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Getting Smart About Your Skin

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Dr. Rachel Herschenfeld
Dermatologist
Tuesday, August 15, 2006; 11:00 AM

Dr. Rachel Herschenfeld talked about how to choose a skin cream, treating acne and what's on the horizon in skin care.

Herschenfeld's practice is based in Wellesley, Mass. After graduating from Harvard Medical School, she completed residencies in internal medicine and dermatology, then joined two other dermatologists to found Dermatology Partners, Inc., a very successful general and cosmetic dermatology practice. Dr. Herschenfeld is board certified in dermatology, and is a Fellow of the American Academy of Dermatology. Her patients rely on her to diagnose and treat skin problems, to provide expert skin care advice and to perform cosmetic procedures including Botox, Restylane, collagen, Sculptra and laser treatments for many conditions.____________________

Bethesda, Md.: Thank you for taking my question today. There are SO MANY moisturizers and eye creams on the market that most of us are almost paralyzed in our attempt to research and identify those that are beneficial for us. I am in my early 60s and have fairly young looking skin but have developed nasolabial (marionette) lines, lines around my neck (in front) and some very fine wrinkles on the outer corners of my eyes. I am looking for either an effective, everyday moisturizer that works all year round or one moisturizer for summer/one for winter. I also need some suggestions on minimizing those fine crow's feet that have appeared for the first time this year. Something for my neck would be very helpful. Many thanks.

Rachel Herschenfeld: First of all, during the day make sure you are using a moisturizer with sunscreen in it. Some of my favorites with sunscreen are Aveeno Positively Radiant or Aveeno Ultra Calming moisturizing cream. At night, choose a gentle moisturizer such as MD Formulations Advanced Hydrating Cream, or Matis Total Youth Cream, or a retinol containing product such as Roc. Those crow's feet may respond to Renova or Avage- for those you need a prescription. You may also want to consider Botox.

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Washington, D.C.:

Just had my first Botox treatment at 57. The lines between my eyes are still present. I only wanted that area treated but the Dr. insisted on treating crow's feet and forehead. For $850, shouldn't the worry lines be gone?

Rachel Herschenfeld: The lines between your eyes may take several treatments to improve substantially, so don't give up! Botox works best with consistent repeated treatments. Sometimes those stubborn lines between the eyes (on the glabella in med-speak)do well when a filler is injected along with the Botox. As for treating the other areas, I frequently treat the forehead, crow's feet and glabella at the same time to rejuvenate the whole upper face. However, if those other areas don't bother you, just concentrate on the frown lines.

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Detroit, Mich.:

Hi, I would like to know what skin-care product lines you recommend to your patients. I am 37 and am starting to notice some aging effects on my skin. Specifically, fine lines around my eyes and loss of tone. Thanks so much!

Rachel Herschenfeld: There are many skin care lines that have good products, but there isn't one line that I can recommend for everything. At the drugstore, Aveeno, Olay and Neutrogena all have good products for skin with acne, for sensitive skin, and for aging. RoC is another good line. You can try Olay Regenerist, which has antioxidants, and Roc Retinol Actif Pur for a retinol containing product. There are also more effective prescription anti-aging products such as Renova and Avage, so check with your dermatologist about these.

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Alexandria, Va.:

What are some good free web sites (besides WebMD) for skin care and acne treatment?

Rachel Herschenfeld: The American Academy of Dermatology has a great website with a lot of reliable, accurate information about all sorts of skin conditions: AAD.org

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Reston, Va.:

What can you use to get rid of blackheads? I am in the middle of IPL treatments to reduce some dark spots left from pregnancy and my doctor instructed me to use just a vitamin C cream and sunscreen but I feel like my pores are now completely clogged. I used to use a beta-hydroxy acid product which worked great but I do not know how to fit that into what I am doing now. I think my doctor is primarily concerned with treating the melasma and doesn't find the pore problem as troubling as I do.

Rachel Herschenfeld: You are on the right track with IPL, but there are other things to try. Some of them I would not recommend if you are nursing. The vitamin C, sunscreen and beta hydroxy are a good start. If your dermatologist agrees, I would consider adding a fading cream such as Triluma or EpiquinMicro to get more fading. It is also possible to have IPL after treatment with Levulan, a medication which sensitizes the skin to light and makes the treatments stronger. In terms of unclogging those pores: consider peels with beta and alpha hydroxy acids, as well as use of a prescription retinoid such as RetinA, Differin or Tazorac.

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Anonymous:

Are there any new treatments for rosacea?

Rachel Herschenfeld: There are new twists on some old treatments. These include lower doses of traditional antibitoics- like Oracea, and the reformulated topical Metrogel 1%- now a higher concentration with other ingredients to help the red. There are also great light treatments to fade the red. IPL is great, so is pulsed dye laser- the VBeam, which can be used in combination with Levulan to enhance it's skin rejuvenating effects.

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Washington, D.C.:

I'm an African-American female and would like to know your opinions on the over-the counter micro-dermabrasion systems that are available from a couple of well-known skin care companies. Should we steer clear of these? I break out usually around the time of my menstrual cycle and have some scarring usually as a result. The cost of microderm and peels here are so high that I am unsure about whether to use these over-the-counter-products or not. I have tried the Microderm scrub(can't remember who it's by though, maybe Neutrogena) but wondered about the actual mini machine version available now. Thanks.

Rachel Herschenfeld: I would exercise caution with home machines- you don't want to overdo it. You may want to consider an at home peel system to exfoliate. Try something like Neutrogena Advanced Solutions or MD Skincare Alpha Beta peel systems.

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Washington, D.C.:

What's the best face regimen for late-20s skin that addresses both breakouts and anti-aging?

Rachel Herschenfeld: Retinoids! Hands down. These include RetinA, Differin and Tazorac. They are effective against acne and also help treat and possibly prevent some sun damage that leads to wrinkles. Any 20 something who cares about how his or her skin looks should talk to a dermatologist about one of these. But don't forget your sunscreen too!!!

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Baltimore, Md.:

Hello Dr. Herschenfeld I'd like to know if different kinds of hair removal methods are bad for your skin. I've heard that waxing your face causes long term damage-- and same with bleaching. Is this true?

Rachel Herschenfeld: Waxing will hurt you if you burn. It can also lead to ingrown hairs, but shouldn't do any other harm if done properly. Using fading creams is a great way to make facial hair less apparent. If the hair is dark, try laser. Also, adding Vaniqa cream to any hair removal regimen helps keep it from growing back as quickly- see your dermatologist for a prescription.

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Arlington, Va/:

Does Mystic Tan, the UV Free, DHA solution have any adverse side effects on your skin such as acne?

Rachel Herschenfeld: I haven't heard that this causes acne, but if you notice a correlation for yourself, avoid it on your face. I am a big fan of the spray on tan, since it can make people feel less need to fry themselves in the sun.

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Kensington, Md.:

Speaking of large pores - I have rosacea, cystic acne and seborrhic dermatitis, along with large pores which is probably due to the rosacea. Anything you can recommend to reduce the craters? Thanks!

Rachel Herschenfeld: Pores seem to be a hot topic today. There is a topical cream that actually shows some activitiy in shrinking pores, but if your skin is sensitive you may not tolerate it. It is called Tazorac or Avage (same thing, different packaging) and it requires a prescription. In terms of treating your acne and pores- you may want to consider Levulan/PDL: a combination of Levulan to sensitize your skin, then laser treatment with a VBeam. This is a very effective acne treatment, and it also improves skin texture and the appearance of pores. See a dermatologist!

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New Haven, Conn.:

I'm approaching my 40s and i have (still) acne and now i'm getting wrinkles! i have found that prescription acne meds are way too drying. What do you recommend?

Rachel Herschenfeld: Try some over the counter retinol containing products such as Vichy RetiC, Roc Retinol Actif Pur, or Affirm 2x or 3x. Also, cleansers with salicylic acid may help such as Olay Clarity. You may also want to consider a light based treatment for your acne- laser or Blu light- which may also help with wrinkles.

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Washington, D.C.:

Hi Dr. Herschenfeld, Do "pre" retinols, like what's found in over the counter moisturizers like Clarins, have any positive effect on skin or is it just a way to sell these skin care items for more? Do you recommend sticking with a prescription retinol or can they be combined?

Rachel Herschenfeld: The distinction is between retinoids such as RetinA, which contains tretinoin, and retinol or retinal products (like Roc, and Avene Retrinal), which are precursors to retinoids. The latter don't seem to be as effective, but are much better tolerated than the actual retinoids, so they are a great option for people who get too irritated by the prescrition creams and I recommend them all the time.

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Washington, D.C.:

Hi Dr. Herschenfeld: I'm in my late '20s and am developing marionette lines as well as a deep wrinkle right between my eyes. I don't think I'm ready for Botox, but I've been told that that topicals aren't helpful in smoothing "motion" lines. Is that true? I'm currently using Retin-A micro but my derm says don't even bother applying it to my lines--it's not going to do anything.

Rachel Herschenfeld: It's true! Dynamic lines need something stronger than a cream- consider the Botox.

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Washington, D.C.:

I'm in my early twenties and experience the occasional breakout and have "combination" skin. I know the best way to keep my skin looking healthy is to take preventative measures. Can you recommend some OTC products that will protect my skin from aging and keep it looking younger longer, without causing a breakout?

Rachel Herschenfeld: Sunscreen, sunscreen, sunscreen! Try Neutrogena Ultra Sheer-it's not very oily and comes in an SPF 55. Also, products containing antioxidants are great during the day to add more protection from sun damage: Vichy RetiC, Olay Regenerist, Skin Medica vitamin C complex or SkinCeutical C and E Ferulic (which I love!). At night, use a retinol product- Roc Retinol Actif Pur, Affirm, or LaRoche Posay Biomedic- along with a cream containing salicylic or alpha hydroxy acids like Skin Medica AHA/BHA. Also, salicylic acid cleansers are great for acne prone skin: Neutrogena acne wash or Olay Clarity are good choices.

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Purcellville, Va.:

My dermatologist gave me a prescription cream (name I cannot remember right now) to "bleach" darker pigmented areas on my face (areas of over active melanin). Does this stuff really work??? It was over $100/tube!

Rachel Herschenfeld: There are many prescription fade creams that do work, and they can be very pricey. Make sure the cream contained hydroquinone. Usually it takes 2 months or so to see improvement.

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Upper Marlboro, Md.:

As a fair skin male, how can I fade dark spots on my face and neck?

Rachel Herschenfeld: There are lots of treatments for dark spots on fair skin. Topical creams containing hydroquinone and other ingredients are usually very helpful. These include Triluma, Claripel, EpiquinMicro and others. Peels with alpha hydroxy acid can also help. Laser or IPL treatments are extremely effective when done properly- for one of these you should see a dermatologist familiar with lasers. Often my patients do best with a combination of several approaches. Whatever you do, don't forget the sunscreen, because sun can bring back almost any pigment which youmanage to fade.

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Alexandria, Va.:

Could you please explain the difference between Botox injections and Collagen injections and which one is the best treatment as a long-term solution for wrinkles, lines and pick marks?

Rachel Herschenfeld: Botox is great for dynamic lines- those caused by repeated motion, such as crow's feet, frown lines, puckers around the mouth and forehead creases. it isn't a filler- it works by relaxing the muscles that cause the lines. Collagen is a filler- it can plump out lines caused by loss of tissue volume, such as lines between the nose and mouth, and marionette lined under the corners of the mouth. I frequently use these two products together(along with other fillers) to provide the best results in treating facial lines.

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Washington, D.C.:

As an Asian woman, is it advisable to get laser hair removal? I have read that my skin coloring and hair texture may not be optimal.

Rachel Herschenfeld: Be careful, since your skin may turn dark after laser more easily than a fair skinned person's would. However, hair removal can be accomplished safely and effectively in darker skin with use of an appropriate laser- so see a dermatologist.

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Baltimore, Md.:

My face is chapped; I can peel flakes off. I have been using Retin-A at night, DDF SPF 30 organic lotion (day), and Dermalogica smoothing cream for night. Before the Retin-A, my skin was all right, but now it's chapped. Is there anything I can do? I'm open to anything. (Retin-A: I'm using a small pea-sized amount.)

Rachel Herschenfeld: It sounds like you're on the right track. A few suggestions: try the RetinA a little less frequently (every other or every third night), or switch to a retinol containing product. Then check with your dermatologist.

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Washington, D.C.:

Every time I go for a makeover or consultation the beauticians try to persuade me that eye cream is the most important thing for me. Usually, the eye cream is in the $80-100 range -- very expensive for not a lot of product. I'm 29. How critical is eye cream?

Rachel Herschenfeld: Eye cream is simply moisturizer that is gentle enough to use around the eye. It isn't critical, but moisturized skin does tend to look and feel better, so I like eye creams. You don't need to spend that much. Try Vichy RetiC, Neutogena Radiance Boost eye cream, or Dermalogica multi vitamin power firm or intensive eye cream.

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Gaithersburg, Md.:

Thank you so much for taking questions. I am a 26 year old woman. I moisturize everyday with Kiehl's Oil-Free Moisturizer. While this product works great for my normal skin, I want to start using a skin cream, or moisturizer to prevent aging down the road. Is this the right time to start thinking about that? What products do you recommend for women my age?

Rachel Herschenfeld: It's never too early to think about anti-aging products. Make sure your daytime cream has sunscreen, and anti-oxidants if possible. Then choose a product with retinol at night- I've listed a whole buch today.

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Arlington, Va.:

I am a 36 year old female with somewhat dry, sensitive skin. I use Replenix 3X at night (a retinoid product, I think), but sometimes it is too drying and I need to apply a moisturizer on top before I go to bed. Is this OK? Am I negating the benefits of the retiniod serum by putting the moisturizer on top?

Rachel Herschenfeld: You're not negating the benefits- and if the moisturizer helps you tolerate the retinol, it;s great. You may also want to use the retinol every other night. I always advise my patients to start slowly with such products.

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Washington, D.C.:

What do you recommend to someone in their 40s who suffers oily skin and occasional acne breakouts but also ruddiness and dried out patches on their face? Moisturizers seem to either make me feel greasy or seem ineffective.

Rachel Herschenfeld: You may want to try a product with ingredients that can help calm inflammation, such as Aveeno Ultra-calming moisturizer or Eucerin Redness Relef.

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Neutrogena Ultra Sheer 45 SPF:

Any ill effects from using this as your SOLE daily moisturizer? or should I use a moisturizer first - especially around the eyes, and which one? Also, any good alternatives to Prevage? If better, spendy is ok.

Rachel Herschenfeld: No problem if this is all you need for moisture. I love Prevage- it's a great anti-oxidant. Other anti-oxidant to consider: SkinCeuticals C and E Ferulic, Skin Medica vitamin C complex, LaRoche Posay Active C.

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Washington, D.C.:

Hi Dr. Herschenfeld, What is your take on the new Accutane registry? My pharmacist remarked that it's easier to get oxycontin now than it is to get Accutane. As a female patient on Accutane (a very low dose - 10 mg a day), iPledge has been really frustrating.

Rachel Herschenfeld: The whole Accutane thing is crazy. The new registry makes it very difficult for me, and all other dermatologists, to prescribe this medication for my patients who need it. Doctors have been very vocal about the problems, and perhaps some of the regulations will change, but we're stuck with it for now.

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Hanoi, Vietnam:

I get ingrown hair on my legs from waxing, shaving. Any long-term solution?

Rachel Herschenfeld: Laser the hair off! This is the best long term solution.

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Washington, D.C.:

Are chemical peels effective for acne. I am 39 years old and dealing with acne flair ups. What cleansers and moisturizers do you recommend?

Rachel Herschenfeld: Peels containing salicylic acid are very effective for acne. In terms of cleansers, try one with salicylic acid such as Neutrogena Oil free acne wash or DDF salicylic wash. Moisturizes should be non-irritating, such as Aveeno Ultra-Calming.

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Washington, D.C.:

What is the best kind of facial to get for someone with large pores and oily skin during the summertime?

Rachel Herschenfeld: I don't usually recommend facials because ther is no medical definition of this term. In general I prefer peels- which involve application of specific solution to the skin in order to exfoliate and cleanse it. So, try a peel. For acne prone skin peels containing salicylic acid are usually the best.

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Washington, D.C.:

Dr. Herschenfeld - I believe that I have hyperhydrosis and would like to proceed with Botox injections within the underarm area. My dermatologist would like to charge $1200 for shots under both arms (she would use the entire bottle). Is this a 'good' price? Also, are there any short- and long-term side effects I should be worried about? Numbness in underarms? Issues/concerns with tissue in breast? I would like to breastfeed my children (when I have some in the next 2-3 years). Should I be concerned about medicine effecting my breastmilk?

Rachel Herschenfeld: Botox is a great treatment for axillary hyperhidrosis. Botox in contraindicated in pregnancy, but if you are not planning to become pregnant for 2 or 3 years it should be fine. You should not experience any numbness under your arms. In fact, the usual side effects are a little tenderness and bruising from the injections. The price you were quoted is standard for this treatment.

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Alexandria, Va.:

How do I get rid of milia? I got microdermabraision, and I think that's what caused it.

Rachel Herschenfeld: Milia can be easily extracted by your dermatologist.

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Washington, D.C.:

I hear a lot about mineral-based cosmetics these days -- do they actually have any benefits over over the counter cosmetics?

Rachel Herschenfeld: I love mineral based cosmetics- the mineral ingredients are very unlikely to irritae the skin. One of my favorite lines is Jane Iredale.

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Richmond, Va.:

Hi Dr. Herschenfeld, I'm 29 and for about 10 years (or more) all I've used for skincare is Dove soap as a cleaner, a mild Kiehl's toner and a mild moisturizer and I've had little to no skin issues. Recently I noticed small bumps/acne around my hairline and on my nose. Are there any good over-the-counter products that I could add to my regimen that could help clear this up?

Rachel Herschenfeld: Try a salicylic acid cleanser such as Neutrogena Oil free acne wash.

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Washington, D.C.:

How can I get rid of acne scars and dark spots?

Rachel Herschenfeld: Acne scars can be treated with lasers such as the Smoothbeam, and sometimes with minor surgical procedures. Dark spots can be faded with creams such as TriLuma, and with peels. See a dermatologist.

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Cleveland, Ohio:

Can you comment on the link (or lack therof) between diet and skin problems? I'm a 30-year old male still dealing with mild to moderate acne, and I've become convinced it's related to what I eat. But the latest research I've come across suggests there's no connection after all.

Rachel Herschenfeld: New research shows that there may actually be more of a connection than we thought. A long term study recently showed a connection between more dairy consumption and increased acne. Whether this will pan out in future studies is unclear, but I think it is likely that we will find more such connections. The truth is that this issue is very complicated, and I don't think we know enough yet to make general recommendations.

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Reston, Va.:

What is the most effective treatment for wrinkles in 55-year-old skin? Is prescription better than over the counter?

Rachel Herschenfeld: Precription creams are usually more effective. I would recommend Renova or Avage if you can tolerate them, along with topical anti-oxidants, sunscreen, and alpha or beta-hydroxy acids. For deeper wrinkles, you may need to see a dermatologist to consider procedures such as laser, Botox or fillers.

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Washington, D.C.:

I use a facial cleanser with microbeads and alpha and beta hydroxies. I like it a lot, but I wonder, if I rinse it off, like you're supposed to do with a cleanser, do the alpha and beta hydroxies do any good? Or, if I'm to get any effect from them, should it come in the form of a cream that I put on my face and that soaks in?

Rachel Herschenfeld: The cleanser does do a lot even though you rinse it off. You can also use a stay on cream with alpha or beta hydroxy such as MD Forte 1,2 or 3, or SkinMedica AHA/BHA cream.

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Washington, D.C.:

Hello, I am desperately seeking an inexpensive peel or microdermabrasion option. Is it better to book an appointment with a dermatologist, or can I get a kit from the drug store? If so, which one do you recommend? Money is a concern.

Rachel Herschenfeld: You can try some at-home peel products such as Neutrogena Advanced Solutions or Elizabeth Arden Peel. In general, treatments in the office will be stronger, and possibly more effective. So, if you're not happy with your at home results, make an appointment.

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Washington, D.C.:

Is La Mer really worth the money or is it just a celebrity fad?

Rachel Herschenfeld: Just celebrity fad!!! It had sea weed extract in it. Do you need to pay so much for that?

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Bethesda, Md.:

I saw that the La Roche Posay sunscreens (containing mexoryl) were recently approved for sale in the US. What is your opinion of mexoryl as a UVA blocker? Are sunscreens containing titanium dioxide or zinc oxide good enough for UVA protection? My skin is sensitive to ingredients like avobenzone, so I'm searching for something else to give broad-spectrum protection.

Rachel Herschenfeld: Mexoryl is a great UVA blocker. The LaRoche Posay sunscreens will hopefully be available soon here, but not the full line yet. If your skin is very sensitive to chemical sunscreens, use mineral blockers. Zinc and titanuim are excellent UVA blockers and can be found in many sunscreens including SkinCeuticals, Blue Lizard, and Vanicream.

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Rachel Herschenfeld: Thank you so much for all of your questions. I hope that you found this chat informative. I look forward to answering more questions next time!

Rachel Herschenfeld MD

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