Contrary to what many people think, genes account for only 30% of total cancer risk. Most cancers actually result from poor dietary habits, smoking, alcohol consumption, lack of exercise, and exposure to environmental toxins. In fact, so toxic is our environment that the World Alliance for Breastfeeding Action (WABA) and the International POPs (Persistent Organic Pollutants) Elimination Network (IPEN) has declared that if every child born anywhere in this world was tested after birth, we would discover that she or he already has a body burden of toxic chemicals like dioxin, polychlorinated biphenyls (PCB’s), mercury, pthalates, pesticides, flame retardants, bisphenol A and other dangerous substances resulting from transplacental transmission during the prenatal period. These substances are potent hormone disrupters or EED’s (Environmental Endocrine Disrupter meaning they are capable of interfering with the action of hormones like estrogen by increasing or decreases its hormonal effects). This tells us that from the moment of conception, the process of immune system suppression leading to cancer already started from the womb. In fact, by age 6, some kids have already accumulated one half of their total lifetime amount of cancer causing chemicals!! So, it is really no surprise why we are diagnosing breast cancer in women in their 20’s or 30’s with no family history of breast cancer.

FREE RADICALS

Environmental agents cause havoc on our bodies by increasing our load of free radicals. Free radicals are are unstable molecules that seek to steal an electron from another molecule to neutralize it. In the process, it acts like a spitfire from a chimney burning holes on your carpet, only in this case, its your human cells. Everytime you breathe, 3-5% of your oxygen is converted to free radicals as well as when your cells burn food for energy (a process called oxidative metabolism). On top of these, exposure to lead, pesticides, cadmium, ionizing radiation, alcohol and cigarette smoke all serve to increase free radical activity.

To give you an idea of how much damage free radicals can do, imagine that these rebellious molecules strike and fracture every single one of your DNA molecules 10,000 times a day. About 9,900 of these breaks in the DNA strand are restored to normal by DNA repair enzymes. About 100, or 1 percent, escape the enzymes’ notice. This unrepaired damage accumulates over time, setting the stage for atherosclerosis, cancer, and other degenerative diseases. You can see why slowing the damage–by increasing antioxidant protection—is an anti-aging regimen. Meats, poultry, fish, dairy products, and eggs are devoid of protective antioxidants and have instead abundant supplies of free radical-forming fats. They’re also likely to contain residues of pesticides, herbicides, and other free radical-producing toxins

Damaged DNA in the nucleus may provide the wrong genetic code leading to too much protein synthesis and/or cell growth which results in cancer. Malins (1996) determined that women with metastasized breast cancer exhibit twice as much free-radical damage to the breast tissue DNA than do women with localized cancer. The researchers, therefore. concluded that antioxidants, especially vitamin C, may play a crucial role in controlling free radical damage to the DNA in breast tissue and may help prevent metastasis.

TOXIC METALS

Several hundred years ago we did NOT have the burden of toxic metals in our bodies that we now do, and we also did not have such an exposure to free radicals. Free radicals are increased in activity and quantity by bumping into toxic metals in the body. If you remove the toxic metals from the body, you then greatly reduce the activity and the number of free radicals. Here are the two most common toxic metals we are heavily and unknowingly exposed to.

MERCURY – According to FDA toxicologist Mike Bolger, Ph.D., approximately 2,700 to 6,000 tons of mercury are released annually into the atmosphere naturally by degassing from the Earth’s crust and oceans. Another 2,000 to 3,000 tons are released annually into the atmosphere by human activities, primarily from burning household and industrial wastes, and especially from fossil fuels such as coal. Pregnant women and women of childbearing age, who may become pregnant, however, are advised by FDA experts, to limit their consumption of shark and swordfish to no more than once a month. These fish have much higher levels of methyl mercury than other commonly consumed fish. Mercury is also used in fluorescent lights, pesticides, dental fillings & seed coatings. Mercury thermometers can break in a child’s body but this is no cause for alarm since it is poorly absorbed and can be excreted in a the child’s stool but if liquid mercury spills in the house, it vaporizes readily and is easily absorbed through the lungs.

LEAD – heavy metal found in lead crystals, plumbing, PVC, batteries, old paint, tin cans. The Clean Air Act of 1970 in the U.S. and subsequent regulations reduced lead in the atmosphere by 90%. The single most important action was the successful removal of lead from gasoline. The Lead Paint Poisoning Prevention Act of 1971 banned the use of lead in household paint. All houses built before 1960 have leaded paint. Of houses built between 1960-1974 20% have leaded paint. Peeling paint is a serious health hazard. Only experienced professionals should remove it. Household drinking water may contain excessive amounts of lead from the pipes or the lead solder. Ceramic dinnerware may contain lead from the glaze of clay. Therefore used only ceramic dinnerware that has a written statement that it is lead free..

ENVIRONMENTAL POLLUTANTS

Other environmental poisons, from pollutants in the air you breathe to chemicals in the water you drink, generate free radicals as well. While you have less control over them than over your diet, you should still limit your contact with them as much as you can. In fact there are many of these free-radical causing toxins right in your very homes and surroundings increasing your predisposition not only to breast cancer but all other types of cancer as well

DIOXINS – are a family of 75 compounds released into the environment during processes such as bleaching pulp and paper, pesticide production, or when plastic, especially PVC and other chlorinated compounds are manufactured or are burned in older incinerators for example, medical waste like IV bags burned in hospital incinerators can release dioxins which are potent hormone disrupters. More than 95% of all dioxins result from human industrial activity, are emitted into the air then deposited on grass and trees and consumed by cows and other animals or is deposited in lakes and streams and ingested by fish. Since these compounds are insoluble in water, are bound to fatty substances and resilient against degradation, they accumulate in the food chain. Ninety-five % of our exposure to dioxin is through meat, fish and dairy products. In Oct. 1977, dioxin was upgraded to a known human carcinogen, one of the most potent ever tested.

POLYVINYL CHLORIDE (PVC) – or vinyl, is one of the most common of all plastics, used in everything from flooring to children’s toys. The manufacture of PVC generates large quanitities of dioxin and burning PVC plastic can create dioxins, especially in older incinerators. However, new, high tech incineration does not produce dioxins. PVC plastic has been called one of the single most environmentally damaging and least recyclable of all plastics.

POLYCHLORINATED BIPHENYLS (PCB) – class of 209 related oily compounds that don’t burn easily, hence making them excellent as electrical insulator, fire retardants coating wood and plastic, adhesive and lubricant. They enter the environment during manufacture, during spill while transporting, leaks from transformers & burning of waste in incinerators. Production has been banned since 1970 but is still used in other countries. The fish, dairy and poultry we eat are the most consistent sources of PCBs in the food chain. PCBs are found to bind to estrogen receptor sites & at least 24 studies of human populations show a possible link between PCBs and breast cancer.

PTHALATES – class of chemicals used as plasticizers to make plastics more flexible. Used in food packaging materials like cling wrap and food plastics, car parts, toys, blood bags, inks, nail polish, fragrances, antiperspirants, footwear, shower curtains, upholstery, adhesive for medical devices, carpet backing, blister packing, toothbrushes. Soft cheeses, chocolate bars, chips, cakes packaged in paper and cardboard, sausages, contain pthalates, 59 samples from fifteen brands of baby milk, tested by the ministry of Britain in 1996 all revealed pthalates. Pthalates were also found in fruit juices and distilled water possibly leaching from the plastic container. It was also discovered that when some plastic baby feeding bottles were sterilized, pthalates leached into the milk which is why Evenflo brought back tempered glass baby feeding bottles back to the market. Pthalates have been associated with premature breast development, which is linked to early onset breast cancer.

BISPHENOL A – a component of plastic.It can leach into our bodies from food and beverage packaging since they coat metal products like tin cans and bottle tops including baby formula bottles as well as water supply pipes. Used in polycarbonate plastics, dental sealants in our children’s teeth and in composites (the alternative to the mercury in amalgam fillings. Six different laboratories have demonstrated that (BPA) bisphenol A is an estrogen as there are at least two published in vivo studies showing that it is almost as potent as our natural hormones although not as potent as DES. Munoz de Toro (2005) showed that perinatal exposure to BPA in particular, and to estrogens in general, may increase susceptibility to breast cancer.

PESTICIDES – DDT has been linked to breast since women with breast Ca were found to have higher body levels of DDT then women of the same age without cancer. Acc. to WHO, the countries have high exposures to DDT are China, India and Mexico since they still manufactures and use DDT. Much of our pesticide exposure is through our agricultural products laced with pesticides so it is best best to eat only organic produce.
Pesticide poisoning can occur when classrooms or buildings are sprayed for cockroaches, termites, mosquitoes, etc. Many pesticide labels claim people can return to a sprayed area 1-2 hours after application. It is best to keep children away and to thoroughly ventilate area prior to return.
P-chlorobenzene-a registered pesticide which is an active ingredient in moth repellants is found in all types of air fresheners: liquid, spray and solid. This chemical has been demonstrated in tests by the U.S. National Toxicology Program to cause cancers in rats and mice. The pure white cakes commonly placed in urinals and public toilets to freshen the air are made of 100% p-dichlorobenzene.

THE VALUE OF BREASTFEEDING

Maybe one explanation why mothers who breastfeed have a smaller incidence of breast cancer is that breastfeeding considerably lessens the mother’s body burden of toxic chemicals. The chemical levels in mother’s milk become lower during each individual feeding, and are even lower after a three to six month period of breastfeeding, and are also lower for subsequent children.

WHAT SHOULD BE DONE

The public’s health is at stake and cannot to wait for proof that certain chemicals cause breast cancer before the concerned agencies move to prevent the occurrence of such a devastating disease. The following measures should at least be taken:

• Educate the public about the health effects of radiation and on how to reduce their exposure
• Tests should be done externsively on all chemicals to check its effect on humans. & phase out chemicals known to cause cancer
• Corporations should be made liable for hazardous practices .
• Establish a comprehensive biomonitoring program to measure the presence of chemicals in people and track resultant health outcomes.

Rebecca B. Singson, MD, FPOGS, FPCPC

With summer clearly manifesting its heat coupled with the end of the school year, families have the time to plan for outings and vacations. For pregnant women, especially for first-time moms, knowing what your limits are in terms of activity can surely keep injury away from you and your baby.

CAN I SWIM?

Yes, certainly. This is one of best exercises for pregnant woman. It mobilizes many different muscles yet there is little strain for the woman to bear the load of that growing tummy since the water supports and partially unburdens her of that weight.  Diving or jumping into the water are best avoided, however, especially in the third trimester of pregnancy. The problem with pools is that the water is chlorinated for antiseptic reasons, i.e. to kill the harmful bacteria that may accumulate in the water. That’s good. But the bad side is the chlorine can also kill the bacteria in the vulvar area, upsetting the bacterial flora, thus promoting fungal infections. So if you get a vaginal itch a few days to a few weeks after swimming, you know what caused it and what it might possibly be.

In the beach, avoid jellyfish stings with a locally available anti-jellyfish lotion by Godiva. Remember to be generous with sun block to prevent free radical formation on the skin (the higher the number, the longer the protection. Look for SPF60) that can induce skin cancer as well as to wear sunglasses to avoid free radical formation in the eyes that can cause cataracts in the future. Prevent dehydration and overheating by taking lots of fluids (coconut juice is great for replenishing electrolytes − much better than plain water).

Avoid water sports that create internal body pressure changes, such as scuba diving. Water skiing and beach volleyball are best avoided but jet skiing may be engaged in if it is something you have been doing even prior to pregnancy, not if you are learning it for the first time.

WHAT ABOUT OTHER SPORTS?

One rule of thumb when it comes to activities and pregnancy is that you can usually engage in it if it was something you have been accustomed to doing prior to pregnancy. However, activities where you run the risk of falling are best to be avoided, since the force of an impact may cause the placenta to separate from the uterus, known as abruption placenta. This is a very serious condition, which will cut off the oxygen supply of the baby, causing fetal death or a dangerous loss of blood from the mother. Therefore, rock climbing, skydiving and horseback riding are definitely to be avoided. Tennis is generally safe during pregnancy if you are not learning it for the first time. A woman should be aware that her sense of balance may change.  Golf and bowling are good recreational sports but don’t consistently pump up cardiovascular function so they don’t really strengthen the heart and lungs. What a pregnant woman needs to remember, however, is that during pregnancy, the hormone, relaxin, causes all the joints to loosen. Furthermore, with a growing abdomen, her axis of gravity changes such she will need to lean back to adjust to her balance. Body-building and strength training can make muscles stronger as well as help prevent the muscle aches and pains that are commonly experienced in pregnancy. This is best done with a professional trainer to avoid muscle and joint injuries.

POINTS TO REMEMBER

1. Vigorous exercises can raise a woman’s temperature to more than 1 ½ to 2 degrees F. This can be dangerous since blood is shunted from the uterus to the skin to regulate temperature back to normal.
2. No swimming in hot springs or hot tubs. Avoid saunas and steam rooms.
3. Wear stretchable or loose clothes that don’t strangle any part of the body with movement. Natural fabrics like cotton let the body breathe vs polyester fabrics that don’t absorb sweat.
4. Use anti-slip footwear especially in wet areas. Use well-fitting, well-cushioned sneakers that will protect the loosened joints and ligaments of the body to minimize injuries.
5. Never train to the point of exhaustion. Once the body sugar runs low, the body will break down fat for energy supply. The by-product of this fat metabolism is ketone formation which can cross the placenta and is not safe for the fetus.
6. Whenever pain, cramping, dizziness, nausea and headache ensue, these are body signals that should never be ignored and should be signs that it is time to stop and rest.
7. Gradually reduce the level of exercise in the third trimester. Walking is the best exercise at this stage of pregnancy, which does the least harm.

It is possible to enjoy the summer and some of the fun activities with friends and family if you know what your limits are as a pregnant woman. As in many other things during pregnancy, it is better to be safe than sorry.

Rebecca B. Singson, MD, FPOGS, FPSCPC

WHAT ARE STRETCH MARKS?

Stretch marks, also known as stria atrophica or striae distensae, is a common skin condition that has no serious medical consequences yet, can cause a major cosmetic concern to people to have it. It may appear in the shoulders of body builders, in the buttocks of adolescents undergoing their growth spurt, and in the arms, breasts, buttocks and thigh of individuals who are overweight. Seventy percent (70%) of adolescent females, and 40% of adolescent males, especially those who participate in sports, have stretch marks. If it occurs during pregnancy, it is called striae gravidarum. It is found in 90% of pregnant white women but is less common among Asian and black women. (2) Striae generally develop late in the 2nd trimester and the areas most frequently affected are the breasts and abdomen.

WHAT CAUSES STRETCH MARKS?

The cause of stretch marks is still unclear, although genetic predisposition, hormones and weight gain during pregnancy each appear to have a role in the etiology. Prolonged use of oral or topical corticosteroids or Cushing syndrome (increased adrenal cortical activity) also causes striae. They represent linear dermal scars accompanied by atrophy of the epidermal layer of the skin.

The skin has three different layers. The top layer is known as the epidermis, the middle, elastic layer is called the dermis, and the deepest layer is called the subcutaneous layer. Stretch marks actually occur in the elastic dermis layer.

These are caused by tearing in the skin and its underlying connective tissue as a result of direct trauma or stretching due to the enlargement of muscle or adipose (fat) tissue. As underlying tissue enlarges due to sudden and drastic weight gain, the dermis is stretched too far too quickly and its collagen fibers break, thus, leaving some microscopic bleeding and inflammation that become the dreaded stretch marks. If you look under the microscope, it will reveal that elastic fibers are absent in the area of the defect and are curled and clumped at the sides. At first, stretch marks appear slightly raised and pink, reddish brown, or dark brown lines that then turn purple or violet. Over time, these lines will fade in color and become almost silvery in comparison to your normal skin tone.

HOW CAN I PREVENT STRETCH MARKS?

A healthy diet for prevention of stretch marks is one that incorporates all the essential amino acids and essential fatty acids, enough Vitamins C and E as well as the minerals zinc and silica have been known to help form collagen and aid in tissue regeneration.

The market abounds with products for stretch mark  prevention. One such product is The Stretch Mark PreventionTM cream which contains 100% natural ingredients such as squalene oil, vitamin E, vitamin A, vitamin D3 as well as aloe vera and grapefruit seed extracts. Together they are designed to blend to increase the elasticity of the skin and stimulate the production and regeneration of new skin cells. Shea butter and olive oil have been age old preventive treatments for stretch marks. PhytoelastinTM, from France, is one of the few products with scientific studies to back up its claim of preventing stretch marks.  Cochrane analysis shows that applying products on the skin does work to prevent stretch marks, although it is not clear whether it is the product that causes the prevention or the act of massaging the skin, thus increasing the circulation that does the trick.

IF I ALREADY HAVE STRETCH MARKS, HOW CAN I GET RID OF IT?

PhytolastinTM has 2 product lines for prevention of stretch marks during pregnancy and another product after delivery to help fade stretch marks. Its proprietary formula changes the composition of your skin deep, deep in the dermal level where new skin cells are made.

StriPeptin™ , is another product that claims to stimulate cell production around the damaged areas, giving a noticeable improvement in your stretch marks. They claim that 93% of users in their clinical study could see a clear, measurable difference in the appearance of their marks after just 8 weeks.

Retinoids — Topical retinoids have been shown to be beneficial in remodeling hypertrophic scars and in improving the clinical appearance, including improvement of the surface texture, fine and coarse wrinkling, skin color, and laxity, of photoaged skin after 3-6 months of therapy.Drug Name

Tretinoin (Avita, Retin-A) — Trans-retinoic acid is a derivative of vitamin A (retinol), effectively used to treat acne vulgaris and other disorders of keratinization for the past 3 decades. It exhibits a certain degree of vitamin A growth-promoting activity and in epithelial cell promotes collagen synthesis.. Topical application significantly improves clinical appearance of early, active stretch marks. Patients are instructed to gradually increase amount of tretinoin until mild erythema and exfoliation develops; may also apply a bland emollient if excessive irritation develops.  It is recommended to apply 0.05% or 0.1% cream on affected areas once or twice a day

Bio Oil is a recent natural product, available in local drugstores made of Vitamin A, Vitamin E, Calendula Oil, Lavender Oil, Rosemary Oil and Chamomile Oil. It has been found to effectively reduce stretch marks (quite safe to use in pregnancy because of the natural oils), prevent the appearance of stretch marks, as well as improve the appearance of scars because it helps enhances the production of collagen.

Early red stretch marks can be improved with the pulsed dye laser. However, older stretch marks show both whitening of the skin (hypopigmentation) and thinning of the skin (atrophy). Although there is no treatment for the atrophy, there are UV lasers developed for the treatment of the white skin associated with stretch marks. The laser emits short powerful pulses of ultraviolet light that stimulate the pigment-producing cells of the skin (melanocytes) to make melanin. The melanin results in a darkening of the white stretch marks and brings the stretch mark skin closer to the natural color of the surrounding skin. By decreasing the whiteness of the stretch marks and making the skin color more normal, the stretch marks become much less noticeable. Treatments are effective for all skin types and ages. Partial pigmentation of stretch marks starts after 3-6 treatments. Treatments are usually delivered twice a week for 4-6 weeks with an 80 percent response rate which varies among patients.

Disclosure

 INTRODUCTION  Section 2 of 10      

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Background: Striae distensae, a common skin condition, do not cause any significant medical problem; however, striae can be of significant distress to those affected. They represent linear dermal scars accompanied by epidermal atrophy.

Pathophysiology: Striae distensae affect skin that is subjected to continuous and progressive stretching; increased stress is placed on the connective tissue due to increased size of the various parts of the body. It occurs on the abdomen and the breasts of pregnant women, on the shoulders of body builders, in adolescents undergoing their growth spurt, and in individuals who are overweight.

Skin distension apparently leads to excessive mast cell degranulation with subsequent damage of collagen and elastin. Prolonged use of oral or topical corticosteroids or Cushing syndrome (increased adrenal cortical activity) leads to the development of striae. Genetic factors could certainly play a role, although this is not fully understood.

Frequency:

In the US: Approximately 90% of pregnant women, 70% of adolescent females, and 40% of adolescent males (many of whom participate in sports) have stretch marks.

Internationally: International figures may reasonably mirror the numbers in the United States.

Mortality/Morbidity: Striae distensae are usually a cosmetic problem; however, if extensive, they may tear and ulcerate when an accident or excessive stretching occurs.

Race: Stretch marks affect persons of all races.

Sex: Striae affect women more commonly than men.

Age: Stretch marks affect adolescents, pregnant women, and patients with excessive adrenal cortical activity.

 CLINICAL  Section 3 of 10      

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Physical: Early striae present as flattened, thinned skin with a pink hue that may occasionally be pruritic. Gradually, they enlarge in length and width and become reddish purple in appearance (striae rubra). The surface of striae may be finely wrinkled. Mature striae are white, depressed, irregularly shaped bands, with their long axis parallel to the lines of skin tension. They are generally several centimeters long and 1-10 mm wide. Gradually, some striae may fade and become inconspicuous. The natural evolution of stretch marks is similar to that of scar formation or a healing wound.

In pregnancy, striae usually affect the abdomen and the breasts.

The most common sites for striae on adolescents are the outer aspects of the thighs and the lumbosacral region in boys and the thighs, the buttocks, and the breasts in girls. Considerable variation occurs, and other sites, including the outer aspects of the upper arms, are occasionally affected.

Striae induced by prolonged systemic steroid use are usually larger and wider than other phenotypes of striae, and they involve widespread areas, occasionally including the face.

Striae secondary to topical steroid use are usually related to enhanced potency of the steroids when using occlusive plastic wraps. They usually affect the flexures and may become less visible if the offending treatment is withheld early enough.

Causes:

The factors that lead to the development of striae are poorly understood. No general consensus exists as to what causes striae. One suggestion is that they develop as a result of stress rupture of the connective tissue framework. It has also been suggested that they develop more easily in skin that has a high proportion of rigid cross-linked collagen, as occurs in early adult life. This is evident in striae due to pregnancy, lactation, weight lifting, and other stressful activities. Increased adrenal cortical activity has been implicated in the formation of striae, as in the case of Cushing syndrome. Additionally, the cellular and extracellular matrix alterations that mediate the clinical phenotype of stretch marks remain poorly understood.

 DIFFERENTIALS  Section 4 of 10      

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Other Problems to be Considered:

Although the diagnosis of striae is usually straightforward, the rare possibility of Cushing syndrome must be entertained. In the latter, striae are characterized by their inordinate breadth, depth, and intense color.

In linear focal elastosis (elastotic striae), asymptomatic, yellow linear bands arrange themselves horizontally over the lower back. These lesions may resemble striae distensae, but they are palpable rather than depressed and yellow rather than purplish or white.

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WORKUP  Section 5 of 10      

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Histologic Findings: In the early stages, inflammatory changes may predominate; edema is present in the dermis along with perivascular lymphocyte cuffing.

In the later stages, the epidermis becomes thin and flattened with loss of the rete ridges. The dermis has thin, densely packed collagen bundles arranged in a parallel array horizontal to the epidermis at the level of the papillary dermis. Elastic stains show breakage and retraction of the elastic fibers in the reticular dermis. The broken elastic fibers curl at the sides of the striae to form a distinctive pattern.

Scanning electron microscopy shows extensive tangles of fine, curled elastic fibers with a random arrangement. This arrangement is in contrast to normal skin, which has thick, elastic fibers with a regular distribution. When viewed by transmission electron microscopy, the ultrastructure of elastic and collagen fibers in striae is similar to that of healthy skin.

 TREATMENT  Section 6 of 10      

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Medical Care:

Adolescents with striae can expect some improvement in their striae with time.

Topical application of tretinoin can significantly improve the clinical appearance of early striae distensae.

Surgical Care: The authors have had good success using low concentrations (15-20%) of trichloroacetic acid (TCA) and performing repetitive papillary dermis-level chemexfoliation. The peels can be repeated at monthly intervals. Significant improvement in regard to skin texture, firmness, and color can be achieved.

Treatment with the 585-nm flashlamp pulsed dye laser at low energy densities was shown to improve the appearance of striae. Multiple treatments at 4- to 6-week intervals are usually required.

Certainly, both modalities (pulsed dye laser and TCA peels) can be sequentially performed for optimal results.

At lower fluences (2-4 J/cm2), The 585-nm flashlamp pulse dye laser (FLPDL) has been purported to increase the amount of collagen in the extracellular matrix. The 585-nm FLPDL has a moderate beneficial effect in reducing the degree of erythema in striae rubra but has no apparent benefit in striae alba. Because of the potential for adverse effects, FLPDL treatments should be performed with extreme caution or even not at all in darker-skinned patients (phototypes V and VI).

Intense pulse light, a noncoherent, nonlaser filtered flashlamp that emits a broadband visible light, has been reported to yield clinical and microscopical improvement in striae distensae. It seems to be a promising treatment modality with minimal adverse effects and little to no down time.

Lasers and light sources emitting UV-B irradiation have been shown to repigment striae distensae (striae alba). The improvement is due to an increase in melanin pigment, hypertrophy of melanocytes, and an increase in the number of melanocytes.

MEDICATION  Section 7 of 10      

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Drugs of choice should have the ability to improve the skin texture and color, to remodel the collagen in the dermis, and to promote elastin synthesis.

Drug Category: Retinoids — Topical retinoids have been shown to be beneficial in remodeling hypertrophic scars and in improving the clinical appearance, including improvement of the surface texture, fine and coarse wrinkling, skin color, and laxity, of photoaged skin after 3-6 months of therapy.Drug Name

Tretinoin (Avita, Retin-A) — Trans-retinoic acid is a derivative of vitamin A (retinol), effectively used to treat acne vulgaris and other disorders of keratinization for the past 3 decades. Exhibits a certain degree of vitamin A growth-promoting activity; however, it is not stored in the body as retinol and its esters. Rather, it is metabolized rapidly and mostly excreted in bile. When administered topically, a minute amount passes through dermis but has not been detected systemically.

In epithelial cells, affects differentiation, neoplastic transformation, tumor promotion, collagen synthesis, wound healing, stimulation and modulation of immune response, inflammation, cell membranes, and many other processes.

0.05% strength has been shown to improve hypertrophic scars. Postulated that this is due to effect on fibroblasts (ie, decreased fibroblast proliferation and decreased fibroblast collagen synthesis). Effect on fibroblasts is mediated through specific binding receptor proteins. Topical application significantly improves clinical appearance of early, active stretch marks. Processes responsible for clinical improvement remain unknown.

Patients are instructed to gradually increase amount of tretinoin until mild erythema and exfoliation develops; may also apply a bland emollient if excessive irritation develops.

Adult Dose Apply 0.05% or 0.1% cream on affected areas qd/bid

Pediatric Dose Apply as in adults

Contraindications Documented hypersensitivity

Interactions Concomitant topical medication, medicated or abrasive soaps, and cleansers, soaps, and cosmetics have strong drying effects; caution with products high in alcohol, astringents, spices or lime, and preparations containing sulfur, resorcinol, or salicylic acid because tretinoin toxicity may increase

Pregnancy C – Safety for use during pregnancy has not been established.  

Precautions Discontinue if reaction suggesting sensitivity or chemical irritation occurs; minimize exposure to sunlight, including sunlamps, during use, and advise patients with sunburn not to use product until fully recovered because of heightened susceptibility to sunlight; wearing protective clothing and applying sunscreen products over treated areas is recommended; weather extremes (eg, wind, cold) may irritate patients; degree of local irritation warrants either less frequent applications or treatment to be discontinued (temporarily or altogether)

 FOLLOW-UP  

• Arnold HL, Odom RB, James WD: Abnormalities of dermal connective tissue. In: Odom RB, James WD, Berger TG, eds. Andrew’s Diseases of the Skin Clinical Dermatology. 9th ed. Philadelphia, Pa: WB Saunders; 2000: 645-6.
• Burton Jl, Lovell CR: Disorders of connective tissue. In: Champion RH, Wilkinson DS, Ebling FJG, et al, eds. Textbook of Dermatology. 6th ed. London; Blackwell Science; 1998: 2008-9.
• Dover JS: Sports dermatology. In: Fitzpatrick TB, Eisen AZ, Wolff K, Freedberg IM, eds. Dermatology in General Medicine. 4th ed. New York, NY: McGraw-Hill; 1993: 1618-19.
• Fox JL: Pulse dye laser eliminates stretch marks. Cosmetic Dermatology 1997; 10: 51-2.
• Goldberg DJ, Marmur ES, Schmults C, et al: Histologic and ultrastructural analysis of ultraviolet B laser and light source treatment of leukoderma in striae distensae. Dermatolog Surg 2005; 31(4): 385-7[Medline].
• Goldfarb MT, Ellis CN, Weiss JS, Voorhees JJ: Topical tretinoin therapy: its use in photoaged skin. J Am Acad Dermatol 1989 Sep; 21(3 Pt 2): 645-50[Medline].
• Hernandez-Perez E, Colombo-Charrier E, Valencia-Ibiett E: Intense pulsed light in the treatment of striae distensae. Dermatol Surg 2002; 28(12): 1124-30[Medline][Full Text].
• Jimenez GP, Flores F, Berman B, Gunja-Smith Z: Treatment of striae rubra with the 585-nm pulsed-dye laser. Dermatol Surg 2003; 29(4): 362-5[Medline].
• Kang S, Kim KJ, Griffiths CE, et al: Topical tretinoin (retinoic acid) improves early stretch marks. Arch Dermatol 1996 May; 132(5): 519-26[Medline].
• Kang S, Kim KJ, Griffiths CE, et al: Topical tretinoin (retinoic acid) improves early stretch marks. Arch Dermatol 1996 May; 132(5): 519-26[Medline].
• Kligman A: Topical tretinoin: indications, safety, and effectiveness. Cutis 1987 Jun; 39(6): 486-8[Medline].
• McDaniel DH, Ash K, Zukowski M: Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser. Dermatol Surg 1996 Apr; 22(4): 332-7[Medline].
• McDaniel DH: Laser therapy of stretch marks. Dermatol Clin 2002; 20: 67-76[Medline].
• Medical Economics Staff: Physician’s Desk Reference. 53rd ed. Medical Economics Company; 1999: 2177.
• Obagi ZE, Obagi S, Alaiti S, Stevens MB: TCA-based blue peel: a standardized procedure with depth control. Dermatol Surg 1999 Oct; 25(10): 773-80[Medline].

By Rebecca B. Singson, MD, FPOGS

Whenever it’s holiday time, it becomes challenging for people to maintain their weights because of the frequent social engagements and office parties loaded with mouth-watering, irresistible goodies. It becomes particularly challenging for the pregnant woman who has an increased appetite and feels she “is eating for two” but is already overweight. If you are slim and non-pregnant, gaining extra weight and eating high calorie but low nutritional food may not be such a great issue. But to the infanticipating woman, there may be more serious consequences if she is not meticulous in watching what she eats so here’s the why and how of being more prudent with your palate during party time.

WHY YOU SHOULD NOT GAIN TOO MUCH WEIGHT

Too many calories and extra pounds can put you at a higher risk for pregnancy complications such as hypertension or diabetes, and may make labor and delivery more difficult. Although you do need extra calories during pregnancy, particularly during the last trimester, you also need lots of extra nutrients, so those extra calories need to be chosen wisely. A woman who is not pregnant needs between 1,800 and 2,200 calories per day. When you are pregnant, contrary to popular belief, you only need to increase your calories by about 300 per day so keep in mind that its quality not quantity is what matters. Remember that if you gain way beyond the prescribed weight, your chances of having a large baby also increases, which in turn may also increase your chances of ending up with a Cesarean section.

Besides all that, the latest, and by far the most disturbing finding by researchers at Lombardi Cancer Center in Washington, DC, and in Finland is that women who gain more than 50 pounds during pregnancy, and did not losing the excess weight after pregnancy, can triple their risk of developing breast cancer after menopause. A lesser pregnancy weight gain of 40 pounds can still increase breast cancer risk by 40%. Knowing that should stimulate you to be more watchful of the weighing scale.

Researchers have shown that pregnancy weight gain has been linked to increased estrogen levels, which in turn is believed to increase breast cancer risk  in a similar way that postpartum obesity does too. Women who gained within the normal limit of 25-35 lbs. during pregnancy were not associated with increased breast cancer risk.

If despite eating moderately, you are gaining more than 2 lbs./wk., you must alert your obstetrician since any rapid weight gain, especially if associated with marked fluid retention and an increase in blood pressure and possibly protein in the urine, can be a marker for the onset of preeclalmpsia. This is a disorder that can be harmful, if not fatal to you and your baby.  

HOW MUCH IS TOO MUCH?

If you are of average weight, it is recommended that you gain is about 25 pounds during pregnancy. Only two to four pounds of that goes on during the first trimester. By 20 weeks, you should have gained 7-10 lbs. and the remaining weigt is added at about a rate of half a pound to one pound per week after that. Some women even drop their weight during the first trimester due to nausea and vomiting but usually recover the weight loss in the course of pregnancy. Underweight moms can afford to gain more weight, at least 28 to 40 pounds, so they don’t end up with a low birth weight baby. But if you’re already carrying an extra baggage of fat by the time you get pregnant, its best that you limit your weight gain to 15-20 lbs.

If you want to know where all that weight goes, here’s how the weight gain is ideally distributed:

• Baby:   7 pounds
• Placenta:   1 pound
• Amniotic fluid:   2 pounds
• Blood volume:   4 pounds
• Body fluids:   3 pounds
• Uterus:   2 pounds
• Breasts:   1 pound
• Fat & protein storage:   7 pounds

WHAT YOU CAN DO

So you can’t say no to these social obligations. At the same time, you’d hate to miss out on the fun. So here are tips to help you keep the scale from tipping over.

• PRIORITIZE YOUR REQUIREMENTS. Make sure you meet your daily requirements first before you allow yourself the treats. Get your fill of the salads and protein sources while filling your healthy carbohydrate requirements. Ear your fruit first before you hover over the dessert table. Hopefully, that would have killed your craving for the pastry department.

• AVOID STARVATION. It is truly difficult to control your appetite if you arrive ravenous during a party. You are bound to eat everything in sight! So before you go to the party, have a nutritious snack like a granola or muesli bar, veggie sticks with yoghurt-garlic dip or some dried fruits and nuts so you won’t be obsessing over the buffet table.

• DRINK BEFORE YOU LEAP.  If you have the urge to splurge, gulp down a glass of water, fruit juice or some soup (preferable clear than creamed). That will instantly appease your grumbling insides and allow you to be more sane and prudent in your choice of food.

• CHEAT SENSIBLY. If you must absolutely give in to your sweet tooth, at least make the wiser, more nutritious choice, lower calorie choice. An oatmeal or ginger cookie is better than an empty sponge cake or a fatty cheese cake.

• IF YOU MUST INDULGE, EAT ONLY A PORTION OF IT.  If you cant resist the cheesecake, instead of gobbling up the whole slice, eat only half or a few bites of it. Remember, it doesn’t matter whether you have had fifty bites or only two. In the end, your mouth is empty. But the fifty bites will take your weight farther down the scale.

• BURN WHAT YOU EAT.  Just because you are pregnant doesn’t mean you can’t exercise. As a rule, you can still continue your exercises, dance or low impact sports (swimming, golf, tennis doubles). Remember that brisk walking for 20 mins., will raise your metabolism the rest of the day and cause you to burn calories faster than if you did not exercise at all.

• DON’T BE A STRESS CHOMPER. Holidays can be stressful times especially when you have to socialize and beat you office deadlines at the same time. So resist the impulse to munch away your stress. Be prepared with your arsenal of anxiety busters like yoga, meditation, massage (caution: masseuse must be trained on pregnant women or premature labor may be induced), instead of taking it out on food.

Remember that staying within your prescribed weight will insure a more favorable outcome for your pregnancy as well as prevent your risk for breast cancer. That’s really worth dieting for.

Rebecca Singson, M.D., FPOGS

Pregnancy is in the only time in the life of a woman when another human being becomes a parasite to her, depending on her body to provide the nutrients the fetus needs in order to grow. It is thus a critical time to be equipped with the necessary micronutrients to prevent damage to the growing fetus as well as to the mother herself. Nature protects the fetus so much that if the baby needs a nutrient that the mother does not have enough of for herself and her baby, the nutrient will be preferentially directed to the baby even to the detriment of the mother.

In this generation when we no longer plant our food the way our forefathers did, the nutrition we get from eating fastfood, bottled, canned, frozen food have become devoid of the nutrients we need to keep our bodies healthy, much less to support a healthy pregnancy. We need to insure ingesting at least the following nutrients to begin working towards an uneventful pregnancy.

FOLIC ACID. Folic acid can be found in foods such as spinach, parsley, broccoli, lettuce, lima beans, turnip greens, asparagus and beef liver. Folic acid supplementation is best taken even before planning your pregnancy since there is strong evidence that folic acid can reduce certain birth defects of the brain and spinal cord by more than 70 percent. These birth defects are called neural tube defects (NTDs). NTDs happen when the spinal cord fails to close properly.The most common neural tube defect is spina bifida which occurs when part of the baby’s spinal cord remains outside the body. The baby may have paralyzed legs and, later, may develop bladder and bowel control problems. The most serious neural tube defect is anencephaly when baby is born without part of its skull and brain, and eventually dies. For all childbearing ages, the Center for Disease Control in the U.S. recommends that all women of childbearing age take at least 400mg of folic acid daily but for all pregnant women, 1mg/day is recommended. Women with a history a child with neural tube defect should take 4 mg of  folic acid 1 month prior to conception and and all throughout the first trimester.1

IRON. According to the Cochrane review, rron supplementation appears to prevent low haemoglobin at birth or at six weeks post-partum.2 The availability or iron for our bodies to use depends on the food source. Heme iron, which is found only in meat, poultry, and fish, is two to three times more absorbable than non-heme iron, which is found in plant-based foods and iron-fortified foods 3.4. The bioavailability of non-heme iron is strongly affected by the kind of other foods ingested at the same meal. Enhancers of iron absorption are heme iron (in meat, poultry, and fish) and vitamin C; inhibitors of iron absorption include polyphenols (in certain vegetables), tannins (in tea), phytates (in bran), and calcium (in dairy products)5.6 . Vegetarian diets, by definition, are low in heme iron but can certainly be increased by careful planning of meals. The CDC recommends taking or low dose 30 mg/day) supplements of iron at the first prenatal visit. In the presence of anemia, treatment involves prescribing an oral dose of 60-120 mg/day of iron.7.

IODINE. This is essential for normal fetal thyroid function. If the mother lacks iodine, the baby may develop cretinsm (congenital hypothyroidism) of which mental retardation is a component. Cretins have abnormal looking faces with the tongue sticking out. Acc. to the Cochrane Review, iodine deficiency is the leading preventable cause of intellectual impairment in the world. Supplementation during pregnancy especially in areas with high incidence of cretinism results in reduction of this problem with no adverse side effects.8

The use of iodized salt is one way to prevent iodine deficiency. Salmon, tuna and seaweeds are excellent leading sources of iodine from food.

If using seaweeds as an iodine source it is best to use seaweeds that have been found to have a fairly consistent iodine content, such as kelp (kombu) or hijiki. It may be dangerous to consume more than 100g/year (by dried weight) of most seaweeds carries a significant risk of thyroid disorder due to iodine intakes in excess of 1000 micrograms per day.

Nori (the seaweed used to wrap sushis with) is low in iodine and several sheets a day can be eaten without any concern about excess iodine. Frequent addition of small amounts of powdered or crumbled seaweed to stews or curries while cooking, or to other foods as a condiment, is an excellent way to provide adequate iodine (in the absence of other supplementation) . 100g of dried hijiki or 15g of dried kombu or kelp in a convenient container in the kitchen provides one year’s supply for one person.

MAGNESIUM. Magnesium supplementation during pregnancy has been associated with fewer pre-term births and less intrauterine growth retardation. 9.10,11 Magnesium deficiency is associated with pre-eclampsia, and pre-term delivery and possibly with low birth weight.12 ,  coagulation defects 13, premature delivery14,15, intrauterine growth retardation 9.15,and muscle cramping16 Diets high in magnesium density would contain whole grains, lean meats, low amounts of fats and sugars, abundant fruits and vegetables, and low-fat milk. Diets low in magnesium density would contain refined cereal grains, fatty meats, high amounts of fats and sugars, few fruits and vegetables and sugar-containing soft drinks.

DHA. In the latest researches it has been found that supplementing pregnant mothers with fish oil may benefit brain and retinal development in their offspring particularly if born prematurely. Supplementing from mid-pregnancy to the 34th week was found to be perfectly safe and more importantly, may reduce the incidence of preeclampsia (pregnancy-related high blood pressure).17 It was found that breastmilk contains DHA whereas formula milk did not. Researchers at the University of Milan report that infants whose formula contains long- chain polyunsaturated fatty acids [especially Docosahexaenoic acid (DHA)] have better brain development than children who do not receive DHA in their formula. The observation supports earlier findings that there is a direct correlation between the DHA concentration in the red blood cells of infants and their visual acuity. The researchers recommend that infants who are not breastfed be fed on a DHA- enriched formula. Nothing is as complete as breast milk since it is already complete with the fatty acids necessary for good brain development.

VITAMIN D:

Vitamin D is produced by the skin and eyes from exposure to sunlight and can also be consumed from foods such as fish-liver oils, fatty fish, mushrooms, egg yolks, and liver. Thus nutrient has multiple functions in the body like helping maintain bone integrity and calcium homeostasis. During pregnancy, vitamin D deficiency or insufficiency may develop. Vitamin D supplementation during pregnancy has been suggested to safely improve pregnancy and infant outcomes. 

Research shows that the Vitamin D supplementation during pregnancy improves the women’s vitamin D levels, as measured by 25-hydroxyvitamin D concentrations at term and may reduce the risk of delivering a baby prematurely (less than 37 weeks of gestation), result in a lower risk of high blood pressure in women and reduce the risk of a low birthweight baby (less than 2500 g).19

MICRONUTRIENT INTERACTIONS.

There are some micronutrients that alter the absorption of others. For example, calcium can block the absorption of iron. Vitamin A may also contribute to anemia by interfering with iron although studies have shown that when given together, there is greater reduction in anemia. Iron supplements can also interfere with the absorption of zinc. On the other hand, vitamin C can increase the absorption of and zinc. Zinc in high doses may interfere with absorption of iron or copper.  But many studies still document achieving greater benefits with combined, rather than single, micronutrients therapy but many more studies are required to evaluate these interactions in malnourished populations. Because of the possibility that there may be multiple deficiencies in pregnant women in developing countries, UNICEF has concluded that a multivitamin–mineral supplement should be given during pregnancy20. By simply supplementing, many complications in the mother and infant during and after pregnancy may be avoided.

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