My Blog
By Michael J. Visconti, BSc & David Fivenson, MD
September 30, 2019
Category: Uncategorized
Tags: Skin   dermatology   medicine   psoriasis   topicals   therapy   eczema  

Many skin conditions are treated with topical medications. Instead of applying active medicine directly onto the skin, “vehicles” are combined with the chosen medication to aid in its delivery. Vehicles are inactive creams, lotions, solutions and/or ointments that change the properties of the medicine mixed into them – assisting its application.

The primary components of vehicles include powders, oils, and liquids. The inherent properties of these three ingredients is translated to the vehicle, and thus how the medicine is delivered on the skin. For example, a vehicle with a prominent liquid component can assist with the drying of wet skin lesions through evaporation, whereas oils can provide an occluding coating to the skin and enhance the penetration of the active medicine.

When vehicles are combined with active medicines, you get “formulations”. Formulations can be creams, ointments, lotions, solutions, and foams embedded with active medicine. Different formulations have different potencies (i.e. triamcinolone ointment is more potent than triamcinolone cream) and different body region applications (i.e. solutions for the scalp instead of creams). The consideration of which formulation to use is crucial, as certain formulations are easier to use, therefore promoting adherence to a treatment regimen and overall improvement of a patient’s skin condition.

Outline of formulations:

  • Cream
  • Ointment
  • Lotion
  • Gel
  • Foam
  • Solution

Creams are predominantly mixtures or emulsions of oils in water. Creams are usually white in color and easily rubbed in without leaving much of a residue. They are applicable to numerous body regions. For these reasons, they tend to be favored by patients and frequently prescribed by clinicians. Creams are particularly beneficial in the skin folds and offer a drying effect to help with wet or damp skin lesions. Additionally, certain creams can be “augmented”, meaning they are more potent and penetrate the skin deeper (i.e. betamethasone dipropionate vs. betamethasone dipropionate augmented). Because a cream is an oil in water emulsion, it requires added agents to keep the mixture stable. This is the same idea as the difference between oil and water salad dressings and a thicker one like ranch or thousand island.

Ointments are mainly composed of oils and greases with a small amount of water. Oils are translucent and greasy, with the latter characteristic making them cosmetically unfavorable for some patients. They provide great lubrication and can be used on dry skin lesions. Ointments are more occlusive, which allows for better penetration of medication through the skin and higher potency. Because of this effect, ointments may not always be indicated for certain regions of the skin that are naturally thinner than others (i.e. the face, armpits, groin folds, etc.). Ointments work best in smooth skin regions lacking hair and on thick and dry skin lesions.

Lotions are composed of powder and water. Lotions are easily spread but only slightly occlusive, making them the least potent topical vehicle. However, lotions are useful in the treatment of moist or exudative skin lesions, as they provide a drying effect through evaporation after application. Lotions can be useful in hairy areas of the skin, as well as large areas due to their ease of application.

Gels may appear similar to ointments, except they are composed of water, carboxymethylcellulose beads, propylene glycol, and occasionally alcohol. Gels are translucent, greaseless, and easy to apply. For comparison, think of the common surgical lubricant or K-Y Jelly. Gels dry and form a thin film, which does not stain or leave behind greasy texture. These features make gels cosmetically favorable, but they are poorly occlusive and do not provide hydration. Gels are particularly applicable for acne and hair-bearing areas, since they do not mat down the hair after drying.

Foams are composed of liquid film and gas bubbles. Foams easily spread and absorb into the skin while leaving behind little residue. Because of this, they are cosmetically appealing and more expensive formulations. Foams provide little to no hydration or occlusion. However, certain types of foams called emollient foams can provide skin hydration and build up the skin barrier - making them advantageous over traditional foams. Because of their easy application, foams are often utilized on the scalp or other hair-bearing areas.

Solutions are very thin and light. They are made from water, alcohol, and other liquids. Solutions come in a clear or hazy, thin-textured, liquid phase. As a result of this, they can be drying from evaporation, easy to spread, and messy to apply. Solutions are most useful for the scalp, as they can penetrate the skin through hair. Due to the presence of alcohols, they are more prone to stinging sensations when applied to inflamed skin.

By Sultan H Qiblawi
September 04, 2019
Category: Uncategorized
Tags: Skin   dermatology   psoriasis   trigger   strep   stress   beta blocker  

Plain Field in Front of Mountain Peak


Psoriasis is a disease that many of us have encountered in our daily lives. Chances are you know someone who has it, or you may even have it yourself. Psoriasis is a disease that causes flaking of the skin with inflammation and thick white, silvery, or red patches of the skin. The scaly patches can be anywhere on the body, but tends to effect the elbow, knees, face, hands and feet, nails, and skin folds (e.g. armpits).

So what causes psoriasis?

Psoriasis is an autoimmune skin condition that speeds up the life cycle of skin cells and causes them to build up on the surface of the skin. The patches and scales that are seen on the affected areas are from this process. There are common things that can trigger a psoriasis flare that are important to know about if you or a loved one has psoriasis.

Triggers of Psoriasis:

1. Strep infections:

Strep throat infections have been linked to causing flares of psoriasis in some people. When you get a strep throat, your immune system responds by sending many immune cells to the tonsils to fight the infection. It is believed that some of these immune cells go to the skin and can trigger a psoriasis flare up. According to a study that looked at the relationship between psoriasis and strep throat, 42% of plaque psoriasis patients reported that their psoriasis got worse when they had a sore throat. Interestingly, 48% of patients who had their tonsils out after getting psoriasis reported that their psoriasis got better.  


shallow focus photography of prescription bottle with capsules


2. Beta blockers:

Beta blockers are a very common drug class that is used for controlling arrythmias, high blood pressure, and many other conditions. This class of drugs has been reported to induce and exacerbate psoriasis in many people. The latency period between taking a beta blockers like propranolol, atenolol, and metoprolol, and a drug eruption can range from several days to 48 weeks. It was also found that eruptions were usually resistant to psoriasis medications until the Beta-blocker was discontinued.

3. Anti malarial medications:

Medications that are used to treat malaria have been shown to exacerbate psoriasis in many patients. Antimalarials are commonly used to treat psoriatic arthritis, which is an arthritis that can be caused coexist with psoriasis, but can commonly precipitate eruptions and flares of psoriasis. Because of this, some authorities say that antimalarials are contraindicated in patients with psoriasis.

4. Stress:

Stress is commonplace in many of our lives, and it can have negative effects on many parts our life. Unfortunately, this is also the case for psoriasis and flareups. Stress is a very common trigger for psoriasis and it is important to reduce stress to lower your chances of having a psoriasis flare due to stress. Exercise and meditation have been shown to help patients reduce their stress and thus reduce the amount of psoriasis flares that can occur due to stress that compounds throughout a long period of time.

Check out the National Psoriasis Foundation website:  for more information about psoriasis.

By Sultan Qiblawi
June 16, 2019
Category: Uncategorized
Tags: Skin   dermatology   pemphigus   autoimmune   medicine   skincare  


There are a subset of dermatological diseases that are not very well known to the general public that can be painful, and potentially life threatening. In today’s post, I want to shed some light on one of these diseases: pemphigus vulgaris.

First off, I would like to give you some stats about how frequently this disease occurs in the general population. Pemphigus vulgaris affects about 0.7-5 people per 1,000,000 per year in the general population. This is not a very common disease, but its affects can be debilitating and missing this diagnosis can pose serious problem for the person who actually has it.

Dr. Fivenson is a nationally recognized leader in bullous diseases, like pemphigus, and he sees hundreds of these patients. He, and his team, are here to make sure you get the most accurate distilled information about rare dermatological disorders, and what you should look out for.

So what is pemphigus?

Pemphigus is a rare chronic blistering skin condition that is caused by the immune system attacking the body. These types of diseases are called autoimmune diseases, and in this case, your immune cells are making antibodies against your skin, specifically the epidermis. This means that the disease is not contagious, and cannot be transferred to people by any mode of transmission (i.e. blood, fluids).  It can happen to people at any age, but it tends to happen to middle aged adults or older adults.

Pemphigus vulgaris: this subtype of pemphigus creates blisters that generally start in the mouth and then appear on the skin or the genital mucous membranes (i.e. vagina, urethra, and underside of the foreskin). There can also be nail loss, alteration of the skin pigment, and severe disability if it is not taken care of quickly. Pemphigus vulgaris is not a disease that will go away by itself. It needs active treatment to control the flares and reduce downstream complications.

What should you look out for?

Pemphigus causes severe blistering in the mouth and other parts of the skin. Sometimes your skin can readily peel off and this can lead to increased infection, dehydration, and disfigurement. The blistering can be very painful, can have severe itching, and can even burn. 

The type of blister you get is also characteristic of the disease: big, flaccid bullae that burst easily. This means that the blisters will rarely form because they rupture almost immediately after they form. The rupturing blisters lead to multiple, superficial, ulcerated sores throughout the mouth. These painful sores are the more common sign that people initially see. 

What should you do if you suspect you have this?

If you suspect that you have this type of dermatological disease or any other concerns with your skin, contact your dermatologist. They will be able to guide you and work with you to see exactly what you have. There are also fantastic resources on our website about pemphigus and other blistering skin diseases that you can read about on Patient Resources page.

Dr. Fivenson is a nationally recognized specialist in autoimmune skin disorders, like pemphigus. He is board certified in dermatology and immunodermatology, and has published over 125 peer reviewed articles in dermatology. 




Global climate change is reaching critical mass. Since the advent of the industrial revolution, we have seen the global mean temperatures raise by 1°C (1.8 °F) and major steps must be taken by 2030 in order to mitigate an even larger global temperature increase of 1.5-3C as predicted by 2030.1 In other words, we are in dire need of change.


This change is not only reliant on governmental policy change, but is a change that we must all make individually. Personal responsibility is key to reducing this detrimental change to our planet. From drinking less bottled water to carpooling, every personal action can play a major role in impacting our planet’s well-being.


In 2018, the American Medical Association passed a resolution to “divest from companies that get the majority of their income from fossil fuels.”2 This was a huge step forward for the AMA and doctors everywhere who advocate for change in the practice of medicine.

The divestiture is much larger than just moving investments away from fossil fuel companies, it also includes a pledge that states that the AMA will only do business with vendors that have environmental sustainability policies. This move shows that the AMA, and doctors across the United States, are ready to make impactful changes that can serve as a template for other industries in the fight against climate change.


The AMA took a similar stance against the tobacco industry in the early 1980s, and was able to divest $1.4 million dollars from its pension fund.3 This separation from the tobacco industry shifted the public’s view of cigarettes, and the positive effects are still being felt today. The move that the AMA made to divest from fossil fuels will, hopefully,  have similar effects .


In terms of dermatological health, there are many diseases that have seen increases that are related to climate change:


  • Lyme disease has tripled over the past 20 years and this believed to be due to the increased geographic distribution of the white tailed deer and Ixodes tick, the natural vector of the bacteria that causes Lyme disease.4 Dermatologists play an important role in early diagnosis of this disease due to its distinct targetoid rash pattern.


  • Fungal infections such as coccidioidomycosis have also seen increases in the Pacific Northwest. These fungal diseases were once only seen in the American Southwest, but have seen a surge in occurrences due to climate change creating new regions where the fungi can thrive.5


  • Skin Cancer is the most common cancer in the United States and 1 in 5 adults will have it in their lifetime.6 Over the past several decades there has been decreasing stratospheric ozone layer from chlorofluorocarbon release from aerosols, has led to increased UV exposure to human skin and increases in skin cancer. It is estimated that 1% loss in the ozone layer leads to an increase of 1-2% incidence of melanoma.7 In addition, warmer temperatures are directly correlated with people spending more time outside which leads to UV radiation exposure and further increases the risk of skin cancer.


These are only a few of the many diseases that have seen increases due to climate change. With wildfires and floods becoming more common and serious in the United States, the burden of climate change is becoming more pronounced.


It is no longer a political talking point or a problem for tomorrow. There are real ramifications to our actions that are being felt now. “In 2013, over 9100 scientists authored more than 2250 climate change articles with broad agreement on climate change.”8 There is an overwhelming consensus in the scientific community that climate change is real, and it is happening now.


These changes may seem daunting and insurmountable, but this is not the case. There are many things you can do to reduce your impact on climate change. Here are some things to consider:

  • Use LED light bulbs
  • Change home filters regularly and maintain air conditioners and heaters
  • Avoid plastic bottles; drink tap water if possible
  • Choose an electric or low emission vehicle
  • Carpool, ride a bicycle, or walk to places when you can
  • Encourage your friends and family to conserve and recycle
  • Reduce red meat consumption - this decreases methane release from meat production. Methane is a chemical that increases the greenhouse effect, like carbon dioxide, and thus increases the warming of our planet.

For more suggestions, please see the resources for climate change education we have posted on our Climate Change page.


Check out our Facebook page ( for more updates and stay tuned for more blog posts about dermatology news, tips, and insight!


You can also visit us on for more patient resources about skin health!


Feel free to leave a comment below talking about your experiences, and what you have done to be more green! We would love to hear your input on the topic.




[1] Dermatol, J. (n.d.). Dermatologists' role critical in depoliticizing climate change. Retrieved from{bb70fa29-8fbc-463a-84e9-c1f2f9b7cdea}/dermatologists-role-critical-in-depoliticizing-climate-change

[2] AMA Passes Resolution on Divesting from Fossil Fuels. (2018, July 05). Retrieved April 16, 2019, from

[3] AMA drops tobacco stocks. (1981, September 29). Retrieved April 16, 2019, from

[4] Kaffenberger, B. H., & Rosenbach, M. (2017). The effect of climate change on skin disease in North America. JAAD. Retrieved April 16, 2019.

[5] Kaffenberger, B. H., & Rosenbach, M. (2017). The effect of climate change on skin disease in North America. JAAD. Retrieved April 16, 2019.

[6] Bharath, A. K., & Turner, R. J. (2009, June 01). Impact of climate change on skin cancer. Retrieved April 16, 2019, from

[7] Bharath, A. K., & Turner, R. J. (2009, June 01). Impact of climate change on skin cancer. Retrieved April 16, 2019, from

[8] Khalifian, S., & Rosenbach, M. (2018). Dermatology, climate change, and the perils of attacks on expertise. JAAD. Retrieved April 16, 2019.


By Sultan Qiblawi
May 15, 2019
Category: Uncategorized
Tags: Skin   Summer   Sunscreen   UV  



With summer right around the corner, most of us will be outside more often and enjoying the sunshine. From traveling across the world, to hanging at the beach. There is one thing we can all count on when the temperature goes up; more sun exposure! While getting some sunlight is very important, it is also important to protect your skin from too much sun exposure. Here’s how you can get ready with our 5 tips for summer skin health.


1. Avoid the sun from 11am to 3pm!

Why? These are the hours that harmful UVA and UVB rays are the strongest. Both Ultraviolet A and Ultraviolet B rays have been linked to skin cancer and it is important to avoid going outside when these rays are the most abundant.

According to the American Academy of Dermatology, skin cancer is the most common cancer in the U.S, and will affect 1 in 5 Americans during their lifetime. Due to this fact, it is important to avoid excessive amounts of UVA and UVB, if possible.

2. Cover Up!

Wear clothing that covers your skin and a hat. Long sleeves and sun hats are helpful for reducing the amount of harmful rays that reach your skin. Look for clothing that have a UPF rating of 50+ as this provides the best UVA and UVB protection.

UPF is the ultraviolet protection factor and it measures the amount of UV rays the clothing blocks from reaching your skin.  UPF measures the fraction of ultraviolet waves that can penetrate the clothing fabric.Example UPF 50: allows just 1/50th of sun’s UV radiation to reach the skin

3. Use sunscreen - the right way!

If you are going out, wear a sunscreen with an SPF of 30 or greater.


Make sure to apply the sunscreen 15 to 30 minutes before you go out.


Apply sunscreen to all bare skin. For adults this means 1 ounce to fully cover the body surface.


Use a broad spectrum sunscreen. This means that the sunscreen protects the skin from UVA and UVB rays, which have both been shown to cause cancer.


Use a sunscreen that is water resistant. Look for sunscreens that are water resistant (meaning they are water resistant for 40 minutes) or ‘very water resistant’ (which means they are water resistant for 80 minutes). It is important to note that sunscreens are NOT waterproof or sweatproof, so you must reapply them every 2 hours or after swimming or sweating.


4. Avoid tanning beds!


A “base tan” does not reduce sunburns, it just results in more overall UV exposure.UV light  damages the DNA of your skin, which increases the risk of getting skin cancer.


Tanning beds can also lead to premature aging, wrinkles, and age spots.


5. Can I use that bottle of sunscreen from last summer?

According to the American Academy of Dermatology, The FDA requires that all sunscreens retain their original strength for at least 3 years (as long as kept in the dark and at room temperature).

Look for an expiration date on the sunscreen, some will include it, but others will not. If it is expired, throw it away because it will not be as effective. If you buy a sunscreen without an expiration date, write the date you bought it on the bottle, so you know when to throw it out (3 years from the date of purchase).

Look for changes in consistency of the sunscreen, or any changes in the color. These can be signs to throw it away and buy a new bottle.


Like and subscribe to our Facebook page: and keep reading our future posts for more skin health tips! You can also visit us on for more patient resources about skin health!

Check out these great resources for more skin health tips:


American Academy of Dermatology:

Skin Cancer Foundation:

Melanoma: How can you avoid too much sun?:


Sultan Qiblawi

Fivenson Dermatology


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