rejuran PDRN into the skin is by the injector gun or the manual injection method. I will delve into a bit more detail for this part.

The Injector Gun Method

The first is the use of the injector gun, as shown in the picture on the right above. This is a popular method for some clinics because of its ease of use, and the ‘wow’ factor when a doctor whips out a piece of the technological device for injection. However, in my opinion, using the injector gun to deliver Rejuran PDRN frequently gives suboptimal results. The reasons may be attributed to the following:

1. Wrong depth of placement. Rejuran is supposed to be deposited in the dermis layer of the skin to exert its effect. When using the injector gun, the needles are directed perpendicularly into the skin, this means that when the injector gun penetrates the skin surface, it will deposit the PDRN at a much lower depth, usually in the subcutaneous layer, instead of the dermis.
2. Leakage leading to wastage. The injector gun is supposed to generate suction to suck the skin before 5-9 micro-needles deliver the product into the skin. Due to the mechanics of the injector gun, much of the Rejuran PDRN tend to leak out during the administration of the Rejuran treatment.
3. Traumatic and easy bruisability. One way to reduce leakage is to increase the suction of the injector gun device. However, this will cause patients to be more prone to bruising after the treatment as the pressure of the device on the skin is much more forceful.

The Manual Injection Method

To me, the manual method offers control and precision for the doctor during the Rejuran treatment over the Injector Gun method. All this leads to a reduction of trauma and bruising for the patient, and in turn, leads to faster recovery time for the patient. Below is a video of one typical Rejuran PDRN treatment I have done using the Manual Injection Method.

Price of Rejuran PDRN in Singapore

A typical Rejuran PDRN treatment in Singapore can range from as low as $350, up to above $1000 per session! Some factors that may affect the price of a Rejuran PDRN procedure include the skill and experience of the injector, the number of treatment regions, and even the brand of the PDRN. Yes, riding on the popularity of Rejuran PDRN, there have been other inferior and non-approved brands of PDRN entering the Singapore market. Please only choose the Rejuran brand of PDRN for your rejuvenation treatment.

Conclusion

Remember: a good quality Rejuran PDRN result depends on a good quality Rejuran PDRN treatment procedure. And a good Rejuran PDRN treatment procedure should be comfortable, employing a manual injection technique, with minimal wastage of the precious Rejuran PDRN, addressing rejuvenation for the entire face, focusing on specific problem areas, and as painless as possible.

In conclusion, to get the best out of your Rejuran PDRN treatments, it is imperative that you carry out extensive research beforehand on the process itself as well as the practicing injectors. It is important to find a skilled injector who has had sufficient experience in executing the relevant procedures, whom you are also comfortable with, before committing to them.

We hope this article has been informative in explaining why the results of Rejuran PDRN treatments may vary. For more enquiries on our Rejuran Healer treatment, please contact us.

References

Are you way past your teenage years and still suffering from occasional acne or even frequent acne breakouts?

Well then, this article is perfect for you! Here’s a no-nonsense guide on how acne should be treated. But wait! Before you skip to our recommendations, we encourage you to first read about what it is (and what it isn’t) so you know how to go about treating this agonizing problem from its root.

Don’t worry. In this guide, we will be weeding out the myths of acne problems, while sharing with you what really works – all in simple and understandable terms. So let’s begin!

What is Acne?

Commonly developed on the face, chest, back and bikini line; acne is a skin condition that occurs when your hair follicles are clogged with oil and dead skin cells. This will cause you to have either one of these symptoms depending on the severity:

• Whiteheads
• Blackheads
• Papules (Small, red and tender bumps)
• Pustules (also known as pimples)
• Nodules (Large painful lumps beneath skin surface)
• Cystic Lesions (Painful, pus-filled lumps beneath skin surface)

It is important that you know where the root of the problem is, and be able to treat it properly as unsuccessful attempts cause scarring and undue emotional stress. The earlier you begin treatment, the better!

But What Causes Acne?

It is a common misconception to think that dirt or poor hygiene causes acne. However, it is actually caused by the excess oil clogging up our pores. All of us have sebaceous (oil) glands attached to our hair follicles. When those glands secrete excessive amounts of oil, it clogs your pores causing the growth of acne. When bacteria penetrate your skin cell, it will further aggravate the acne. So what causes the excessive secretion of oil? Here are some factors:

1. Hormonal Changes

   An increase in hormones during puberty causes the sebaceous gland to enlarge, making more sebum (oil). In adults, conditions such as unhealthy stress levels, pregnancy and even taking oral contraceptives lead to irregular hormonal imbalances.

2. Hereditary

   If any of your parents had severe acne in the past, there is a chance that you might have it too.

3. Dry skin

   Yes, you read it right. When your glands are producing just the right amount of sebum (oils), our skin looks healthy and not shiny. Yet when our skin is too dry over a prolonged period of time, the glands will end up in overdrive of sebum production.

4. Irritation to the Skin

   Harsh cleansers or razors used on dry skin can cause irritation. This lowers your skin’s defenses and causes a protective reaction that leads to inflammation like acne. Constantly using off-the-shelf products (tea tree oils, topical creams like Oxy10 and oil absorption sheets) that dries out pimples and acne, without the use of moisturizers can lead to dehydration and irritation of your skin.

Other Causes of Acne

1. Pressure on Skin

   Pressure or friction caused by clothing or any equipment worn (i.e. a helmet strap). Although this has nothing to do with the secretion of oil, it can also aggravate acne.

2. Medication

   Certain medication causes a change to hormones and can trigger adult acne. Some of these are corticosteroids, antidepressants, and epilepsy treatments.

What DOES NOT Cause Acne?

Here are some myths you might have heard:

1. Myth #1: Eating fried food causes acne

   You might have been told by your parents or a friend that you should not eat greasy food when you have acne. Fortunately, that is a myth. There is no evidence proving that eating oily or greasy food causes acne.

2. Myth #2: Poor hygiene causes acne

   Contrary to popular belief, this is a myth. Acne is not caused by dirty skin as most of the biological reactions occur beneath your skin. In fact, washing your face more than twice a day can aggravate your skin as this often dries it out, promoting the over secretion of oils from your glands that causes clogging of your pores.

3. Myth #3: Makeup makes acne worse

   While some makeup products clog your pores and ultimately cause pimple outbreaks, the right makeup can improve acne conditions. Powder-based mineral foundations absorb oil that would otherwise clog your pores. Make sure that your makeup is ‘non-comedogenic’ – which means that the product hasn’t been found to promote acne development.

4. Myth #4: Acne skin does not need moisturizers

   Since we know understand that excess oil secretion and clogged pores cause acne, it may seem counterintuitive to apply moisturizers on acne skin. However, this goes back to the fact that dehydrated skin produces more pore-clogging sebum than hydrated skin. Consider applying lightweight moisturizers daily to avoid forcing your glands to over-work and malfunction.

5. Myth #5: Acne will go away on its own

   Acne problems do not resolve on their own. Without treating it, acne often progresses and becomes worse. Stop burying your acne woes with more myths.

Why You Should Treat Acne?

1. Early treatment. Early recovery.

   It takes time to treat acne. Don’t expect it to magically disappear after a day of using a pimple cream. You may have heard of such stories from a friend but more often than not, it doesn’t work that way. The earlier you start proper treatment that targets the root of the problem, the less severe the condition you’ll need to treat.

2. Reduced scarring

   Not treating acne inevitably leads to permanent and severe scars that you definitely do not want, especially if it is on your face.

3. Prevent mild acne from turning severe

   This is important as when mild acne develops into a severe acne condition, you will need stronger medication to treat it. These medications have possible side effects and require close monitoring by your dermatologist.

4. Avoid emotional distress

   No matter the severity, having acne can cause people to feel insecure and inferior about their appearance, often withdrawing themselves from others. It can take a toll on a person’s psyche and cause one’s self-esteem to suffer.

5. More affordable to treat

   This is too obvious. Treating mild acne would cost less than treating severe acne. However, if your condition is severe, we’d advise that you still seek treatment so that it doesn’t spiral out of control.

   Severe acne is no gone-case. All acne-related conditions can be treated by certified professionals.

How to Treat Acne?

The goals of taking/using acne medication are to reduce oil production, speed up skin cell turnover, fight bacterial infection and reduce inflammation. The type of medication required depends on your age as well as the type and severity of your acne.

We always recommend speaking to a trusted aesthetic doctor or dermatologist to understand the risks and benefits of the medication and treatments.

Here are 5 ways to treat acne:

1. Cleansing and skincare

   Mild cleansers: Usage of mild cleansers (e.g. Dove, Neutrogena and Cetaphil) will keep your skin clean and minimise sensitivity and irritation. They are popular and inexpensive too.

   Exfoliating cleansers and masks: Facial masks and scrubs can also be used to remove the outer layer of your skin and open up your pores.  Just be sure that you don’t use one that’s overly abrasive. Products containing glycolic and alpha hydroxy acids are fabulous skin exfoliators that are gentle on facial skin.

   Customized Skincare Products: If you’ve tried off-the-shelf products and have been disappointed, we’d like to recommend The Ogee Clinic’s Ogee Skincare System that personalizes skin care products for patients. No need for your face to be a guinea pig – this is a sure-fire way to ensure that you’re using the best skincare product for your skin.

2. Reduce excess oil

   You can never stop your oil glands from producing oil. In fact, the oil produced is good for you as they are natural lubricants to keep your skin moisturised. However, too much (or too little) will cause the issues aforementioned.

   Use a gentle toner to wipe away oil and make sure to use oil-free products to avoid dry skin and to keep your skin moisturised. You will also find that most of us with acne issues fair better with gel-based moisturisers as compared to the thick and heavy creamy alternative.

3. Reducing bacteria

   Antibacterial cleansers: They are applied externally and can come in the form of a cream, gel or lotion. The most popular antibacterial cleanser is benzoyl peroxide; an agent that kills surface bacteria. However, take note that benzoyl peroxide can cause red skin irritation to a small number of people. If it affects you, stop using it!

4. A healthy lifestyle

   Well-regulated hormonal levels will help to put a stop to acne issues. Getting good sleep, exercising, and engaging in stress-reducing habits such as mindfulness and meditation can boost the wellness of your lifestyle.

5. Seek professional help

   Many times, acne problems can be stubborn. When our self-confidence takes a hit, our unhappiness spirals out of control and emotions like these are part of a vicious cycle involving stress and yes – more acne popping!

   Seeking a trusted professional’s help could be the best way to put a stop to stress and your acne issues. Consider The Ogee Clinic’s Acne Buster Programme that customizes acne treatment based on the needs of patients.

   Focusing on the root of acne development, the programme entails sebum control, elimination of inflammation to the skin, untrap clogged pores and regulating the healthy generation of new skin cells.

Whatever You Do, Never Pick!

You might be impatient and tempted to scratch your blackheads out or pick your pimple but never ever do so! Not only will it potentially cause permanent scarring, but bacteria from your hands can also penetrate further into the deeper layers of your skin cell causing further inflammation.

Professional and Effective Acne Treatment in Singapore

There are definitely many treatment methods and medications available but it is always best to speak to a trusted professional to find out which is appropriate for your skin condition. To zap away your acne woes for good, make an appointment with The Ogee Clinic for an evaluation of your condition, be treated, and give your self-confidence the deserved boost!

Women (and men) search high and low for anti-aging skin care tips and products. In reality, anti-age is impossible and the term is only widely used in marketing for our comprehension.

However, there are realistic skincare habits to foster in aging gracefully.

Below are 15 scientifically-proven habits that we’ve gathered for this ultimate skin care guide for women living in humid countries like Singapore.

Stop Going To Sleep With Make-up On

All of us have probably heard of this, yet commit this ultimate skin-sin every now and then. Many make-up products have ingredients like silicone that blocks pores. Hence, sleeping with make-up clogs pores, causing breakouts, dries out skin and speeds up the aging process due to a collagen breakdown. Eventually, it leads to premature wrinkles!

Whatever your reason may be, STOP. Regardless of how tired you are, remove them before bedtime.

Cleanse Thoroughly

People with healthy skin wash their faces regularly. However, the frequency depends on your lifestyle, environment and skin condition.

Most of us have a good habit of cleansing our face daily, but we need to be mindful of how we do so. We are so familiar with washing our face that we wash with our eyes closed and the hands go auto-pilot, without knowing if the motion is right.

Make a point to observe how you wash your face tonight. Ensure that your fingers (and not your whole palm) move in an upward circular motion. Start at the corner of your mouth and work up to the sides of your nose, forehead, temples, cheeks and then the chin, before rinsing with water.

Pat your face dry with a towel gently after rinsing. Never wipe or rub your towel against your skin because our facial skin is thinner and will cause stretches.

Exfoliate Regularly

We experience high humidity in Singapore all year round and the tropical weather usually leads to enlarged pores, constant perspiring and increased oil production. Throughout the day, our skin is also exposed to micro particles from air pollutants that will congest the open pores of your skin.

Exfoliators help to clear clogged pores and dead skin, along with accumulated grime, to  allow your skin to breathe.

Be mindful of the type of facial scrub you use. Choose one that is less abrasive. While using a facial exfoliator, be sure not to use too much force on your face. Limit its usage to once or twice a week. Overdoing it and your face is not going to be happy with you. Over-exfoliating can irritate your natural skin barrier, causing your skin to lose moisture and become more susceptible to sunburn.

Hydration Is Vital

Keeping your skin adequately moisturised helps it stay smooth and supple – which means fine lines and wrinkles are less likely to deepen! Equally important to having healthy skin, hydrated skin also keeps sebum glands in check so they will not produce sebum excessively to compensate for the moisture lost.

While using a moisturiser helps, choosing a suitable moisturiser is just as important and this will depend on your current skin condition, which may change over time. Below is a general guide to choosing the right moisturiser for your skin type:

• • Oily or Acne Prone Skin

    Light moisturisers that do not clog pores. Look out for labels such as “oil-free” or “non-comedogenic”.

  • Dry Skin

    Living in Singapore and being exposed to the humid weather, heavy moisturisers are only recommended when you are frequently exposed in an air-conditioned environment. If your skin is really dry, use a cream-based moisturisers that soothes dryness and has long-lasting, all-day hydrating benefits. Moisturisers with coconut oil, shea butter or jojoba oil work well. Look out for urea, lactic acid, hyaluronic acid, dimethicone, lanolin, or mineral oil in the ingredient label.

  • Sensitive Skin

    When your skin has a weaker immune function, certain ingredients can irritate it easily. Avoid moisturisers that contain retinoids, alpha hydroxy acid (AHA), and beta hydroxy acid (BHA). Look for unscented hypoallergenic moisturisers instead.

  • Normal Skin

    Keep your moisturiser light and non-greasy. Choose lightweight oils or gel-based moisturisers. Avoid creams as they are too rich for your skin type and may clog pores, causing pimple outbreaks or worse, milia seed growths.

Stop Trying Every Fad Product

No two individuals have the same skin condition and we require different products for the best outcome. If you don’t have a strong grasp of your skin condition, exposing your face to any skincare product may backfire. Stop trying every ‘hot’ product. Save money for products and treatments that have proven to work.

If you’re unsure about your skin type, make an appointment with an aesthetic clinic for an assessment. If you’re in luck, the clinic may provide services that formulate personalized skincare products for their patrons!

Do Not Fall Asleep With Your Facial Mask On

We all love pampering ourselves with a facial now and then. For the busy women in Singapore, time is scarce and doesn’t allow us to visit beauty parlours. Packed facial masks are our to-go when our skin feels the need for a nutrient buffet. While regular facial treats at home is reasonable, the recommended 20-minute waiting time has proven enough for us over-worked ladies to doze into slumber.

Unless the face mask you use is creamy and meant to stay overnight, leaving them on for an extended period doesn’t ensure better work. Leaving them on your face long enough for them to dry can do more damage (and dry-out) than good to your skin.

If you’re worried you might fall asleep or lose track of time, set a timer.

Go Au Naturel

We all have imperfections to conceal with make-up and having to leave home bare-faced is like waging war with self-confidence. No one is willing to leave home with eye circles that is as dark as an Oreo cookie, with unconcealed scars caused by acne or dull skin that lacks luster.

However the regular use of makeup, particularly with heavy make-up, can lead to premature aging of skin. Make-up, particularly oil based ones, tends to clog pores and aggravates fine lines below and around eyes (a common sign of aging). Talc based make-up products (commonly in lipstick, face powder, foundations, blushers and eye shadows) can dry skin up and cause rapid wrinkling. The various chemicals in make-up products can cause the loss of tone and elasticity in skin too.

What our mothers’ and grandmothers’ nagging about slapping on too much ‘powder’ seems right.

Never Skip Sunscreen!*

You may have heard this many times, and the importance of using sun screens worth the mention in this ultimate ageing guide. Ultraviolet (UV) rays from the sun can damage our skin and cause up to 90% of skin to age. Sun exposure is actually responsible for most of the visible aging on our skin – more than all other factors combined!

I hope this has intensify your desire to slather on those sunblocks religiously when you’re out.

Drink More Water

Drinking plain water has proven to be a natural anti-aging and clear skin remedy. Water helps to cleanse the bodily toxins that causes our skin to age prematurely. Not only does water helps to purge the toxins, it also aids skin cells repair and increase elasticity.

This calls for the need to hydrate in such warm and humid weather of Singapore even more –  not only to replenish the bodily fluid loss, but also for our skin too!

Load Up On Antioxidants

Choose skin care products that are enriched with antioxidants as the antioxidant are essential in fighting free radicals that hastens skin aging. Look out for these common antioxidants like vitamin C, vitamin E, polyphenols, resveratrol, coenzyme Q10 and niacinamide.

Don’t forget to include foods into your diet that are rich in antioxidants, and we promise you’ll like some of these foods that have made the list:

• • • Dark chocolate
    • Pecans
    • Blueberries
    • Cranberries
    • Artichoke
    • Goji Berries
    • Kale
    • Red Cabbage
    • Kidney beans
    • Spinach
    • Red wine
    • Matcha tea

Avoid Excess Sugar

Your daily cup of sweetened beverage is not only expanding your waistline but could also be aging your face. Foods with high glycemic index increases cortisol through a process called “glycosylation”, where sugars bind to collagen and weakens it, promoting premature aging. Just skip the candies.

Sweat It Out

Logging a few hours a week getting sweaty has proven to not only slow down skin aging process but can reverse the signs of aging skin! Aim to have at least 30 minutes of activity, five times a week for dewy and youthful skin!

Find Your Inner Zen Zone

For busy women in Singapore, chronic tension and physical stress is just part of life. However, stress can cause surges of cortisol in the body. This hormone, cortisol, breaks down collagen and elastin, ultimately leading to wrinkles. To slow down the process of skin aging, it is important to find your inner ‘zen zone’ and relax.

7 Hours of Snooze Time

Sleep is the time when your body repairs itself. While sleeping, your skin’s blood flow increases, restores collagen and repairs damaged cells caused by UV exposure, reducing wrinkles and age spots. On the other hand, sleep deprivation induces the body to produce more cortisol (the hormone as we’ve mentioned above) that is responsible for breaking down skin collagen and causing premature aging. Studies have shown that just one night of poor sleep can cause:

• • • Hanging eyelids
    • Swollen eyes
    • Darker eye circles
    • Pale skin
    • More visible wrinkles and fine lines
    • Visibly droopy corners of the mouth

While we should embrace ageing, we don’t want to speed up the process while choosing to stalk friends on Instagram or watch TV for hours over having a good night’s rest. For healthy and youthful skin, seven to nine hours of sleep is recommended for each night.

Reducing Visible Signs of Aging

There is no anti-aging formula in existence (at least for now) but we can protect ourselves from the effects of premature aging if we practise the tips above.

Aesthetic practitioner, Dr. Heng Wee Soon, whose primary focus is on reducing visible signs of aging has helped both men and women regain youthful looks and personal confidence.

Make an appointment with us or walk-in at our clinic and resolve your skin-aging woes today!

I believe that many people over the weekend have read about the case of a young lady (32 year old property agent) who went for a beauty injection, presumably “BOTOX”, at a local licensed clinic, only to go unconscious during the procedure, had to be sent to the hospital, and unfortunately pass on after five days in the hospital.

The whole incident is unfortunate, and my condolences go out to this lady’s family. Because of the number of eyeballs looking at this piece of news, it is so important to get the facts right. This news has led to people being nervous about BOTOX treatments. Just yesterday alone, I had many clinic patients asking me if doctors are still comfortable performing BOTOX injections.

What really happened? Was it BOTOX that caused the death? Should we be afraid of BOTOX now? From the news headlines, it seems the blame has been pushed to BOTOX right from the get go. From a professional point of view, objectively, I feel it is very unlikely that BOTOX caused the death and without further formal information from the investigation, I highly recommend media outlets and everyone to refrain from jumping to conclusions so early.

After reviewing the information that has been published in the news thus far, I will share some of my thoughts on the theoretical scenarios for BOTOX to be the culprit, and why at this point in time, these scenarios are considered low probability.

First let me establish some facts on BOTOX:

1. In any aesthetic clinic, there are usually more than one type of injectable procedure.
2. Botulinum toxin injection is only one of the common cosmetic injection procedures that can be done in an aesthetic dermatology clinic. Actually, there are many other, for instance
   • Botulinum toxin injection (many brands)
   • Sculptra filler injection
   • Ellanse filler injection
   • Radiesse filler injection
   • Hyaluronic acid dermal filler injection (many brands)
   • Rejuran injection
   • Skinbooster injection (many brands)
   • The list goes on
3. The terms ‘BOTOX’ and ‘Botulinum Toxin’ are NOT INTERCHANGEABLE. The news reports singled out the the product branded ‘BOTOX’ being the medical product that had led to the misadventure. BOTOX is just the name of a brand of Botulinum Toxin. There are other brands of Botulinum Toxin that doctors use in Singapore: e.g. Dysport, Xeomin.
4. Many people instinctively refer to all types of botulinum toxin injections as BOTOX injections simply because the name ‘BOTOX’ is memorable and catchy, but they are actually not the same. Think Coca Cola vs Schweppes Cola.
5. Botulinum toxin is a neurotoxic protein. To use it as a medicine, strict manufacturing controls and standards has to be put into place. This allows it to be properly purified, extracted, packaged and stored, resulting in a consistent, predictable, highly effective medicinal product that doctors can trust every time he or she opens a new bottle of botulinum toxin. Allergan, the pharmaceutical company behind BOTOX, has been producing it for more than 20 years, and in my opinion, they are the best in class in terms of manufacturing quality.

Next, let’s proceed with the scenarios.

Scenario One: Botulism caused by BOTOX leading to cardiorespiratory failure

Botulism is a rare illness where botulinum toxin produced by the bacteria Clostridium botulinum, start attacking the body’s nerves. Clinical signs of botulism include muscle weakness, ptosis, facial droop, difficulty in walking, even breathing.

Caveats

1. In this study, it demonstrated that 86 cases of botulism from botulinum toxin injections were not deadly, and all were discharged from hospital after 1-20 days of medical intervention. The onset of botulism effect ranged from 0-6 days, implying that there is usually some lead time for the patient or his/her closed ones to notice the signs and symptoms.
2. In another study, 4 cases of botulism has found to have occurred after injections of high doses of Botulinum toxin. These botulinum toxin products are preparations of unlicensed brands. NONE of them were BOTOX.
3. Lethal dose of botulinum toxin in humans has been estimated to be 40U/kg. This means that for a female of average weight 50kg, her theoretical lethal Botox dose is 2000U. Using a standard 100U Botox bottle, she will have to be injected with 20 bottles of BOTOX to have a lethal effect.
4. Cosmetic dosages of BOTOX tend to fall between the range of 20-100 units, well within one bottle of BOTOX.

Scenario Two: Manufacturing and production screw-up

1. In this situation, higher-than-normal doses (e.g 20 times in this case) of BOTOX have to be packed into the containers, a situation that cannot happen with only one product, as these products are usually manufactured in batches. In this instance, usually many clinics are affected, sometimes across a few countries. A huge regional or global recall of the product will have to be undertaken.
2. I find this situation even more unlikely.

Scenario Three: Hypersensitivity (anaphylaxis) reaction to BOTOX leading to respiratory distress and death

Similar to peanut allergy or bee-sting allergy, your body’s immune response goes into overdrive after exposure to a specific trigger (peanut or bee sting toxin), leading to crashing of your blood pressure and heart rate, shutting down of the circulatory and respiratory system.

Caveats

1. Anaphylaxis reaction requires a prior exposure to the trigger, in this case BOTOX.
2. The patient was reported to have gone for botulinum toxin injections in the clinic before.
3. If she had an allergic reaction previously, the clinic would have known, and will also have the necessary equipment to be able to stabilize her when that happened.
4. With a known allergic reaction, she would have been warned against undergoing any more BOTOX injections.
5. With an anaphylactic reaction, the patient should display signs of breathing difficulties, eye swelling, signs of acute allergic reaction. However, from various reports, the patient suffered seizures and cardiac arrest, and loss of consciousness shortly after receiving the cosmetic treatment. These are not typical symptoms of an anaphylactic reaction.

Scenario Four: Patient’s medical conditions causing a much stronger BOTOX effect

Certain medical conditions can cause BOTOX to have a stronger effect. These medical conditions are usually neuromuscular conditions, like myasthenia gravis.

Caveats

1. Individuals with myasthenia gravis or other neuromuscular conditions will have tell-tale signs like facial paralysis, trouble talking, some degree of difficulty in walking, etc.
2. However, the lady patient is young, and looked very healthy in the photos in the media news, without the signs of such neuromuscular conditions. There was also no mention of the lady patient having any significant past medical problems of note.
3. Secondly, the ‘stronger effect’ of BOTOX in these patients usually come in the form of a prolonged duration (e.g. BOTOX lasting 9 months instead of 3-4 months), NOT an increase of muscle weakening severe enough to cause collapse and coma.

Scenario Five: Other medications or other medical conditions directly responsible for the misadventure

When we go down this scenario, there can be so many possibilities:

Caveats

1. Medications that were given separately or together with the BOTOX injection can trigger an adverse reaction
   • Local anaesthetic agent like lidocaine, or
   • Concurrent dermal filler injection together with BOTOX, of which there can be various filling products used.
   • Other brands of botulinum toxin, or unlicenced brands of botulinum toxin
   • Other medical injections that were not reported
2. Medical conditions of the patient.
   • Epilepsy
   • Unreported asthma condition
   • etc

Conclusion

This academic exercise shows that there are so many possible scenarios, that we should not jump ahead of ourselves or start to believe in our own speculation. In addition, BOTOX has been around for decades, with a good track record, and we should not panic easily. Of course, if at the end of the day, the investigation show that BOTOX is indeed responsible for this misadventure, the aesthetic dermatology community will need to revamp what we know about this ‘miracle drug’, a painful but necessary move. I will keep myself updated and post again should more information surface.

Photo credits: mothership.sg for the featured image.

You have seen celebrities like Kylie Jenner, Madonna or Nicole Kidman spotting pouty lips and perfectly sculpted cheeks and heard the Kadarshians talking about the benefits of their dermal filler treatments on their social media accounts. Because of this constant influence, you have finally decided to go for a dermal filler treatment to continue looking young and beautiful.

Before you make the plunge and step into the treatment room, these are the 10 things to know about dermal fillers.

1. There are many different kinds of dermal fillers

   You may not know this, but dermal fillers have been around for decades! The first agent to be approved for cosmetic injection was bovine (cattle- source) collagen all the way back in 1981! Since then, there have been many injectable filling agents developed, and many of them are already FDA approved and HSA (Health Sciences Authority)-approved for cosmetic injection use. Currently in Singapore, the popular filling agents include:

   Hyaluronic acid: Juvederm, Belotero, Restylane
   Human fat: No brands, using your own harvested fat
   Calcium hydroxyapatite: Radiesse
   Polycaprolactone (in gel carrier): Ellanse
   Poly lactic acid: Sculptra

2. They are not the same as Botox

   

   Do not confuse dermal fillers with other injectables like Botox, Xeomin, and Dysport. These are neuromodulators, also known as wrinkle relaxers. Yes these products are also described as ‘injectables’, but they work their magic differently. They work to reduce and relax wrinkles like crows feet, frown lines, and forehead furrows by temporarily weakening specific facial muscles. They don’t fill, but they can be used together with dermal fillers. In fact, for our popular Liquid Face Lift treatment, our doctor uses both Juvederm fillers and Botox to achieve a face lift effect without surgery or incisions.

3. Highly versatile product for facial rejuvenation

   
   While the bulk of the dermal filler is made with hyaluronic acid, within the hyaluronic acid dermal fillers, there are many different types with different uses.

   Those with larger particle size, gel hardness, or increased viscosity have the strength to support sagging tissues, reinforce structure of our cheekbones, forming a great foundation for Liquid Face Lift. Those with a lighter gel hardness, less viscosity can be used to address fine lines, plump lips, or even hydrate the skin.

   Hyaluronic acid dermal fillers are highly versatile products and their main benefits include, and are not limited to the following

   • Recontour face shape
   • Revolumise sunken areas
   • Enhance certain facial features
   • Increase overall hydration of the skin
   • Reduce static lines and wrinkles

4. Some fillers are HSA-approved, some are not!

   
   Due to the popularity of dermal fillers, there was an explosion of dermal filler brands out in the market. And due to the accessibility of social media and the internet, as well as multi-functional social messaging apps like LINE and WeChat, there are many brands of filler that we know are circulating within Singapore, outside of clinics! To ensure safety and peace of mind, always choose a filler product from a brand that is HSA-approved.

5. Where and how they are injected will vary from person to person, and change as you age.

   Dermal filler injections are personal and intimate, and the doctors should make the decisions on where to place them based on your face shape and the result that you desire. There is no one-size-fits-all approach when it comes to Liquid Face Lift. An aesthetic physician is like a sculptor enhancing a patient’s face – he should always customize the treatment plan for his patient.

   In addition, how your dermal filler treatment is done will change based on your age. When you are younger, you may be focused on having a sharper chin, or a set of pouty lips. However, as you age, the priority of dermal filler treatment will be to correct age-related volume loss, as well as add structural support to cheekbones that suffer from bone resorption.

6. Good fillers are invisible

   

   Duck lips, pillow-face, unsightly bumps along prominent wrinkles. These are very obvious signs that a filler treatment has been done, so much so that they can be noticed by even a lay person. In the expert’s eyes, these are poorly done filler treatments. When administered by an experienced doctor, the end result of the filler should look natural. “A professionally-done filler will have the people noticing you because you look refreshed and attractive, but they will never know what procedure you have done.”

7. The dermal filler product matters.

   Actually, among hyaluronic acid filler products, there are countless brands. Remember to go for the ones that have been legalized, as these brands have demonstrated their products are reliable, safe and effective. At the Ogee Clinic, we are big users of Juvederm range of fillers. The list of HSA-approved dermal filler brands are as follow:

   • Juvederm
   • Belotero
   • Restylane
   • Teosyal

   If you have been shopping around online, or doing your own research online, you may have found that there are some doctors who swear by certain dermal filler products, only using one brand of dermal filler in their practice, while there are other doctors who use a variety of brands of dermal fillers. Each camp will have its own justifications as to why their approach is the best. The most important aspect is that no matter which brand of filler the clinic is offering, the injecting doctor must have mastery of it And the brand of the product is reliable, the brand has a range of models in their product range to cater to different rejuvenation needs.

8. The doctor matters

   Every injecting doctor has different treatment philosophies, different techniques, and levels of experience. How to choose? Be sure that your physician understands your concerns and expectations, and communicates with you about realistic results. Do not be afraid to ask about training and certification too. Dermal filler treatments are essentially everywhere now.

   
   There are even reports in Straits Times and Lianhe Zaobao that there are beauticians caught peddling dermal filler injection services in HDB flats, offering a much cheaper alternative to professionally done services in the MOH-approved clinics. Question is, will you dare to try?

9. There are potential risks with dermal filler treatments

   Most common side effects include bruising, which will resolve on its own after 3-4 days. It pays to be injected by an experienced injector to lower the risk of such side effects occurring. They are not life threatening in any way, but cosmetically, you wanted to come for a dermal filler treatment to look better, not worse.

   Lumps, bumps, and asymmetries. These happen when the injection is not done smoothly, or the filler has been injected in the wrong plane.

   The most serious complication is when the filler is injected into a blood vessel. This can happen when the pressure in the syringe is too high, the needle or cannula of the syringe is inside the artery when the injection was done, or rarely, compression of the artery by the external filler. When this happens the artery becomes blocked, and is unable to supply blood and oxygen to the skin, or other organs it is supposed to supply, causing problems like skin necrosis, nerve damage, even blindness.

   Yes, filler treatments, like all medical procedures, has an inherent risk for potential complications, though the risks described above are really rare (less than 0.1%). And fret not. In the right hands of an experienced doctor and reputable clinic, such complications are literally unheard of. This is why you should always visit an experienced cosmetic injector to be safe. And not just any dermatologist or plastic surgeon. When it comes to dermal filler injection, being a specialist alone doesn’t imply competence in that procedure. There are many specialists who do not routinely perform dermal filler injections. Experience, skill of the doctor and his/her understanding of facial anatomy and product characteristics are very important factors for a successful and safe filler treatment.

10. If the price seems too good to be true, it probably is.

    In Singapore, a syringe of filler can set you back around SGD$500-1200. Costs go up higher depending on the amount of filler material required. For Ogee Clinic’s Liquid Facelift procedure, patients may require 4-6 tubes of filler to reap the optimum benefit from the dermal filler treatment. Because of the R&D, testing, sterility assessments, and precise manufacturing processes involved, filler products from reliable brands like Juvederm comes at a slight premium. When a clinic tells you that it is using Juvederm fillers for your treatment, you can be reassured you are being treated with the right product.

    On the contrary, if we see a deal for an inexpensive filler, be very skeptical. There are fillers being sold as cheaply as SGD$150 per tube, and these are not done in medical aesthetic clinics. At these prices, we highly suspect the quality of the material, and the safety of the product.

A dermal filler procedure is one of the most effective treatments to achieve facial rejuvenation. At the Ogee Clinic, our Liquid Facelift Program focuses on using the best dermal fillers to achieve a face lifted appearance without scalpels and incisions. We hope that you have found this article informative and useful. Be well, look good, feel good, and we will see you around!

Wasted $5,000 on ‘Pico’

During one of my clinic sessions, a new patient came for her appointment to consult with regard to her facial pigmentation. She was told to have melasma, and paid close to $5,000 for multiple sessions of a ‘new Pico treatment’ that was sold to her in another clinic a few months ago.

At the end of her course of treatments, she developed further darkening in some areas of her melasma patches. Needless to say, she did not feel that her melasma had improved.

She wanted to immediately embark on another set of laser treatments, and asked me if I have something better than ‘Pico Laser’.

I explained to her that she should not start on another course of laser treatments now. I incorporated a lightening agent, retinoid, and antioxidant formulation into her skincare routine. I also changed her sunscreen and her frequency of sunscreen application.

She has been on follow-up with me for 6 weeks, with fair improvement in her facial pigmentation. I may add a laser treatment in future if further lightening of her dark pigment patches is warranted.

Firstly, what is melasma?

Melasma is a type of hyperpigmentation that is very common among Asians. They appear as symmetrical, blotchy, brownish patches on the face, and sometimes the neck, chest and even forearms.

Women are at a higher chance to have melasma, the ratio of women to men having melasma is 9:1 in some studies. Onset is during childbearing years, and is frequently described as ‘mask of pregnancy’. It starts during the mid-30s, and continue to affect individuals into their 60s and beyond.

Unfortunately, there is no cure for melasma. The causes are multifactorial and I will list them out in the table below.

Factors increasing chance of melasma

• Asian skin type (especially Fitzpatrick Skin Type III and IV)
• Women
• Child bearing age
• Physically active, history of sun exposure
• Family history of melasma

Other medical conditions

• Pregnancy
• Increased female hormones
  • Oral contraceptive pills
  • Hormone replacement therapy
• Thyroid disease
• Low testosterone

Why laser treatment for facial pigmentation is so popular

I believe most of you are familiar with Q-switched lasers. These dermatological lasers became commercially available since the 1990s, and has grown wildly popular ever since.

Prior to this period, lasers were thought to be only capable of treating pigmented lesions limited to the skin surface, and it come to everyone’s surprise that it can selectively target tattoo pigments and pigmentation within the skin.

These lasers shown great results in the treatment of various skin pigmentation disorders, like solar lentigines, freckles, even deeper pigmented lesions like ABNOM(Hori’s naevus), and became an invaluable tool in any physician’s clinic who is serious in the treatment of pigmentary disorders.

Why MOST laser technologies FAIL to treat melasma.

Look at the diagram above: The topmost layer of the skin is called the epidermis. In this layer, there are the keratinocytes, the so call ‘normal skin cells’. And each of the skin cells have a certain amount of melanin pigment within the cell. This melanin pigment is actually produced by the melanocyte cell, which is found at the bottom part of the epidermis.

One of the most popular treatment method involving Q-switch laser is: LASER TONING. In this no-downtime protocol, the laser is applied in such a way as to break down melanosomes, which contain the melanin pigment, within the epidermis of the skin. This is done without causing any redness or bruising to the patients, making it very popular.

But because it doesn’t address any of the root causes of melasma, the sensitised melanocyte is still producing a lot of melanin pigment! This way of treating melasma is a sure way for frequent relapses to happen!

What about pico-second lasers? I hear they are the latest technology!

Q-switched nano-second laser machines generate laser energy with pulse widths at the nano-seconds range, that is one billionth of a second (1.0 ns =10⁻⁹ s).

To put things into perspective,
1 nano-second = 0.000000001 seconds

Recently, a new wave of laser technology, pico-second lasers, have become commercially available. These lasers generate laser energy with pulse widths at the pico-second range(1.0 ps =10⁻¹² s). The theory is that by having a reduced pulse width of the laser energy, pico-second lasers are more superior to nano-second Q-switched lasers — with reduced side effects and increased efficacy.

This superiority is targeted at laser tattoo removals. Nano-second Q-switched lasers are good at treating pure black tattoos, but when it comes to multi-coloured tattoos (red, green, blue, etc), nano-second lasers are not able to treat them fully. In theory, by having a shorter pulse width, many different colour-types of tattoo pigments can be treated. That is the premise on which the pico-second lasers were developed, and marketed.

Why Pico laser treatment IS NOT the answer to your melasma.

Although pico-second lasers have started to make inroads into the clinics, I feel that the technology is not at its most refined yet. Theoretically, the pico-second laser technology sounds great, however:

Points to note:

1. Pico-second lasers are supposed to be better at removing multi-coloured tattoos conventional nano-second Q-switched lasers. However, their advantage to remove skin pigmentation has not been firmly established yet.
2. Some medical evidence suggest Pico-second laser technology is not fully ready yet
   • On treating skin pigmentation, one study concluded that using pico-second lasers to treat skin pigmentation is ‘premature anticipation’, and requires more basic studies to be performed ^[1}
   • For tattoos, one study concluded that ‘there is sparse evidence that pico-second lasers are more effective than their nano-second counterparts for black and blue tattoo removals.’ ^[2].
   • I have to point out here that the studies mentioned above are not sponsored by, and not affiliated to any laser manufacturers or companies, so we can be assured about the unbiased truth of the study conclusions drawn.
3. Since pico-second laser treatments for skin pigmentation disorder is a new concept, literature available is limited to case reports or case series (collection of case reports).
   So far, the published evidence is WEAK.Take for example the data chart shown above. This is done in one of the studies ^[3] and measures the amount of melanin in the skin 7 days after different laser treatments. From the chart it actually shows that QS 1064 Nd:YAG laser is MORE SUPERIOR than a pico-second laser in reducing melanin pigment!

Look, I am in no way against pico-second laser machines. I have been looking for a pico-second laser for my own clinic ever since I started my own practice. In fact, I have tested no less than 6 different pico-second laser machines, trying to find one that suit my clinic’s treatment needs. I feel that in the near future, a truly great pico-second laser will emerge, and I will be more than happy to buy it. But perhaps the time is NOT now.

Moving on…

It is Melasma’s fault, not Pico Lasers

This is true. Melasma is one of the most difficult cosmetic pigmentation in the world to treat as it is multifactorial. Just look at the diagram below showing the risk factors that can trigger or contribute to melasma. THERE ARE MANY. The factors that cause melasma to occur in the first place will continue to stimulate the skin to develop melasma pigment as long as the individual is exposed to them.

Laser and light therapies directed at reducing pigment and melanin molecules within the skin, cannot prevent the formation of new pigments within the skin. The melanocytes, which produces the melanin, are continuously stimulated or irritated to produce large amounts of melanin (picture shown above). That is why blindly applying laser beams on melasma lesions almost always lead to failure of treatment. Remember: laser and light treatment is NOT first line treatment for melasma. And any clinic or doctors who blindly sell you laser treatments without understanding the underlying nature of your melasma will only set you up for failure.

The Best Melasma Treatment in Singapore

Unfortunately, there is not a single treatment that can be said to be the best in removing melasma. So I would suggest to not waste your time in looking for one. Always remember: a sound medical approach is the BEST way to manage towards melasma , not the latest or most expensive laser machine!

Dr Heng’s Systematic Approach to Melasma Treatment

Start with the Correct Diagnosis

Melasma is diagnosed based on clinical examination alone. I usually will use a Wood’s lamp and other vision enhancement aids to help me examine the severity and depth of the melasma. At the diagnosis stage, I am also able to see the presence of other pigmented skin conditions, which can influence my treatment plan for the patient.

So what are some of the other common pigmented skin conditions we see?

Freckles	Sun spot or solar lentigo
ABNOM or Hori’s Naevus	Post inflammatory hyperpigmentation (PIH)

As you can see, melasma is not the only pigmentation that can occur on your face. Frequently, my patients present with a combination of different pigmentation conditions.

Because each of the above pigmentation has different characteristics, when we do use laser procedures to treat them, we require different types of lasers to manage.

A good doctor should be able to identify the various lesions and devise a treatment plan that can treat all lesions comprehensively.

Reduce ALL risk factors (as much as possible)

Hormonal factors are a leading cause of melasma development, It is very common for the condition to flare up when a woman is pregnant or on oral contraceptive pills.

For melasma arising from pregnancy, very frequently, the pigment patches will lighten and improve after childbirth.
If the melasma condition is brought on by oral contraceptive pills, these pills will have to be stopped and other forms of contraception has to be advised.

Besides the melanocytes being stimulated by hormonal changes to produce melanin pigmentation readily, recent studies have also shown that non-pigment producing cells- the keratinocytes (normal skin cells), and blood vessels also play a role in the development of melasma.^[4]

Therefore a complete melasma treatment should also target treating the skin cells (keratinocytes) that have large amount of melanin pigment, and also reduction of number of blood vessels in the skin^[5].

Adequate sun protection

Sunscreen, sunscreen, sunscreen! I cannot emphasize enough the importance of sun protection. Choose a broad-spectrum sunscreen, that is able to block out both UVB and UVA rays. I shall cover more about sunscreen in future posts. For now, pearls to sunscreen success are as such:

1. Use a broad-spectrum sun screen
2. At least SPF 15
3. Apply sunscreen at least 20 minutes before going out to the sun!
4. Frequently reapply!

Pigment removal through doctor’s prescriptions

Such prescriptions are usually in the form of creams to target the various pathways of melasma development. Hydroquinone is an effective skin lightener, and although there were concerns about its long-term application, it still remains the gold standard in clearing pigmentation like melasma, solar lentigines and some freckles. It can be effectively combined with retinoids and a mild corticosteroid. Doctors use different variations of this combination.

Besides the usual hyroquinone, and retinoids, there are other agents that has been shown to work to a smaller degree:

• Kojic acid
• Arbutin
• Azelaic acid
• Ascorbic acid (Vitamin C)

Your doctor should be knowledgeable in how these lightening agents function, how they interact with your pigment to remove them, and also have a good knowledge in how to combine them to clear your melasma in a convenient way.

I sometimes prescribe oral medications for patients. One classic example is tranexamic acid. This oral medication was found by accident to be useful in lightening melasma lesions. Further studies done showed that it helps to treat melasma by inhibiting plasminogen activator and prevents pigment formation ^[6].

What about chemical peels?

Chemical peels are what I will group as second-choice management therapy for melasma, similar to laser and light therapy. Options include, but not limited to:

1. Glycolic acid
2. Malic acid
3. Lactic acid
4. Jessner’s peel

In principle, these chemical peeling agents cause superficial skin effects, thus it enables removal of epidermal melanin (remember the skin layers?)

However, if the patient present to my clinic with dermal melasma, I will tend to avoid chemical peels. At this depth, there is risk of injury to the skin. This usually manifest as a type of pigmentation known as post-inflammation hyperpigmentation, or PIH for short. PIH is especially common among Asian skin. NOT a good trade-off when you get another pigmentation while trying to treat your melasma.

So, WHEN do we use LASERS to treat MELASMA?

There are not many situations where I will start using lasers to treat melasma. The following are some of them:

1. Recalcitrant melasma. Where the melasma has poor response to topical creams and medications after 6-8 weeks of therapy
   
2. Other pigmentation disorders. Where the lasers can improve other pigmentation for the patient while the melasma is being treated simultaneously. (e.g. freckles, sun spots, Hori’s)
3. Patients want a faster clearance of their melasma. Usually for patients who want to prepare for an upcoming event, like a wedding, or DnD event. Not the best-case scenario, as I always advise patients to get their melasma treated early, at least 4-6 months. In these situations, I will have to incorporate laser treatments into the main treatment approach.

So what are some of the lasers that can be used to improve melasma?

The following is a non-exhaustive list of lasers that had been shown to work in reducing and improving melasma, either singly, or in combination with other lasers.

Q- Switched 1064nm Lasers

• DuoliteQSby DEKA
• Neosys by FineMEC
• Helios III by LaserOptek
• Spectra by Lutronic
• Revlite by Cyanosure
• Tribeam by Jeisys
• M22 QS ND:YAG from Lumenis

Non Q-switched 1064nm Lasers

• Fotona SP Dynamis by Fotona
• ProYellow Laser by Ascelpion Technologies
• Dual Yellow Laser by Norseld
• Fraxel Dual by Solta Medical
• Lavieen BB Laser by WonTech

Combination Lasers pave the way to SUCCESS.

That’s a lot of lasers you say?

Yes, no doubt. And for good reason too. Remember earlier in the article where we talked about melasma being multi-factorial? That’s right. Now if we want to successfully treat melasma and prevent complications, the best way is to use combination laser therapy to target the various pathways that cause melasma to develop.

Combination laser treatment is a cornerstone approach that I take for all my melasma patients undergoing laser treatments, every time.

I am not saying that my approach is the best. Each doctor will have his or her own approach when it comes to laser treatment, determined by the knowledge and experience with the laser, and an in-depth understanding of skin physiology. And as a patient you have to find a doctor and aesthetic clinic that you are comfortable with and confident in.

Another point to note:

All the lasers listed above, are in my opinion, very well-manufactured devices, and from reputable brands. Many of them are what I consider reliable, traditional nano-second Q-switched lasers. I made it a point not to include ANY Pico Laser to the list. Again this points to the fact that that successful treatment of melasma can be achieved even without the most-hyped, and most expensive laser machines.

Melasma has no cure, but it is NOT the end of the world.

Yes, melasma is a complex condition. Its pathogenesis is not completely understood. However, for patients who are compliant to doctors’ instructions, stay away from the sun and irritative cosmetics, follow a disciplined approach to topical creams prescribed, and if need be, sound and effective in-clinic procedures, they usually see very visible improvement to their melasma, and can maintain their good skin complexion for a long time.

Always remember: the key to the successful treatment of melasma does not depend on the latest, most expensive laser technology. Instead, a sound medical approach, skincare discipline, and expertise and experience of the doctor in treating pigmentation is FAR MORE IMPORTANT.

If you are suffering from recalcitrant melasma or other pigmentation problems, do find out how our treatment for pigmentation removal can help you.