Terrasil (Thuja Occidentalis) Ointment: What It’s For

Recently, a patient asked me about using Terrasil for wart removal. Thuja Occidentalis Ointment, also known as Terrasil Wart Removal, is a homeopathic remedy for warts.  Natural ingredients include: organic beeswax, cedarwood oil, and jojoba.

Because Terrasil is a homeopathic remedy and not a drug, the FDA does not regulate non-drug substances for accuracy of the company’s claim of effectiveness. Thus, there is no scientific evidence yet to support the claim that homeopathy is an effective method of treatment. It may work, but the company doesn’t need to prove it.

But this patient’s question jogged my memory about an article in the New England Journal of Medicine in 2004. The article describes a clinical trial of human alpha-lactalbumin coupled to oleic acid that was highly effective for treating human warts. The substance, known as HAMLET, is purified from human breast milk and applied topically.

In an accompanying editorial, commenters expand the possibilities for HAMLET treating malignant tissue such as HPV induced cervical cancer and cutaneous squamous cell carcinoma (which may have HPV as a cofactor with ultraviolet light). HAMLET is used to treat cells causing apotosis (cellular death) and appears to be a leave normal cells alone. Thus, the side effects on normal tissue would be minimal.

Medications like HAMLET are no doubt in the pipeline. Additionally, I think it’s curious that breast milk may provide answers to some of our most pressing medical problems. There may be room for more research there.


Bavinck JNB, Feltkamp MC. Milk of Human Kindness? — HAMLET, Human Papillomavirus, and Warts. New England Journal of Medicine N Engl J Med. 2004;350(26):2639-2642. doi:10.1056/nejmp048086.

Label: TERRASIL WART REMOVAL- thuja occidentalis ointment. DailyMed. https://dailymed.nlm.nih.gov/dailymed/druginfo.cfm?id=119689. Published February 28, 2014. Accessed August 1, 2016.

Castor Oil Has Skincare Purposes I Didn’t Know About

A patient came to me having tried a number of remedies, including castor oil. I’ve heard of this, but I didn’t know if it had any relevance to dermatology. I decided to do some research on the topic.

The oil itself comes from the castorbean, which is native to areas of Eastern Africa and the Mediterranean. Specifically, the castorbean’s seeds contain the best source.

People know castor oil as a laxative ingredient, but it also treats skin ulcers and other wounds. It comes as an ointment or a spray, and its brand names are Granulex, TBC, Vasolex, and Xenaderm.

The oil is also found in cosmetic products like creams and lipsticks. When combined with Glyceryl Ricinoleate, it absorbs UV light. Overdoses and allergic reactions may occur if product is not used as directed.


Castor Oil/Peru Balsam/Trypsin (On the skin). National Institute of Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/pmht0009483/?report=details#uses. Published July 1, 2016. Accessed August 16, 2016.

What is Mitchell’s Disease and How Can it Be Treated?

A patient said that I was “saddled with Mitchell’s disease,” which I had never heard of. After doing some research, I learned Mitchell’s disease is another name for Erythromelalgia. Erythromelalgia is a clinical syndrome that often goes unreported.

Erythromelalgia is a rare pain disorder characterized by a burning ache in the hands and feet. Severe redness and raised skin temperature are also symptoms. Erythromelalgia was called Mitchell’s Disease, named after Silas Weir Mitchell. Mitchell discovered and named the disease in the late 19th Century.

Presently, the cause of Erythromelalgia is unknown. There are a few theories floating around, but researchers think the underlying root is dilation and contraction abnormalities in blood vessels in the hands and feet.


Symptoms can manifest quickly or slowly. Some report a sudden, rapid onset of crippling pain over weeks. Others say that they’ve had relatively mild symptoms for years. Theories suggest that Erythromelalgia does get worse as it goes on. Some cases have even started in the feet, and spread up from the toes to the face and ears. Erythromelalgia is nonfatal, but it is chronic, which can cause interferences with a patient’s daily life.


Some suggest that patients relieve their symptoms by putting their extremities in a colder environment (e.g. ice water). However, in several cases, repeatedly immersing in ice water actually triggered an episode. Most doctors advise patients to stay in a cool environment, but that makes it more difficult for people who live in warmer areas. Topical medications appear to be more helpful, such as a local anesthetic like lidocaine.

As mentioned before, the disease is nonfatal, and most patients can live a normal life. Research into cause and treatment for Erythromelalgia is ongoing.


Erythromelalgia – NORD (National Organization for Rare Disorders). NORD (National Organization for Rare Disorders). http://rarediseases.org/rare-diseases/erythromelalgia/. Accessed August 12, 2016.

What Causes Skin Laxity and What Can We Do to Treat It?

A patient asked me what could be done for sagging skin in the upper arms. So, I decided to do some research into what causes it.

While excessive weight loss and pregnancy can be factors, the cardinal cause is age. As one gets older, skin relaxation occurs: the lean muscle in the body begins to deteriorate, and pockets of fat begin to show up. The amount of sagging depends on the individual, on factors such as body type and weight. As one ages, the skin around the stomach, upper arms, and legs begins to droop, creating a flabby, almost shapeless look to the body.

Though skin laxity is a natural process, it can have a negative impact on one’s body image. Fortunately, there are several treatments that can contour and tighten the skin.


While liposuction, abdominoplasty (tummy tuck), and brachioplasty (tightening of the arm skin) are the mainstream solutions, However, patients are looking for less invasive alternatives. Luckily, a new treatment method has been developed.

According to a study reported in Lasers in Surgery and Medicine, combining infrared light (IR), bipolar radio frequency (RF), and vacuum and mechanical massage has proven effective for skin laxity.

Though this looks promising, doctors and scientists have only conducted studies on the arms, legs, sides, and stomach. Researchers have yet to research this treatment method on other parts of the body. As a result, studies are ongoing.


ASDS — American Society for Dermatologic Surgery. Sagging Skin. http://www.asds.net/sagging-skin/. Accessed August 11, 2016.

Brightman L, Weiss E, Chapas AM, et al. Improvement in arm and post-partum abdominal and flank subcutaneous fat deposits and skin laxity using a bipolar radiofrequency, infrared, vacuum and mechanical massage device. Lasers Surg Med Lasers in Surgery and Medicine. 2009;41(10):791-798. doi:10.1002/lsm.20872.

Teimourian B, Malekzadeh S. Rejuvenation of the Upper Arm. National Center for Biotechnology Information. http://www.ncbi.nlm.nih.gov/pubmed/9703097. Published August 1998. Accessed August 9, 2016.

The Four Cosmetic Intervention Techniques Backed By Science

Cosmetic intervention is a hot-button issue in the dermatology industry. There is ongoing research into what works and what doesn’t. Everyone wants protect their facial skin from damage, and everyone wants to avoid wrinkles. As a practicing physician, I only use techniques that have been proven to work through scientific studies and trials.

Right now, there are only four cosmetic intervention techniques that fulfill that criteria.

  1. Sunscreen, daily: ultraviolet (UV) light and natural aging causes most damage to the skin. Protecting your fibroblasts from UV damage lessens their impairment. It also protects the epidermis, melanocytes, and skin-associated immune cells from UV damage.
  2. Retinoids: A retinoid (topical derivative of Vitamin A) applied to the skin helps fibroblasts “wake up.” The activation of fibroblasts produces more collagen. Since fibroblasts lose function with age, retinoids help restore fibroblasts and repair normal function
  3. Fillers: Adding volume to the dermis actively stretches the fibroblasts and wakes them up. As a result, fibroblasts begin to produce more collagen, much like the response to retinoids.
  4. Carbon Dioxide Laser Resurfacing: Usually a laser will remove a thin layer of tissue. Then stem cells from hair follicles resurface new dermis and epidermis.

I recommend that my patients use options 1-3. Resurfacing works, but it’s expensive, risky, and involves significant down time.

In conclusion, these four techniques are the only cosmetic intervention methods that scientific evidence can back.  Though this may seem limiting, there is ongoing research into other techniques, as people are eager to seek out alternative methods. But since there is nothing scientific to back up alternative methods, we’ll just have to wait and see.

Topical Cortiscoteroid Therapy’s Lesser Known Side Effects

A long time patient of mine made an appointment with me just to ask some questions about his topical corticosteroid therapy. He had read the package insert, and had become concerned. The side effects stated that the medication could potentially make his diabetes worse. His “sugars” were higher after applying the medication for a couple of weeks.

I have to admit, I was dismissive at first. But when I researched my patient’s question, I found that that he was correct. I also discovered that potent topical corticosteroids can cause significant pituitary gland suppression. 20% of patients using these drugs for more than 3 weeks suppress the release of cortisol from their adrenal gland. The dose can be as low as 2 grams per day.

So sometimes, I find I need to rediscover things that I used to know. Thanks to this patient’s perceptive question, I can help others avoid side effects from these frequently prescribed medications.

What Good Does Niacinamide Do?

I prescribed a patient Niacinamide for prevention of actinic keratosis (premalignant tissue) as per a study done in the NEJM in December 2015. “First of all, they look like horse pills,” the patient said. “How does this work? Is it really necessary?”

Niacinamide is structurally related to Niacin (Vitamin B3), and is converted into other substances (NAD, NADPH). These substances are crucial in regulating cellular energy levels. NAD is bound by the enzyme poly-ADP-ribose-polymerase 1 (PARP-1). This enzyme has important roles in DNA repair and expression of inflammatory messengers.

Niacinamide exerts an anti-cancer effect after it converts to NAD and activates PARP-1. Whether all patients who have significant history of skin cancer and premalignant tissue should take niacinamide is not clear. If a patient is niacin deficient, then they are more likely to develop a wide range of cancers. Giving individuals excessive Niacin levels may not accomplish anything as is often the case with”supra physiologic” doses of vitamins.


Australas J Dermatol. 2014 Aug;55(3):169-75. doi:10.1111/ajd.12163.

 J Med Chem. 2016 Jul14. [Epub ahead of print]

J Nucleic Acids 2010 July 25

Healthcare Progress Wasn’t Made in a Day

Rome wasn’t built in a day. Neither was the current state of healthcare progress in the US. While watching the film Ben Hur last week, the subplot of Leprosy in the ancient world impressed me. The fear of contagion and social isolation is reminiscent of some recent epidemics: syphilis, TB, and HIV. Now, Ebola and Zika trigger the most panic.

What struck me is how much healthcare progress the global medical community made in the last century. We’ve been able to eliminate and control so many infectious diseases. The USA is the primary leader in this effort, with investments in basic medical research. Shoutout to taxpayers!

Although many see large pharmaceutical companies as “robber barons”, they have also played a major role in drug development. They conducted well-crafted clinical trials that were necessary to healthcare progress. So while there is much to gripe about in the current state of healthcare in the US, what we can cure would amaze a citizen of Ancient Jerusalem.

In conclusion, we have much to be thankful for in the way of healthcare progress. But while we are arguing about healthcare delivery, let’s make sure we invest heavily in the basic research of disease. Collectively, I think it is one of the costs we must bear.

Surgical Technique From The Western Frontier to Present

I recently watched The Revenant and am now reading the book. Wound care in the 1800s Western frontiers shocked me. I’m sure surgical technique was different in big city hospitals. But out in the wilderness, all people had were crude remedies. There was no local anesthesia. People treated wounds with poultices of pine tar and Native American astringents.

In 200 years, we have come so far with surgical technique: we’ve developed anesthesia (circa 1850), sterile technique (circa 1860), and antibiotics (circa 1930). Now, major trauma centers (circa 1980) are a large part of the medical world.

Doctors learned many of the innovations in military field hospitals. As a result, these techniques made their way to general practices. Looking back, this is an area where necessity is the mother of invention. The medical community has advanced significantly in helping the body to do its job. This is truly an impressive feat in a short amount of time.

Can Apple Cider Vinegar Clear the Skin?

Many patients tell me that apple cider vinegar helps reduce wrinkles and signs of aging. Since I’ve never heard of any scientific research done on it, I decided to look it up. I found nothing in any medical database.

There is a rumor circulating that apple cider vinegar enhances the skin. But there’s no scientific evidence just yet. We’ll just have to wait and see.