Today's top dermatologists, dedicated to research that delves deep beneath the skin's surface, are finding new and better ways to improve appearance.
October 1991
JULIA REED reports on the latest techniques
Photographer: Mary Ellen Mark

The new breed, CLOCKWISE FROM TOP LEFT Wilma Bergfeld, M.D., of the Cleveland Clinic and incoming president of the American Academy of Dermatology; Arnold C. Toback, M.D., of Columbia University's College of Physicians & Surgeons, New York City; Nicholas Lowe, M.D., of UCLA School of Medicine; Mary Ellen Brademas, M.D., of St. Vincent's Hospital, New York City; Karen Burke, M.D., Ph.D., of Cabrini Hospital, New York City.

When I was an adolescent, the person I despised most was not my biology teacher or even my mother but my dermatologist. He put me under sunlamps and forbade me to eat chocolate. He turned my teeth gray with antibiotics and raised my estrogen level with birth control pills. He gouged my face and dried my skin, but what he could not do was cure my acne. There was, Wilma Bergfeld, M. D., tells me, vitamin A, and he could've used it, but I won't push it. It was a small town.

Bergfeld is the incoming -and first female- president of the American Academy of Dermatology. She has, quite simply, the most beautiful skin I've ever seen. More important, she is part of a growing army of dermatologists who want people with lesser genes to have beautiful skin, too. "Looking good is not bad," she says. "If people have good perceptions of themselves when they look in the mirror, they have better job performance, they perform better psychologically." So intertwined is our face with our psyche that in 1987 when the University of Pennsylvania opened the first Center for Human Appearance in the country, a noted psychiatrist, Michael Pertschuk, Ph.D., was on staff. Clearly something has happened since my sessions under the lamp. "Dermatologists," says Bergfeld, "are expanding themselves."

Indeed, dermatology is virtually a new profession. While they once concentrated on treating skin disorders, now dermatologists treat skin to minimize lines and discoloration, to repair sun damage and slow, down aging, to smooth it out or plump it up, to make it look better all the time. They speak constantly of "the new age of preventive medicine"; they counsel patients on topics from their diets to their sex lives. The torturers of my youth have given way to champions of beauty and psychic well-being. The new skin doctors speak the same language as plastic surgeons -they talk not of "treating you" but of "transforming your appearance."

"In the past," says Bergfeld, who is also head of clinical dermatological research at the Cleveland Clinic, "the bread and butter of the field was acne, psoriasis, eczema, maybe skin tumors. But the population is living longer, feeling better, exercising more. And people not only want to feel and be strong, but they want to look younger. I see one of my fortes as being able to give people guidance on how to stay looking youthful." Or at least looking like they want to look. Recently Bergfeld treated a bald man on his way to becoming a woman. "I didn't have to risk feminizing him, because that's what he wanted anyway, so I pulled out all the stops. Now his billiard ball is growing hair, and he's lost his beard. Very phenomenal. We can address a lot of problems."

Mary Ellen Brademas's patients include "models, show girls, mistresses, executives' wives, TV people playing parts years younger than they are, people whose fortunes depend on their faces." Brademas, the extremely straightforward wife of former Indiana Congress member and New York University president John Brademas, didn't go to medical school until she was thirty-eight, but she knew she wanted to be a dermatologist. Now chief of dermatology at Saint Vincent's Hospital in Manhattan and assistant clinical professor of dermatology at New York University, she must be pushing fifty, but like Bergfeld, she looks at least ten years younger. "I have no compunction about plastic surgery," she says. "I've already had my eyes done. Between dermatologists and plastic surgeons we can make you look so good, heads will snap when you walk in the room."

The patients of Arnold C. Toback, M. D., run the usual gamut from teenage kids with acne to men and women with sun damage, but, he says, "we definitely have more patients who are interested in maintaining their appearance." Toback, assistant clinical professor of dermatology, at Columbia University's College of Physicians & Surgeons and president of the Space Dermatology Foundation, is not unfamiliar with the connection between appearance and well-being. "I was an internist before I was a dermatologist. And we've all, as internists, taken care of patients with, say, end-stage kidney disease, and they're bleeding and they're going blind, but they want to know what is this little bump on their forehead."

The logo on Karen Burke's skin-care products reads, HEALTH IS BEAUTY AND BEAUTY IS HEALTH. Burke, attending physician at Manhattan's Cabrini Hospital, says that today beauty is defined by health and diversity. "I'm all for plastic surgery for individuals who worry about how they look, but the thing is we have all these homogeneous, plastic beauties. Now, with the advances in the treatment of the skin, a beautiful person can be different. Perfect features are going to be boring."

Nicholas Lowe, M.D., doesn't talk much about beauty, but he's on the cutting edge of how best to achieve it. Clinical professor of dermatology at UCLA and director of his own Skin Research Foundation of California in Santa Monica, Lowe is willing to reel off the latest techniques to improve the skin, some only months old: the sunscreen he's researching to cut out UVA and UVB rays, the laser that zaps sun and age spots and the one that eliminates broken capillaries, the thinnest collagen to fill the fine lines around the eyes, the safest rejuvenating peels. "There is," he says in typical understatement, "a lot we can do."

Would that they had been around when I needed them. The above five doctors are among the top in their field. They are all involved in research -some groundbreaking- but they all have a regular practice as well. Practicing in an age when new drugs and technology are constantly being made available, they are heirs to the respected dermatologist Norman Orentreich, M.D., who pioneered the cosmetic dermatology still practiced today at his New York clinic, including the use of dermabrasion and silicone and a comprehensive skin-care regimen he originally adapted to help create the Clinique cosmetics company. (The Orentreich Foundation for the Advancement of Science is now in its thirtieth year of biomedical research, dedicated to "adding years to life and life to years.")

Needless to say, I am very interested in all this, since the best thing I can say about my skin is that it doesn't look like it did when I was sixteen. But it has still not quite recovered from all the various pummelings it received.

I tell Dr. Lowe that I am sick of all my broken capillaries but that I am sicker still of having them zapped one by one in an excruciating process involving electric needles and thousands of dollars and probably about thirty years to get them all. No problem, he says. He can get them with a laser in a matter of minutes. All of them? Yep, with the same kind of laser developed to eliminate port-wine stains like the one adorning Gorbachev's forehead. "It's not dangerous, and it doesn't scar."

I am crazy about Lowe, a no-nonsense Brit with all the answers. He is obsessed with preventing skin cancer and will tell you that you are never safe, not when it is cloudy, not even when you are in a car. He's perfecting a sunscreen that fights the evil and ever-present UVA rays, which somehow exacerbate the damage of the UVB rays. It is obvious that he wants to get back to this enterprise as soon as possible. He took the red-eye from L.A. to New York to have his picture taken for Vogue, and he took the night flight right back.

They are all busy. Burke's assistant changes our interview date three times -Burke does skin cancer research in La Jolla, California, practices in New York, and writes a health column for The Diplomatic World Bulletin -and finally asks me if I would mind coming at night. "She's better then," she says, and it's true; Burke is settling in at about seven in the evening with coffee and fruit. She has
just returned from La Jolla, and she wants to make sure I'm getting everything. She paces, retreats, has sheaves of papers copied for me, shows me charts, but I'm looking at the Warhols on the wall signed, "With love to Karen." It seems Andy was her first patient. "He felt that it is our responsibility to take care of ourselves. Just as if paint were chipping off the walls."

Speaking of chipping, Burke is working with an Australian company on a cream with elastin that seems to eliminate lines. "We don't understand how yet, but it seems to work," she says, and she's testing it in a double-blind study involving masks that take an imprint of your face. Do I want to be involved? I'd love to, having reached the point where late nights no longer manifest themselves in hangovers alone but in far more insidious lines creeping around my eyes. Burke has late nights, too, every night, but it doesn't show. She's working, after all, and she doesn't go out in the sun, and she never smokes. "Each puff has ten to fourteen free radicals," she says reprovingly.

Burke has a grant from the Henkel Corporation to figure out smoking's exact effect on skin; by now there's not a person alive who doesn't know what the sun does to you. I am still amazed that I was made to lie under fake sun to cure my skin. So is Bergfeld, who urges me to have more frequent checks for skin cancer. I already know this, since my father has walked around with periodic purple stains and Band-Aids on his face for as long as I can remember.

Bergfeld, of course, hasn't been out in the sun in almost thirty years. She says her husband used to go nuts when she showed up on their sailboat with long sleeves and huge hats, but hey, now he's married to a fifty-three-year-old woman who looks thirty-five. She warned her daughters, but they didn't listen, and now they're in their twenties and screaming about wrinkles and spots on their chests.

Mary Ellen Brademas, whose skin is so pale it's almost translucent, won't even take patients who continue to go out in the sun unprotected: "It's a waste of time."

What they'll all do is help you repair the damage from the stupid stuff you've already done. In addition to Retin-A, which used over time is said (without FDA confirmation) to retard aging brought on by the sun, there are trichioroacetic and glycolic acid peels for faces with small precancers, sunspots, and fine wrinkles. Unlike the dangerous phenol peels of old, which threatened to take off your nose (or worse if not done properly), the newer peels leave the skin better than new in a couple of days. "They're like super-Retin-A, only in one sitting," says Bergfeld. "Acid peels resurface the skin. The epidermis becomes healthier, thicker, and there is a little bit of increase in collagen in the upper dermis. The fine lines go away. You get rid of the freckles."

Forget freckles. I can cope with them -all I've ever wanted was someone to tell me how to get rid of the dread large pores. Brademas, Burke, and Bergfeld waste no time in telling me that I can't. I'm devastated until they explain that there are no such things as large pores, just full ones and empty ones.

"What are known as 'big pores' are pores that under the microscope are filled with dead surface skin," Burke explains further, "so just using an exfoliant and a Buf-Puf makes pores appear smaller. Retin-A stops dead skin from sticking to the surface, so it also makes pores look smaller. That's how Retin-A helps acne, because with acne, pores are filled with dead skin and sebum that can't get out, so bacteria grow in the sebum and the skin becomes infected. If I gave you nothing but a pumice, you'd have beautiful skin."

"Anything that exfoliates can help," says Brademas. "Loofahs, acids, pumices, brushes, even a rough washcloth."

She is very big on this subject. "Debridement works. When you take off your skin, it turns over faster."

Toback winces when I tell him this -he doesn't want his teenage patients scrubbing their skin off in the shower. He tells people to be gentle, to forgo the pads and brushes. This is not the first time dermatologists have disagreed with each other, although they share enormous amounts of research. Brademas advises cold cream instead of soap and allows only oil-based makeup; Bergfeld can't use moisturizer but believes in it for those who need it. Orentreich and Burke create products; the others think that's a conflict of interest. Burke is experimenting with the trace mineral selenium as a topical cure for skin cancer; Lowe says the only thing it's going to get rid of is dandruff.

I decide to go with Brademas and buff the hell out of my face anyway, but even I know I can't exfoliate away the vertical crevasse rapidly deepening between the eyes. Occasional concentration has taken its toll. That's easy, I am told by my hero, Lowe. When the time comes, just have a little Zyderm injected, the thick collagen for deep lines, as opposed to the Thinflow, the brand-new stuff that won't bead when injected in the fine lines around the eyes.

This is great. At this rate maybe I'll never need a plastic surgeon -at least not any time soon, because Burke and Bergfeld have even figured out how to stop sagging facial muscles. "Exercise," says the eminently practical Bergfeld.

"Yoga," says the Zen-like Burke. Whatever, the theory's the same. "Keeping your body fat stores down, as athletes will tell you, results in a better, healthier appearance, and that should be relevant to the face," says Bergfeld. "The muscles of the face get pretty lax. What do we do but chew and smile?" Says Burke, "I think if you do yoga and certain other exercises you can postpone facelifts for years. People who do yoga have those sharp jawlines because they're doing a total stretch.”

What is most astonishing about all this is that dermatologists are now interested in telling me how to keep my jaws sharp as well as whether my mole is really melanoma. Of course, they're still serious people.

But if lasers and Retin-A and acid peels and even exercise already have the power to make us look younger and healthier, what could possibly be next? Toback and his Space Dermatology group and NASA are studying results of skin's behavior in space to find out. Normal skin, as opposed to diseased skin, had never been seriously studied until NASA began sending people up in space. Scientists had to quantify for the first time what healthy skin takes from and gives to the environment. They learned of the impact of stress on skin, and they developed technologies such as digital image processing. Today not only is this used to substantiate claims made by various cosmetics companies (Estee Lauder, for example, has successfully used it to test some products), but the University of Pennsylvania's Albert Kligman, M.D., has also used it in his research on Retin-A.

Toback wants to further tap into the space program by giving astronauts a questionnaire to take with them into space. "Once we have the data, once we know what happens to the skin, then we take it a step further. The skin is the largest immunologic organ of the body. We ask what we can do to maintain health, to predict health problems and initiate ways to prevent them."

There are already breakthroughs involving products that penetrate the skin, and there will be more. "We're going to be able to nourish the skin through the skin, through percutaneous absorption," says Bergfeld. “Rogaine [the product that encourages hair growth] was developed on that principle. Instead of waiting for the blood to take what's in the pill to the skin, we put it on the skin, we force it through.” Avon, Bergfeld notes, already has a product based on research by a dermatologist at the University of California at Berkeley. Called Collagen Boosters, it contains vitamin C, which goes through the skin and may promote collagen and make it thicker.

"We already have vitamins C and A at work," says Lowe. "Women put moisturizers all over their bodies. Why not throw in some vitamins? Why not see if other vitamins and drugs may be delivered through the skin? We could deliver a lot of drugs with the common things that people do."

Bergfeld wants to get the National Institutes of Health to look at skin more directly. She was stunned that at this year's NIH information meeting (at which the amount of federal money being put into the study of aging was discussed), skin was not even mentioned. It is an omission she intends to address when she takes up her post at the American Academy of Dermatology next month. "We're marching into an era in which 50 percent of the population will be over fifty, and the NIH is looking for ways to keep these people healthy. As we look at people who live longer, we must look at the skin because it reflects internal disease, and skin cancers can shorten people's lives."

Then comes the kicker, the difference between Bergfeld and her predecessors: "And there is the fact that the quality of life could be improved by the visual appearance of youth."

Of course, dermatologists have always dealt with the quality of life, but more and more are also now dealing with the "visual appearance of youth," treating the skin to make it look the absolute best it can.

Who would have thought that the same guys who tortured me with pimple pushers would be telling me how to exercise? That the same people who dried my skin to flakes and put me under a sunlamp can now zap all my broken blood vessels away with painless lasers? Not me, but, boy, am I relieved.