Most of us can identify freckles. They are small (usually less than 0.5 centimeters), harmless brown spots that show up on the face, neck, shoulders, chest, arms, and backs of hands. Fair-skinned people and people of Celtic origin with light or red hair and blue eyes often have freckles. Freckles develop due to a combination of genetics and sun exposure. Your skin contains cells called melanocytes, which manufacture the pigment melanin. After exposure to ultraviolet (UV) rays, the melanocytes accelerate production and deposit the pigment in one spot in the skin.1 The spots fade or disappear when you stay out of the sun but then reappear with sun exposure. That’s the key difference between these brown spots and others that occur on our skin. They are neither moles (nevi) nor skin cancers, because those don’t come and go but, rather, barely change or continue to grow.

How to Prevent Them (If Possible)

While the freckles themselves do not pose a health risk, people with a proclivity to freckles are also candidates for skin cancer. Therefore, those who easily develop freckles should avoid the sun and certainly tanning beds, and use a broad-spectrum sunscreen of at least SPF 30. The National Weather Service and the Environmental Protection Agency (EPA) developed a zip-code-based UV index to forecast the risk of excessive exposure to UV rays. You can access the index, which tells you how cautious you should be when outdoors in your area, on the EPA’s website: www.epa.gov/sunsafety/uv-index-1.

Treatment Options

Freckles are generally harmless. However, if you don’t like your freckles for cosmetic reasons, try covering them up with makeup, or better yet, stay out of the sun, to minimize their appearance and decrease your risk for premature aging and skin cancer, too! There are treatment options to lighten many of your freckles and maybe even eliminate some of them, but in general, the results are temporary. Sunlight is the main instigator, so if you protect yourself from UV rays, you may be able to slow the return of your freckles, but don’t be surprised if they reappear. Embrace them! Many people consider freckles a sign of cuteness or youthfulness. Smile and be proud of your freckles!

1. SKIN-LIGHTENING CREAMS, also known as bleaching creams, containing kojic acid and up to 2 percent of a depigmenting agent called hydroquinone can be purchased over the counter. You’ll have to get a prescription for products containing higher concentrations of hydroquinone. You must apply these creams consistently over several months to see lightening. The best results come by combining regular use with sun avoidance.

Dermatologists in the United States typically prescribe topical hydroquinone cream in higher strengths—usually 4 percent and sometimes as high as 8 percent or more—but this is not without some controversy: in 2006 the US Food and Drug Administration (FDA) proposed banning hydroquinone because studies testing the medication in rodents showed that it heightened the risk of cancer if administered to the animals in very high doses via a feeding tube. Keep in mind that the results of animal studies are not always replicated in humans. There remains no ban on the topical use of hydroquinone; in fact, no evidence of increased carcinogenic risk in human beings has ever been reported. But due to this history and information, some people fear using this product on their skin. Personally, I don’t know a dermatologist anywhere in the world who refuses to prescribe topical hydroquinone in the strengths we favor. However, hydroquinone needs to be prescribed responsibly—not because of any risk of cancer but rather the risk of developing a skin condition called ochronosis.

It is ironic, given that patients may use hydroquinone to lighten their skin, that long-term use of the agent in high concentrations may actually darken the skin, causing a blue-gray pigmentation. Ochronosis may or may not fade after the person discontinues hydroquinone. Because of this, many dermatologists will not prescribe it in strengths above 4 percent. But I have seen prescriptions as high as 16 percent written by other physicians. I advise caution with the use of such high strengths, especially for a long duration. You don’t want your skin to turn even darker when you’re just trying to lighten and brighten it a little!

1. THE RETINOIDS TRETINOIN (RETIN-A), TAZAROTENE (TAZORAC), AND ADAPALENE (DIFFERIN) are often combined with topical skin-lightening creams to help lighten freckles over several months when applied regularly.
2. IN CRYOSURGERY, LIQUID NITROGEN is applied lightly to the skin, essentially creating a superficial frostbite. Most freckles respond to this safe, simple procedure. Liquid nitrogen treatment can potentially leave a permanent white spot by inadvertently destroying the pigment-producing cells at the treatment site if treatment is too aggressive. Accordingly, your doctor may start slow and small to see how your skin responds.
3. SEVERAL TYPES OF LASER TREATMENTS have demonstrated a high success rate in fading and removing freckles. These are safe procedures with a low risk of discoloration or scarring. Neodymium:YAG and alexandrite lasers, the most common ones used, release small bursts of a specific wavelength to destroy the colored pigment that the freckles absorb.
4. INTENSE PULSED LIGHT (IPL) TREATMENTS also lighten and remove freckles successfully. The pulsed light device distributes a broad wavelength of light, and that energy is also absorbed by the pigment of the freckle, destroying it.
5. CHEMICAL PEELS can provide great results in removing freckles. Peels cause the outermost layers of your skin, which contain much of the pigment that makes up a freckle, to desquamate, or peel off.

Healing Time/Results, or “What to Expect”

The aforementioned treatments are generally successful, but everyone’s skin is different, and results will vary. Oftentimes multiple treatments or a combination of treatments are required to achieve optimal results. Even if your freckles are removed completely, it’s important to know that the spots can reappear with repetitive UV exposure. Think of it as a maintenance treatment: you will need to return regularly—maybe on a yearly basis—for touch-up visits, depending on the number of freckles you have and the level of improvement you want.

What You Can Do at Home, Where Applicable

Wear your sunscreen daily and reapply it every two hours if you have been actively perspiring or have gotten wet. At home, daily bleaching creams also do not require a visit to the doctor.

Okay, I don’t want to freak you out, but what you may think is a freckle could be something dangerous, like a skin cancer. The $10 million question is: How do you know? Well, there is a simple way to remember the potential signs of melanoma, which we commonly call the ABCDEs of melanoma:

A stands for asymmetry. If you drew a line down the middle of a freckle, are the two sides near mirror images of each other? Or does the spot have an irregular shape, with the two parts looking very different? That’s a characteristic of melanoma.

B stands for border. Look for a jagged or otherwise irregular border.

C is for color. Does the color look mottled?

D is for diameter. Is the “freckle” larger than a green pea?

E is for evolution. Has it changed noticeably in size, shape, or color over a few weeks or months? Always see your doctor if you notice changes in your skin, including any of the ABCDEs of melanoma.

When to See a Doctor

Your dermatologist is trained to evaluate you for skin cancer. Make an appointment right away if you notice a freckle, mole, spot, or growth that is new, changing, irritating, bleeding, asymmetric, has irregular borders, is variably colored, or is otherwise bothering you. If you can’t see a dermatologist, consult your primary health care professional, and if necessary, they will refer you to a dermatologist.

IF YOU ARE A REGULAR VIEWER OF MY YOUTUBE CHANNEL, YOU WATCH ME address all kinds of skin-related topics, using specific medical terms. I tend to stick with what works, the tried and true, but, of course, I have learned many things along the way. Here I’m going to give you a crash course in Dr. Pimple Popper and some skin basics. This will set you up for what follows in the rest of the book and give you a chance to think about your own skin. It’s important when you read Put Your Best Face Forward that you don’t think I’m speaking a foreign language! Just as people use the metric system to talk about measurements, dermatologists use their own special terms to understand and communicate skincare concerns and concepts. These important terms and techniques help you understand the different conditions and treatments I refer to in the book and on my social media. This guide can even help you to understand your own skin better, and to discuss questions and concerns with your dermatologist. (They’ll be impressed by your new vocabulary!)

A PRIMER ON DERMATOLOGIC LESIONS

• MACULE: This completely flat lesion on the skin measures less than 1 centimeter in diameter and can be any color of the rainbow. A good example is a freckle or a flat mole. When you run your finger over it, you don’t feel any change in the surface of the skin.
• PATCH: A patch is flat just like a macule, only larger (greater than 1 centimeter in diameter). Examples include vitiligo (white patches where pigment cells have been destroyed), melasma, and a large, flat birthmark.
• PAPULE: An elevated, raised, well-rounded growth projecting from the skin’s surface that is less than 1 centimeter in diameter. This is different from a blister, a vesicle, or a pustule. Good examples are a raised mole, a cherry angioma, a seborrheic keratosis, and a wart.
• PLAQUE: This is what we call a papule that is greater than 1 centimeter in diameter. Again, it’s elevated and well circumscribed. Psoriasis is commonly described as plaque-like growths, but many other dermatologic conditions appear as plaques.
• NODULE: A raised growth under the skin, but it is deeper seated and not as superficial as a papule. You popaholics know this well. A nodule is often at least 2 centimeters in diameter, or about the size of a penny. We use this term to describe lesions such as cysts, lipomas, keloids, and two common skin cancers, basal cell carcinoma and squamous cell carcinoma. See, I taught you something without your even knowing it!
• VESICLE: A raised, well-circumscribed growth, less than 1 centimeter in diameter, but primarily filled with a clear liquid. This is what we see in cold sores (herpesvirus), chicken pox, and shingles.
• BULLA: This is something many of you popaholics would get excited to see, because it’s essentially a big blister; a large, water-filled vesicle greater than 1 centimeter in diameter. This is how we describe a friction blister (the type of blister we get from ill-fitting shoes), and also, we see it in many blistering disorders of the skin.
• PUSTULE: An elevated, circumscribed growth that is much like a vesicle, but instead of being filled with a clear liquid, it is filled with a purulent fluid, pus. This is seen in acne.
• CRUST: A layer of dried sebum (an oily substance secreted by the sebaceous glands located in the skin and often attached to hair follicles), pus, or blood mixed with epithelial (tissue) or bacterial debris.
• SCALE: An excess buildup and/or shedding of stratum corneum, the outermost layer of the skin.
• FISSURE: A linear crack in the skin, which can often be quite painful. You may get one or more of these on the heel of your foot or even on your tips of your fingers when the areas are irritated.
• EROSION: A superficial open wound with loss of skin.
• ULCERATION: A deep open wound with a partial or sometimes complete loss of skin and even deeper structures.
• EXCORIATION: Loss of skin due to picking or scratching.
• ATROPHY: A thinning of the epidermal or dermal tissue.
• LICHENIFICATION: An increase in skin lines and creases as a result of chronic rubbing.

The Truth About Tumors

When many people hear the word tumor, they automatically think of something malignant (cancerous) and life threatening. I think of that scene in the movie Kindergarten Cop where Arnold Schwarzenegger yells to the kids, “It’s not a too-mahhhhh!!” Actually, tumor is a generic term, simply meaning a growth on the skin or on an organ within the body. We refer to nonmalignant tumors as benign. So don’t let the word tumor frighten you!

THE TECHNIQUES AND INSTRUMENTS I USE AS DR. PIMPLE POPPER

NUMBING MEDICATION AND 30-GAUGE NEEDLE

I probably get the most complaints about posting video footage of numbing procedures, including videotape of my administering anesthesia with a needle and syringe. It gives many people more heebie-jeebies than the purulence, or pus, that emits from an abscess does! But it’s important you see what I do here.

I would certainly argue that dermatologists are the best compared with any other medical specialty when it comes to administering local anesthesia with the least amount of pain and discomfort possible, since we do this on a daily basis. I actually perform many maneuvers at the same time when I stick someone with a needle. I know that this is one of the main reasons why some people avoid going to the doctor: they are afraid of needles. My ultimate goal is to anesthetize patients painlessly—in fact, to numb them before they even realize I’m doing anything at all to their skin—because it instills trust between patient and dermatologist. Here are several of my favorite techniques:

1. HIDE THE SYRINGE: Needles are not on display in my office. They are hidden in my pocket or held close to my side, passed to me on the sly by my assistant—certainly not waved in front of patients to increase their anxiety.
2. I’M “BASIC”: Numbing medication such as lidocaine is acidic, which is why it burns when we inject it under the skin. We temper this burning sensation by adding sodium bicarbonate to the mix. NaHCO3 raises the pH of the liquid, reducing the acidity and thus making the injection more comfortable.
3. 30-GAUGE NEEDLE ONLY: I don’t use any needle thicker than a 30-gauge, which is very thin: not much wider than the size of a single hair. Because the smaller the needle, the smaller the pinch; the smaller the pain, the smaller the hate.
4. SHAKE OR PINCH THE SKIN WITH MY NONDOMINANT HAND: This is an important one, and one that draws a lot of attention on my videos. People watching sometimes think I’m nervous or have a tremor. I don’t. I’m actually doing this purposefully.
5. INJECT SLOWLY AND TAKE ADVANTAGE OF FIELD EFFECT: This is actually something I don’t think a lot of physicians realize if they don’t inject as often as we dermatologists do all day, every day.
6. TALK-ESTHESIA: An important one. I don’t think I’m actually a chatterbox in real life. (I’ll bet that many of you who’ve watched my videos find this hard to believe.) But I ask open-ended questions, or just chatter on about current events or even about myself, to distract the patient from the task at hand, including the sounds that the scalpel makes as it cuts the skin and the “sliding” sound of the suture (stitch) that passes through the skin. Also, if a patient is formulating an answer to one of my questions, his or her focus is no longer on the surgery. It’s all about distraction, and it works.

11 BLADE VERSUS 15 BLADE

These are the two main types of surgical blades I use. The 11 blade is what I rely on instead of lancets (small, short pins), because it comes to a very sharp point and allows me to nick the skin very superficially to cause as little damage as possible before I extract a whitehead or milium. I use a 15 blade in surgeries to excise tissue before I place sutures, or to shave off a layer of skin to send for a biopsy.

COMEDONE EXTRACTOR AND TWEEZER

There are so many different types of comedone extractors, but the Schamberg-type tool is really my jam. It avoids excess trauma to the skin and allows controlled, even pressure around blackheads or milia in order to best extract them efficiently.

The comedone tweezer is something I’ve discovered myself because of—guess what?—social media! I, too, was transfixed by videos that I saw on Facebook and Instagram of a physician using a curved tweezer to push against the skin and then to pull out completely the extruded blackhead. I’ve tried it out, and I like it, but it doesn’t replace my original comedone extractor. It’s also particularly satisfying to pull out sebaceous filaments using these funky-shaped tweezers designed specifically to get into tight spaces and pull gently from the skin stuff that shouldn’t be there.

THE PUNCH VERSUS EXCISION

Many of you ask me how I decide which approach to use in removing a cyst: whether to excise the area or to pull out the “punch” biopsy tool that so many of you are enamored of. Well, it has everything to do with the size of the cyst, its location, and my mood that day. In other words, there are many instances when I can do either a punch or a standard elliptical excision, but let me explain my criteria for choosing one option over the other.

In all instances, I could perform a standard elliptical excision, but sometimes the punch excision is quicker, which is partly why I may choose it. First, you should understand that this circular cookie-cutter-type tool is traditionally used to take a skin sample (biopsy) when the goal is to obtain a deeper component of skin, as opposed to a shave biopsy, where we merely take off the superficial layer. We also use the shaving technique to take off a mole sitting up on the skin, so that the area is left flat and flush with the regular skin.

The punch biopsy tool takes a core of tissue so that we can assess the dermal and subcutaneous tissues, the deeper components of the skin. In the case of cyst removal specifically, I use the punch tool to create a larger opening in the cyst so that I can squeeze out its contents and keep the surgical repair line short. Punches come in many different sizes, from as small as 1 millimeter to probably as big as 2 centimeters or so. There are even elliptical-shaped punches (which I don’t use because you can’t cut through the skin with a twist, as the tool is not circular). It’s important to understand that the larger the circular punch, the more difficult it is to close the resulting wound from side to side without creating “dog ears” or “Burow’s flaps”—that is, pooching up of the outer edges of the surgical wound.

This is actually why excisions are elliptical or diamond shaped. Seamstresses understand this concept, as they know that a circle cannot be sewn together without getting bumpy, but “darts” have to be created on the outer edges so that the clothing will lie flat. This is why I perform punch excisions of cysts only if the sacs are on the smaller side. I really use only punches that range in size from 2 millimeters to 5 millimeters; any larger than, say, 6 millimeters, and the dermatologist will need to convert to a more elliptical excision, so I might as well do that in the first place!

Location is also important when determining punch versus standard excision. Areas with thinner and more mobile skin and areas that are generally covered by clothing would be possibly punchworthy. You really won’t see me doing a punch on the face unless the skin is really loose and movable, as in the case of an older gentleman with thin cheek skin. Elliptical excisions are more elegant and cosmetically superior. I don’t use a large punch excision on the thick and stiff skin of the back in a large person because a slit excision may be preferable: any wideness to an excision has to be pulled together, and the more tension that is created, the wider the excision, with increased risk of the scar spreading and an inferior cosmetic result.

AND THE CURETTE RAN AWAY FROM THE SPOON

Before I “became” Dr. Pimple Popper, I was handling maybe ten cyst excisions a year; now I probably do about that much in a week. Needless to say, I’ve gotten better at preparing and predicting cyst behavior, improving the final result, and decreasing the incidence of recurrences. There’s actually a video on my YouTube channel that shows the moment I realized that the curette would be pretty useful when ensuring the complete removal of cysts. The curette is a standard instrument used by medical dermatologists, but most commonly, it’s for scratching or scraping off lesions that grow atop the skin—particularly seborrheic keratosis. I also use a curette to clean out the “hole” at the excision site, to ensure that the entire cyst and cyst wall have been eliminated. Leaving behind any tissue from the cyst wall heightens the risk of a recurrence.

MESSY VERSUS CLEAN CYST EXTRACTION

As with politics, this is a divisive topic. Some people prefer watching messy cyst extractions; others prefer watching a cyst excised completely cleanly and intact. I just wonder if one group is composed more of Democrats and the other of Republicans. But as a physician, I always stay away from the topic of politics! Personally and professionally, I prefer a clean extraction, mainly because this reduces the odds of the cyst recurring. Also, as you have seen from my videos, the contents of a cyst sac can be all colors of the rainbow, chunky like cottage cheese or egg salad, creamy like mashed potatoes, or thick and sticky like oatmeal or wet newspaper.

I know you’re not grossed out if you’re a popaholic! In addition, I have learned that the larger the cyst size and the longer it’s been around, the more likely the contents have liquefied somewhat, so if this cyst is opened rather than removed intact, it can create quite a mess. And you guys don’t have smell-o-vision, but you often comment on this; you both want to know and don’t want to know what the contents of the cyst smell like. Well, in general, we in the room don’t want to know, so if we avoid opening up the cyst, we minimize any odor detected.

What do these pops smell like? Not all of these growths I pop out from the skin smell, but like I say all the time, I don’t really try to smell them! We all wear masks, and I would say that smell is not my dominant sense. (Thank goodness in this case.) However, I know that so many of you people are curious about this, so let me give you the best idea, and maybe one of these days I can create a scratch-and-sniff that you guys can get and see for yourself! First of all, it’s mainly epidermoid cysts and infected cysts that have a strong odor. But not all epidermoid cysts have a strong smell. Lipomas don’t smell; they look like raw chicken breast, so I’m guessing if I stuck my nose real close and took a whiff, they would smell like that?

But trust me, I’m not trying this anytime soon. Pilar cysts often don’t give off an odor. However, noninflamed epidermoid cysts can certainly emit a pungent odor that often stays with you hours later, and I’m always reminded that the reason we smell things is because tiny microparticles actually escape into the air and get caught in our nasal passages and nasal hairs, so we are actually inhaling and ingesting odors in order to “smell” them. Gross, huh? Thought I would share that with you. Since I have to deal with that unnecessary and regrettable knowledge, so should you!

YOU KNOW THOSE TIMES WHEN—BING!—YOUR EYES JUST POP OPEN WITH some profound realization you had overlooked before? For me, it was just past three o’clock in the morning when I felt a wave of anxiety wash over me. “What did I do yesterday?” I thought to myself. Did I really just start a GoFundMe page for one of my patients, whom I affectionately call Pops, without asking his permission? The day before, I had posted a video on my YouTube channel, Dr. Sandra Lee (also known as Dr. Pimple Popper), of some amazing blackhead extractions I had done on Pops. Blackheads, which are open comedones, are like snowflakes: each one is an individual; they are so satisfyingly unpredictable. Sometimes you squeeze one and get the most amazing pop: you never know if it will sputter out with a little light pressure from my comedone extractor or if it will slide out smoothly. Pops’s blackheads were no different, and removing them had been an ongoing journey for us, since he had so many of them.

I have to back up a bit here for those of you who are not avid “popaholics,” as I like to call them. The story of how I came to be Dr. Pimple Popper was unexpected—kind of a happy accident that I noticed and seized upon, and Pops has a lot to do with it. I have been a board-certified dermatologist in private practice for more than a decade, specializing in skin cancer and cosmetic surgery and reconstruction and laser surgery. You may wonder, aren’t extractions something a dermatologist does regularly? Isn’t this what a dermatologist is supposed to do? It’s not that dermatologists aren’t capable of “pimple popping”—that is, extracting blackheads, whiteheads, and milia, and surgically excising cysts. It’s that this is such a small part of what our profession is about. We are experts who deal with all medical conditions of the skin, hair, and nails. And believe you me, there are so many!

In 2014 I had started an Instagram account, @DrSandraLee, intending to showcase my life as a dermatologist—to educate people on the many facets of my profession. Instagram is flush with gorgeous filtered images: mouthwatering pictures of food, exotic places traveled, and beautiful do-it-yourself makeup, hair coloring, and styling tutorials. I saw a quickly increasing popularity among makeup and hair gurus, as well as a growing interest in spa treatments and cosmetic treatments. Would these same people, and others, be interested to see what I do day-to-day, as well? Hmm . . .

One day Pops came in for a regular appointment, but something was different. For years, I had seen him as one half of a whole, or what I lovingly call a “package deal,” meaning that he and his wife came together. Always. Except this time, his wife wasn’t with him. I knew she had been ill; recently, she had taken to waiting in the car during his appointments, not feeling up to coming into the office. I couldn’t help but ask how she was doing, and instantly regretted doing so.

“She’s gone.” Pops choked back tears and looked down at his hands. She’d been his whole life. She ran the show. And now he was lost without her. I noticed that his clothes weren’t as neatly pressed as they usually were, he had a stain on his slacks, and his hair appeared a little more disheveled. Nothing I do can take away a person’s emotional anguish, but I wish I could have waved a magic wand and made some of that pain and sadness disappear. Opening a GoFundMe page in his name was an impulse move—a result of my learning about his economic hardships and overwhelming grief since his wife had passed away. People who watched my videos from around the world sent the kindest messages of hope and love to Pops and donated money to help someone whose face they’d never seen! They’d just heard his story and knew every blackhead extracted from him by heart! My popaholic fans are amazing: we ended up exceeding the $5,000 goal and raised more than $14,000 for Pops!

Pops and his wife had been my patients for many years, but in all that time, I was examining his skin and mainly treating and controlling his precancerous skin lesions and skin cancers (non-life-threatening but locally destructive squamous cell carcinomas and basal cell carcinomas). It actually took the unfortunate passing of his dear wife for me to bring up the fact that those bumps on his nose were benign blackheads and whiteheads. It wasn’t until this point that he confided that he knew they weren’t dangerous, but he absolutely detested them. Not because he could see them; his eyesight was failing and he couldn’t. But because he could feel them, and he couldn’t get rid of them himself, and they made him feel ugly and ashamed.

So I asked him, “Would you like me to extract as many of these as I can? This is a procedure I can’t bill to insurance, but if you allow me to film the procedure for others to watch, I won’t charge you.” He immediately agreed, very happy that I was going to take care of them. This surprised me. I had never offered this service to my patients in the past because, as a dermatologist, I avoid extractions that aren’t medically necessary, as health insurance doesn’t cover them. Patients normally have to pay out of pocket for these “cosmetic” procedures, and they can be very expensive because they are time consuming.

Just a couple of months prior to this, I had posted a video on Instagram of me extracting a blackhead on the back. To my surprise and curiosity, there was a noticeable increase in “likes” on this post and, subsequently, on any posts involving “pimple popping.” In fact, my most popular Instagram posts were simple blackhead extractions. Would followers be interested in other things that I pop out of people’s skin? Yes! People were mildly interested in what it looked like to administer Botox or treat a wart, or even to see what psoriasis looked like. People seemed to get really excited, though, when I posted a milia extraction or a blackhead squeeze. Once they saw that, they were hooked. I am talking about unbridled enthusiasm. People who liked it loved and obsessed about it. People who hated it detested it. Either way, they tagged their friends because they just had to share. I had happened upon the discovery of a pretty substantial demographic of popaholics.

No longer wanting to limit myself to fifteen-second clips on Instagram (today the app lets you post one-minute clips, but back in the olden days—a couple of years ago—fifteen seconds was its limit), I posted a full-length pimple-popping video to my YouTube channel, a platform I had created and originally used for TV appearances, and which was meant to appeal to a much smaller fan base. What should I call this Instagram page and YouTube channel that I would devote mainly to sharing things that I’m able to pop from the skin? Well, I gave myself the moniker Dr. Pimple Popper, and things really erupted from there.

People were demonstrating a substantial interest in an area of medicine that usually doesn’t get much attention. My YouTube videos of Pops, his blackheads, and his emotional progress after losing his wife have been viewed—get this—more than sixty million times! As I write this, I have exceeded 2.5 billion total views on my YouTube channel, with the vast majority of them coming since 2015. Because of this social media exposure, which I created in a very DIY fashion, I went from being a private-practice physician to an international social media personality and influencer, with beauty magazines and TV talk shows seeking my expert opinion, and my social media pimple popping being featured in the Wall Street Journal, the Washington Post, and New York magazine.

I’ve come to realize that it’s a shame most dermatologists don’t treat these benign cosmetic conditions, because it’s very obvious to me that these “ugly” bumps and embarrassing spots on our faces and bodies have so much to do with how we feel about ourselves, and this, of course, affects every aspect of our lives.

Now if I notice that one of my acne or skin cancer patients has a blackhead or milium, I like to offer to extract it for free in exchange for permission to videotape the procedure so I can post it on my social media. Happily, very few people decline this offer. I’ve been pleasantly surprised to learn that they are extremely grateful that I suggest it, making for win-win-win situations. My patient gets rid of something that has been bothering them for some time, and at no cost. Viewers of my YouTube channel, Instagram, Snapchat, Twitter, and Facebook page get to witness the glory and satisfaction of a good blackhead extraction. Finally, for me it’s been an unexpected win, as I hadn’t realized how very appreciative many of my patients would be after I removed a growth that had been a source of embarrassment, shame, and even depression because other physicians may have refused to remove it.

I really have no simple clear concrete idea why people like to watch pimple popping, but I certainly have some theories. For many, it’s akin to slowing down and staring when driving past a car wreck, while for others, there is this feeling of fright followed by euphoria and exhilaration, similar to riding a roller coaster or watching a scary movie. And for those who keep coming back, there is something hypnotic about watching a pop or a squeeze or even an incision; it’s satisfying on a deep psychological level, perhaps because eliminating a blemish of any kind offers a sense of closure, resolution, and accomplishment. Ultimately, the reason I continue to do this, and why my viewership continues to grow, is that watching pimple popping seems to make people happy. Can you believe that? It’s fascinating to me and mind boggling at the same time.

How my life has changed since I started posting my work on social media. I would have thought the private practice I share with my dermatologist husband, Jeff Rebish, in a quiet suburb of Los Angeles would continue to grow gradually over time and that my workdays would be filled with surgical and cosmetic procedures: Mohs micrographic surgery (a technique to remove skin cancers), Botox and fillers, acne treatment, eyelifts, liposuction, and lasers to treat brown spots, red spots, and fine lines and wrinkles. A few years ago, I never would have believed that I would be extracting thousands of blackheads, cysts, lipomas—anything that pops from the skin. I have removed more blackheads, excised more cysts, and popped out more lipomas in the last few years than I have during my whole dermatology career before then—times a hundred!

I still do all the things a dermatologist does in private practice, but the other day, before my first patient arrived, I filmed a segment with a British TV talk show about how celebrities with acne get red-carpet ready. The next day, I talked to an Australian morning radio show about what makes people obsessed with popping pimples. A few days later, I answered questions about skin on Facebook Live with a well-known American magazine. After that, I collaborated on a video with a famous YouTube star from Amsterdam. And now I have a television series on the TLC channel, named, appropriately, Dr. Pimple Popper.

Fame has its moments too—good and bad. My least favorite experience was when I just had my first child via C-section and I was in the hospital recovering. The nurse came in the day after delivery, woke me by opening the drapes to bring light into my room, and announced I needed to get up and use the bathroom. One of the first major steps you have to take to get a hospital discharge is to be able to use the bathroom on your own. Man, that was tough! I hobbled slowly, completely stooped over, making my way to the bathroom while almost overcome with waves of nausea and light-headedness—I thought I was going to pass out! I left the bathroom door open so the nurse could get to me in case I hit the floor. As I was sitting on the toilet trying to catch my breath, I’m sure with no color in my face, the secretary at the labor and delivery desk darkened my bathroom doorway. “Hi, remember me?” she said excitedly. “You saw me for the spots on my back a few months ago, and I have more and was wondering if you could take a look and tell me how I can get rid of them?” Please don’t do that to anyone.

Another instance was when a patient’s daughter approached me on the golf course. I was in midswing when I heard a golf cart approach me from behind. Her father had instructed her to cross over two golf fairways to ask me to look at the mole on her back and tell her it was okay! Please don’t do this to your dermatologist. It’s difficult to assess your moles or give you any skin advice when we are away from our office and don’t have your personal history in your chart or our instruments to properly assess your skin growth. Needless to say, I took a mulligan on that hole!

It’s not that I don’t want you to say hello when you see me, but try to save the medical questions for the office setting, please. Okay, well, I do secretly have a favorite time when a patient of mine approached me. In the grocery store, this happens every now and again: A sweet patient will come up to me and say “Hi, Dr. Lee, it’s So-and-So. Remember me? You did surgery on me last month!” My favorite response: “Oh, hi! Sorry, I didn’t recognize you with your clothes on!” I love doing that. Makes my day, haha.

Putting my work life on display on social media was eye-opening to me, because it validated to me that the hard work I put into making sure my patients are comfortable and relaxed in my office is truly one of my best attributes as a physician. And I really learned this from my father. I still recall the words he told me in the first few weeks I began work as a dermatologist myself. He said to me: “Always remember, Sandra, that the physician that graduates at the very top of his medical school class, who receives the most respected accolades and awards in medical school and residency, who is considered one of the most intelligent physicians around, can have a crappy bedside manner—be cold and curt, impolite and condescending, and will quickly be regarded as a terrible doctor. Conversely, the physician who had mediocre grades and accomplishments during her training but who has a wonderful bedside manner—who is open, warm, inviting, confident, and inspiring—will easily be touted as an excellent physician in intellect and skill.” Obviously, we all ideally want to be smart and accomplished and have a great bedside manner, but this advice was meant to explain to me that how we treat our patients emotionally is just as important as how we treat them physically. This is one of the very best (but certainly not the only) pieces of advice my father has given me.

LET’S REWIND

I should explain how and why I became a dermatologist, which was much more complicated than a standard résumé can express. The most obvious reason that dermatology was on my radar at all was because my father was a dermatologist (now retired). My father grew up very poor in Singapore, one of ten kids. As a child, he loved to read and was obsessed with books. He would stare longingly into the windows of bookstores. All the money he could scrounge up by doing odd jobs was used to buy books. Needless to say, the house that I grew up in was full of books, with stacks of volumes on every conceivable subject to be found on every table, bedroom nightstand, and even available counter space.

If my dad didn’t know the answer to a question or was just curious about a particular subject, what would he do? He’d buy a book! I knew the aisles of our local bookstore intimately. Nearly every weekend, we used to spend a couple of hours at the shop, where I would wander off to discover the wonderful titles lined up neatly on the store shelves. I’d listen for the comforting sounds of my dad’s keys jingling in his pockets and his whistling familiar tunes—reminders that he was close by. I think my father bought every dermatology textbook ever published!

Just the other day, I was meeting with a group of ladies in their late twenties. One of the women, who is struggling with adult acne, asked me a question that I kind of dread: “What is the one single thing we all can do that can get rid of our pimples?” If I could give her a simple one-size-fits-all answer, I wouldn’t have to work another day in my life and would be living on my own private island!

As with most skincare-related questions, the answer is complicated. I need to know important information before I can give a correct answer that is specific to the person asking a question. You are unique, and so is your skin! Is your skin oily or dry? How old are you? Is your skin sensitive and/or red, or do you have family members with severe acne or other chronic skin conditions? It’s helpful to know your occupation, your hobbies, your interests. In other words, a variety of skin types, genetic factors, and environmental conditions play a role in the kinds of skin issues that plague us. That’s why there are so many treatment options for acne and other conditions. A successful acne treatment plan—or any skincare treatment plan—must be tailored to you personally. And it must be based on your specific skin type.

The Fitzpatrick test is a well-known and dependable skin classification system that was developed in 1975 by Harvard Medical School professor Thomas Fitzpatrick, MD. It’s pretty straightforward, and an excellent and fun way to figure out what kind of skin you have. Remember, our skin changes as we age: your skin at nineteen is not the same as it will be at thirty, forty, or beyond. So even if you think you know your skin type, if you haven’t taken this or another similar skin quiz in a while, you might be due for a redo. Skin type quizzes like the Fitzpatrick Skin Type measure two factors: genetic disposition and your skin’s reaction to sun exposure. Skin type quizzes are available online—and they even do the calculations for you!

MAKE THE RIGHT CHOICES

Different kinds of skin types are determined by genetics. We are born with a certain kind of skin, and we have to make the best of whatever gifts we’ve been given. Such skin types vary and depend on several factors that can include:

• water content, related to your skin’s firmness and comfort;
• lipid or oil content, related to your skin’s texture and nutrition; and
• sensitivity, or the degree to which your skin tolerates topical and ingested substances.

Once you know the kind of skin you have, you can make the appropriate choices to take care of it. What follows are some general guidelines for taking care of your skin according to type.

NORMAL

The majority of people have normal skin—a balance of water and lipids in your skin. You don’t have many imperfections or harsh sensitivities to external stimuli. Your pores are small, and your complexion is clear. Normal skin usually has good circulation, little trace of oil, and a soft, smooth, even tone.

Basic Care for Normal Skin

• Wash your face two times a day using a mild cleanser and lukewarm water.
• Use sunscreen during the day.
• At night, apply a light moisturizer.

Did You Know

Soaps, in general, have gotten a bad rap, and now most people prefer to wash their faces with cleansers or washes. Soaps definitely clean our skin, but they contain harsher ingredients such as sodium lauryl sulfate, which is a surfactant, using foam and bubbles to help remove the oil, dirt, sweat, and debris. However, this can strip the protective layer of natural oils and proteins on the surface of our skin that helps to maintain the moisture barrier. Antibacterial soaps contain triclosan, which helps to destroy bacteria on the skin; however, this ingredient irritates some people’s skin. I’ll admit it’s nice to use a soap that leaves your skin smelling fragrant, but soaps with a strong scent actually work against you, drying you out more.

All this being said, not all soaps are bad! Those bar soaps that you can see through contain glycerin, which helps keep the moisture in your skin. Also, there are superfatted soaps impregnated with extra lipids such as stearic acid, lanolin, or triglycerides to form a protective barrier on the skin’s surface, minimizing the loss of moisture. Cleansers and washes were created to be less harsh on the skin, and more moisturizing and hydrating, which is why many dermatologists recommend them over soaps.

DRY SKIN

Dry skin often has visible pores and sometimes a visibly dull, rough complexion. Red patches are sometimes evident. As you age, your skin loses its elasticity, and lines are visible. When dry skin is exposed to conditions such as wind, sun, dry air, cold air, dry indoor heat, long, hot showers and baths, and certain ingredients in soaps and cosmetics, it can become flaky, or it can crack and peel, itch, and even become inflamed. Very dry skin can develop a scaly appearance, especially on the hands, arms, and legs. Severely dry skin can become itchy and painful and lead to eczema (inflamed and irritated skin). Menopause can also contribute to dry skin, and more women begin to experience drier skin as they age.

I have very dry skin. In fact, I have a skin condition called atopic dermatitis, meaning my skin’s moisture barrier is not that great. I keep a tub of moisturizer in my shower and by my bedside. If I don’t have moisturizer close at hand, I’m usually in trouble after twenty-four hours. If I start to itch a little, I know I’ve got to get up from my (probably comfortable) position and put on some moisturizer stat, because the more I scratch, the more I’ll itch. Sometimes, when I’m particularly dry, I’ll put petroleum jelly such as Aquaphor or Vaseline on my skin. Some of you with oily skin probably recoil in horror imagining zit central after doing the same, but those of us with dry skin sometimes need to slather on a heavy ointment in order to keep our skin hydrated.

Did You Know

Drinking water does nothing to hydrate dry skin! I mean, if you’re dehydrated, yes, your skin can look more sallow. But the more you drink, the more you’ll . . . pee, and your skin won’t look amazingly improved.

Basic Care for Dry Skin

• Switch out long, hot showers and baths in favor of warm, short showers. Go for the coolest temperature that you can. Avoid long Jacuzzi soaks. Personally, I hate cool showers, so I compromise and take very quick hot showers, with minimal soap or cleanser.
• Instead of soap, use a gentle, unscented, soap-free cleanser. You don’t need an expensive brand, either. Cetaphil, CeraVe, and Dove have great, inexpensive mild cleansers.
• After washing, pat skin dry gently with a soft towel.
• Moisturize while your skin is still damp. I keep a tub of moisturizing cream in the shower so that when I’m just towel dry and still damp, I slather on the moisturizer. This keeps water from evaporating from your skin and drying you out more.
• When outdoors, use sunscreen and wear sunglasses rated for blocking 99 to 100 percent of UVB and UVA to protect both your eyes and the skin around your eyes.
• Avoid putting direct heat on your face from blow-dryers, portable heaters, and other similar implements.

SENSITIVE

Sensitive skin reacts to environmental elements more severely than other skin types. You may be more prone to allergies or to contact dermatitis, which is when your skin reacts after having come in contact with an irritant such as makeup, certain plants, or even something that blows in from a breeze, like pollen. If you have sensitive skin, understand what external factors cause it to react, leading to rashes, dryness, or bumps. Common irritants include perfumes, bath soaps, laundry detergents, cosmetics, household cleaners, dryer sheets, certain fabrics, latex, plants, certain foods, nickel (which can be found in watches, zippers, and jewelry), and even some moisturizers. People with sensitive skin can often develop allergic contact dermatitis. Interestingly, although this is often seen as a rash around the eyes, the condition is not usually caused by eye shadow or moisturizer or anything else applied on the eye area.

Did You Know

You can use the same exact cosmetic product daily for decades and then suddenly, out of the blue, develop a sensitivity to one of its ingredients. So don’t immediately eliminate a product that you have been using for years as the possible culprit for your red, irritated, bumpy, itchy skin. If you don’t know the cause of your rash but suspect it’s something you are coming into contact with, try to eliminate everything that you apply to your skin. Then stick with only a mild cleanser such as Cetaphil, and slowly add products back into your regimen, one at a time, to see if you can isolate the source of the irritation.

Basic Care for Sensitive Skin

• Use scent-free products.
• Avoid products with dyes, such as laundry detergents.
• Don’t use topical products that are acidic or that contain alcohols.
• Stick to fibers or fabrics that are nonirritating. (For example, some people are sensitive to wool, which is a natural fiber. “Natural” doesn’t guarantee a product or fiber won’t be irritating to your skin.)
• Use fragrance-free sunscreen.

I have dry and sensitive skin. And the older I get, the more sensitive and drier it seems. The key is knowing what type of skin you have, because then you can head off problems at the pass before you are deeply involved in a relationship with redness, irritation, flaking, and bumpiness.

COMBINATION

Combination skin has an imbalance of lipids and water. It can be dry or normal in some areas and oily in others, especially around the so-called T-zone, commonly defined as the forehead, nose, and chin. Combination skin is common, and requires that different areas of the face and body must be treated accordingly. Combination skin can sometimes show itself through enlarged pores on some areas of the face, blackheads on the nose or the T-zone in general, and shiny skin on the forehead or chin.

What about if you’re unsure which type of skin you have? You’re not alone; some people just aren’t sure. Sometimes I’ll ask a patient if they are dry or oily, and they’ll reply, “I just don’t know.” So I’ll ask them about two situations: (1) When they wash their face, does the skin feel a little tighter a few minutes later? This is a sign of dry skin. (2) When their photo is taken, do they notice a conspicuous shine on the forehead, cheeks, or chin? Well, they likely have an oily complexion.

Basic Care for Combination Skin

• Use a soap-free cleanser.
• Treat oily sections with a light moisturizer and dry sections with an oil-based moisturizer.
• Use a gentle exfoliation product.
• Use sunscreen during the day.

Did You Know

Pore size is largely genetic. There are many products and devices out there devoted to the promise of shrinking the size of these “holes” we hate in our face, but this is largely temporary. We’re all really born this way, and we pore this way. So, in general, don’t expect these products or treatments to make pores disappear for good.

OILY

The technical term for oily skin is excess sebum on the face. Oily skin peaks in younger people, who are going through hormonal changes that happen during puberty, adolescence, and even into the twenties and sometimes into the thirties. As with other skin types, a tendency toward oily skin is genetic. So no, the pizza you ate last night does not cause oily skin! It happens when glands in the skin secrete too much oil. If you have oily skin, you might notice that your pores are large, your skin often has a sheen that is not caused by perspiration, and you have a propensity for blackheads and other blemishes. But remember the positive side of having oily skin: you have your own built-in moisturizer! One of my dear friends, also a dermatologist, has oily skin. One day during our dermatology residency training in Illinois, I mentioned to her that my skin was so terribly dry. She looked at me with subtle contempt, rubbed her nose and cheek with her finger, and said, “Here,” as she presented me with her own human-made moisturizer. We still laugh about this. People like my oily friend will stay younger looking for longer, unlike us dry skin types!

Did You Know

You may detest your oily skin, but you are actually lucky! Your built-in moisturizer will keep your skin more youthful, and the fact is that you will likely get a little drier as you age. So don’t detest it. Embrace it while it lasts.

Basic Care for Oily Skin

• Wash twice a day with a mild cleanser.
• Use a light moisturizer at night that is labeled “noncomedogenic” and “oil free.” The same holds true for sunscreens.
• Avoid cosmetics and lotions that contain ingredients such as lanolin, mineral oil, and cocoa and shea butters.
• Use spot acne treatments as needed.
• Blot oily skin with a skin blotting paper.