BASICS OF AGING SKIN
The skin is a living organ composed of millions of cells that renew themselves by shedding and regeneration moving the old and worn cells to the surface as the new and vibrant cells rise from the lower depths where they are formed. Age and nature contribute to the changes we see in the skin, but most notably the lackluster appearance, blotchy pigmentation, roughness, sagging, wrinkles, and skin cancer are features of sun damage not aging alone. Aging itself contributes to less elastic, thin, and fragile skin as seen in sun-protected skin covered by clothing. About 85% of skin aging is related to the effects of sun. Our main approach to the skin is therefore directed at prevention of sun damage from childhood through adulthood.
ANATOMY AND FUNCTION AS RELATED TO AGING AND TREATMENT
The skin is composed of an upper layer or epidermis which serves to retain water and provide sun protection. The outer part of the epidermis called the stratum corneum helps slow water loss and provide a barrier to the sun. The inner part of the epidermis or basal layer has pigment or melanin which serves to block the penetration of sun rays.. It is this layer that reacts to sun and causes deepening of skin tones called a tan. It is also the place where less desirable skin tones can develop such as freckles, lentigos, and blotchy skin.When sun strikes the skin too hard over a short period, a sun burn results. Repeat sun burn and cumulative exposure with tanning can lead to the changes called photoaging noted above.
The epidermis becomes thicker and drier. The influence of age and hormonal changes add to skin discoloration The dermis loses its elastic fibers, collagen support, and the special tissue glue that holds cells bonded together. Small blood vessels called 'spiders' develop and the skin easily bruises. Abnormal pigmentation that is usually higher in the skin in the epidermis gets displaced deeper in the dermis where it is most resistant to treatment. The fat in the skin thins out with age, and especially in the back of the hands, around the eyes, and mouth. Major fat loss contributes to the deeper facial lines we see.Below the dermis and fat lies muscle. Facial expression thickens these muscles creating deep lines and wrinkles which lead to creases and folds. All these components determine how effective skin therapies can be, and remedies that address each component may be necessary. In order to maximize the results for your skin care, you may need one of several methods of treatment over time.
Other components of skin including hair follicles, sweat, and oil glands are the key elements in the skin repair and restorative process, except in the palms and soles. Those areas ordinarily thicken as a result of constant trauma and pressure for which they are naturally suited. It takes about 6 weeks for new skin to form and reach the upper surface of the epidermis..
COMMON SKIN CONDITIONS
Acne inflammation and overactivity of the oil glands of the face, neck, and back usually initiated in adolescence but can continue far into adulthood and occur when the oil thickens and plugs the pores causing a pimple which is an inflamed accumulation of dead skin cells mixed with bacteria. It is influenced by warmer climates, stress, pregnancy, close contact from longer hair styles, constant hand touching and picking, reactions to makeup, ingested medication, constipation, and sun exposure. The preceeding condition is called milia or white heads which contain dead skin cells and little bacteria in a blocked pore, or comedones (black heads) which have both dead cells and moderate bacteria. The adult form can focus on the central face and nose and lead to deep deforming red bumps, spider vessels, and breakouts called Rosacea. It can occur in all skin types and colors. The nose can enlarge to create a bumpy deformity called Rhinophyma. Rosacea and Rhinophyma can be controlled but not cured, and are affected by intense exercise, stress, and sun exposure.
Simple freckles are the most common skin condition and relate to the superficial production of tiny amounts of melanin pigment.
Lentigo simplex is the appearance of pigment deposited high in the upper dermis and look like brown stains and are essentially large freckles.
Senile lentigo is an aging process of pigment deposition into darker brown stains in the elderly and these can change into melanoma.
Melasma or mask of pregnancy is the present of blotchy pigment in the cheek areas after pregnancy and can be associated with estrogen use which stimulates melanin pigment production. It is one of the most difficult pigment problems to treat and must be accompanied by good UV protection.
Postinflammatory pigmentation is seen after sunburn, chronic sun exposure, and after normal healing in scars, in some darker skin types. It requires attention to UV protection.
Actinic keratoses are sun related skin lesions that appear as dry red flakes and can lead to basal cell skin cancer.
Basal Cell Skin Cancer occurs in the lower layers of skin, arising as a scaly red spot with some spider veins associated, and can be a raised bump as well. It can burrow down over long periods. It is rarely fatal and responds to local therapies. It is the most common skin cancer.
Squamous Cell Skin Cancer occurs in the upper layers of the skin, is raised and thicker in quality, and must be more aggressively treated and can spread in some situation.
Melanoma is one of the most life threatening body cancers arising in the pigment cells of the skin and is most malignant when arising from the back, shoulders, arms. nailbeds, hands and feet. It is characterized by a salmon, brown, or black spot with advancing edges, irregular edges, several color shades, and a change in appearance over time
SKIN TYPES BY ETHNIC SUNBURN CLASS ( FITZPATRICKS CLASSIFICATION)
TYPE I White Always Burn, Never Tan
II White, Usually Burn, Difficult Tan
III White, Sometimes Burn, Average Tan
IV Moderate Brown, Rare Burn, Tan with Ease
V Dark Brown, Very Rare Burn, Tan Very Easily
VI Black, No Burn, Ran Very Easily
SKIN TYPE BY SUN DAMAGE FEATURES (GLOGAU CLASSIFICATION)
TYPE I No wrinkles (Minimal Wrinkles) Early Photo (SUN) Aging
II Wrinkles in Motion Early Moderate Photo (SUN) Aging
III Wrinkles at Rest Advanced Phot (SUN) Aging
IV Only Wrinkles Severe Photo (SUN) Aging
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ANATOMY OF A WRINKLE
Fine wrinkles are due to a breakdown in collagen and elasticity of the skin due to aging and sun. Deep wrinkles are associated with the buildup of the musculature far below the skin surface. The use of the facial muscles of expression will thicken this muscle layer like building an arm muscle by lifting weights. Some wrinkles are present when the muscles are used such as smiling, frowning, or squinting, and others are present at rest.
ANATOMY OF A BLEMISH
Discoloration is related to collections of melanin pigment in the epidermis and dermis. In birthmarks, the pigment rests deep in the dermis and is very durable .With the aging process, as more melanin pigment is produced as a reaction to sun exposure, general aging, and hormonal influences, and is pushed up into the epidermis where it is more easily treated, some pigment may be driven down into the dermis where it is hard to reach by many therapies without causing adverse effects such as scarring and worsening pigmentation.
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SUN PROTECTION
GETTING STARTED
SKIN CARE
1. Glycolic Acid Facial Lotions for twice daily care. Increases turnover of epidermis removing the dead upper cells more quickly restoring luster to skin. Usually in concentrations of 15-20% best. Cream less irritating than lotion. It also cleanses pores in acne prone individuals.
2. Topical Vitamin C has natural UV protective qualities and can now be absorbed through the skin in the newer preparations. Vitamin C is an essential in skin repair and especially from UV induced damage. The more stable lipid soluble ascorbyl palmitate is the best Vitamin C form to be transported into the skin by topical application .. Jan Marini C -Esta Serum and Cream are suggested products and are also auggested to improve healing after laser and peels as well as providing added sun UV protection. It can also reduce the redness following a sunburn as a measure of its antiinflammatory effects. It thickens the dermis where wrinkles develop so as to help with aging skin.
SUNSCREENS
SPF RATING
Look for sunscreens that have at least an SPF (sun protective factor) of 15. SPF is based on the exposure time it takes for your skin to begin to burn. SPFs from 30-45 are similar and provide only a few percentage points higher protection than do the 15 SPFs. When the screen touches the skin, the effectiveness is halved in many cases, so a little added protection is perhaps better. The sunscreen should have UVA and UVB protection. The UVB rays are the burning rays while the UVA rays are the warming rays. With added outdoor exposure, the build up of UVA can be even more damaging than UVB, and thus tanning booths providing UVA light are really very dangerous.
ALLERGIES
Some people are allergic to PABA, and thus seek a sunscreen without PABA. About 4% of people may be allergic to titanium oxide, so be aware of this ingredient as well.
ACNE
If you have tendency for acne and skin breakouts, obtain a screen that states: noncomedogenic. Many of the sunscreens used by surfers and beach-goers who need something durable in the higher SPFs over 20-30 for all day protection, are heavy and oily and can block the pores.
LONG PERIODS IN THE SUN
Likewise with more durable screens, you still need to reapply them every 3-4 hours, since they still can wash off in water and after perspiring. Window glass in cars has an SPF of 7, so that some of the offending rays of the sun can still penetrate. Wear a sunscreen at most all times out of doors, including driving.
MAKEUP/ MOISTURIZERS/ FOUNDATION
Sunccreens that are added to makeup, lipstick, moisturizers, and foundation may not provide the most optimal protection but are nonetheless important for daily use whether driving or in the sun for brief periods. . Choose sunscreens that blend well with your own moisturizers, and that don't have conflicting textures, thickness, and fragrance.
COVER WEAR ( Wash Additive for SPF Enhancement of Fabric)
Hats, UV protective glasses, and clothing are still important, as sunscreen cannot provide complete protection. RIT SUN GUARD Laundry Treatment UV Protection adding this to wash your clothing can take a t shirt with a normal SPF f 4-5 and increases the sunprotection factor to 30. It works even if the shirt is wet and is safe for all ages. It is approved by the Skin Cancer Foundation. It contains sodium chloride (salt) with nonionic surfactants that create a SPF shield in the material and one wash is good for 20 subsequent washings.
PRODUCTS TO CONSIDER FOR SUN PROTECTION
Cellex-C Sunc Care SPF 30 and 32 Sun Protection Face Cream
For sensitive skin that burns easily, giving great maximum routine protection. combines the particulate metal sun blocks zinc oxide and titanium oxide with salicylate, and has no PABA nor fragrance. It may not blend with your usual moisturizer.
For maximum overall protection
Allergan MD FORTE AfterCare Environmental Protective Cream SPF 30
Allergan MD FORTE SPF 20 Sun Protector which is oil free and has the Skin Cancer Foundation stamp of approval
For the heavy overall protector with high SPF, but not for very oily skin
Hawaiian Tropic Baby Faces 50SPF
Lancome Soleil Ultra Protection Eye Creme with SPF 40 has a light matte texture and is non-irritating around the eyes and upper cheeks
Robanda's Anti-Aging Hand Cream SPF 20
Ocean Potion Face containing zinc oxide with SPF 45 and avobenzone for blocking UVA rays with a lemon fragrance and doe not leave any residue and non irritating around the eyes and is very durable in the sun
Ti Screen a long time high potency UVB and UVA screen that lasts hours in the sun, and comes in a very easy to apply gel leaving a light film
Jan Marini Antioxidant Daily Face Protectant SPF 30 waterproof with a coconut aroma and is durable may be oily for some
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TREATMENT OPTIONS for PHOTOAGED SKIN BY WRINKLE CLASSIFICATION
1. Glogau Type I no wrinkles with minimal photoaging
Glycolic Acid Peels 40-99%
TCA 17.5-20% Peels
Botox Type A injections
Retin A
Micro-Retin A
Renova
Kinerase ( and Kinetin) ( furfuryladenine) natural plant-derived growth factor and can be used for patients sensitive to irritating effects of Retin A preparations ( light lotion or moisturizer cream)
Topical Vitamin C ( 10% L -ascorbic acid)
AzelaicAcid ( Azelex 20% cream) acne exfoliant, decreases pigment. Antiseptic
Tazorac 0.05% contains ascorbic acid as active ingredient
2. Glogau Type II wrinkles in motion, early-moderate photoaging
Repeat Jessners Peel
20-30% TCA peels
Microdermabrasion penetrates upper epidermis
Erbium-Yag Laser
Collagen Injection and other soft tissue augmentation
Fat injection, Cytometra, Fascian
Botox Type A injections
3. Glogau Type III wrinkles at rest, early-moderate photo-aging
TCA peels 30-45%
CO2 laser resufacing eyes and mouth
Erbium- Yag laser resurfacing
Collagen and other soft tissue augmentation
Fat injection, Cytometra, Fascian
Botox Type A injections
4. Glogau Type IV only wrinkles, severe photo-aging
Phenol Peels
Brow Suspension
Face Lifts
Blepharoplasty
C02 laser resurfacing entire face
CO2 plus Erbium: Yag laser resurfacing
CO2 laser plus TCA peel
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Frequently Asked Questions on Skin Resurfacing to Improve Skin Appearance
1. What is skin resurfacing and what is new in advanced skin treatments?
Skin resurfacing is the incorporation of advanced techniques including chemical peels, laser and abrasive methods to treat discolored, sallow, and wrinkled skin, to help restore a youthful vitality. It may be combined with surgery to lift and reposition sagging skin and muscles and is most often applied to the face and neck. At the millennium, the laser by itself shares the spotlight again with deep phenol chemical peels, combination laser and chemical peel, dermabrasion, photofacials, and microdermabrasion as well as the implementation of new skin care regimens that include new forms of retin A, botanical growth factors, topical vitamin C, and more protective sunscreens.
2. How is a weekend facelift different from facial resurfacing, and a general face and neck lift?
A weekend facelift may consist of neck liposuction, a mini-face lift, a neck lift, or facial skin resurfacing. Recovery may take 3 days for the more minor of these applications. It may be a misrepresentation to state a facelift can be a weekend recovery particularly if it does not involve contouring the usual skin, fat, and muscles, as is the case with a general face and neck lift. Moreover a deep skin resurfacing of a severely aged face may take many days of recovery, but also provide a subtle lifting as well. In faces with minimal sagging and good bone structure, treatment by chemical peel, laser, or abrasion, can result in an obvious mild tightening effect.
3. How do I know if I am a candidate for skin resurfacing?
Ethnic variations in skin type may pose specific problems and can influence what procedures are the most safe and effective and which ones are not. One must first assess the Fitzpatrick Sun burn Skin Type Classification which ranges from Type I skin that easily burns and never tans to very dark Type VI skin which never burns and tan very easily. One must then assess the 'skin wrinkle' or Glogau classification which ranges from Type I skin that has no wrinkles and mild sun damage to Type IV which only has wrinkles and severe sun damage. Patients in the lower skin types may benefit from simple home care regimens and superficial peel, laser, and abrasive treatments.
4. What if I only want a light freshening of my facial skin, have rough skin from years of sun exposure, but no real wrinkles?
This would be a good situation for a home care regimen that includes twice per day glycolic acid or lactic acid facial lotion care with gentle cleansers, then adding a Retinoid such as Retin A, or Renova, applied nightly. For skin that is sensitive to Retin A or Renova, Kinerase (furyfurlyadenine) can be substituted. Superficial skin blemishes may be treated with mild bleaching agents and exfoliants such as Azelex (Allergen Pharmaceuticals) (also used for acne); Eldoquin line of Hydronquinones from ICN pharmaceuticals, or Melanex from Neutrogena. Vitamin C serums or creams can be for the upper face and 1 ids, (best activity with the form Ascorbyl palmitate). A sunscreen with SPF of at least 15-20 is also recommended. While most makeup with sunscreens have low SPF factors, one may use a lighter foundation and undercover and add a standard SPF 20-30 sunscreen as the final step. Some moisturizers do not blend well with sunscreens, and it is best to experiment with your makeup line. One can also benefit by Botox injections to relax any fine lines around the brow and crows feet.
For breakouts that compound the problem, then the use of Azelex for mild acne or Tazorac can be used for more active breakouts, combined with a short course or tetracycline (Sumycin) or Minocin but the former is less expensive. A typical antibiotic preparation such as Benzamicin (refrigerated suspension containing Erythromycin), Cleocin, or Erythromycin, may be added. Cleaning the skin with dry agents such as Benzoyl Peroxide 5 or 10% can reduce oil plugging. An agent with salicylic acid 2% can also serve to reduce oiliness.
You may try some light office peels such as 40-99% glycolic acid, the Obagi Blue Peel, 17.5-20.0% TCA, and the Standard or Modified Jessner's Peel. These may create a mild skin redness and flaking for a day or two in the higher strength peels.
5. What if I want a deeper freshening of my skin since I have some light wrinkles and uneven areas of my complexion?
This should prompt a home care regimen for perhaps 3-6 weeks using one of the AHA acids such as glycolic (Allergan, Neostrata, Murad, Glyderm, Biomedic, Jan Marini) or lactic acid (Therapon), and nightly applications of Retin A, Renova, or Azelex. A bleaching cream twice a day will help reduce melanin pigment in the very superficial blemishes, and can also help prepare the deeper completed individuals who may opt for an entry level light peel, light laser, or light abrasion.
6. Are there any stronger treatments for acne and blemishes?
Acne tune ups incorporate the use of exfoliators and agents that penetrate the epidermis to deliver medication. Acid pigment gels, exfoliators or microspot Cyro (Cold Freeze) Therapy. The Cyro cold slush and other methods may be available from your Dermatologist, and you may wish to check there first. There may be some skin irritation at the site of these treatments, and light makeup may be recommended. The tiny bumps and lumps may be variations of freckles, lentigines, seborrhic keratosis, sebaceous hyperplasia, actinic keratoses, or lesions that could suggest skin or other underlying malignancy. A biopsy of suspicious lesions is recommended when there is doubt as to source and course. If the lesions are tiny, they can be amenable to liquid nitrogen microcryotherapy to freeze them off. They will turn darker over the next few days, and fall off, leaving tender new skin at the base. The treated areas may at first, look worse then the original lesions, but that is because the lesion is rendered lifeless, and destined to separate and fall away after a few days. Some chemical exfoliators can be applied to the skin to cause similar separation and removal, but may leave a larger scab or healing spot since they are applied with a blunt cotton tip applicator, instead of pinpoint micro tip delivery canister. It is best to keep these treated spots dry, so the skin separates at the site when it is ready, and not beforehand. An emollient ointment may be preferred if the healing is itchy or irritated as it is healing.
7. I am someone who has skin that it is so blotchy, that I cannot go outside without makeup. I am in the sun a great deal and have taken estrogen in the past for birth control. I also had some blotches on my cheeks during the last pregnancy. What can you do for me?
This is one of the toughest problems in skin care, since the pigment in this situation is usually very deep in the skin and may not accessible, except over a prolonged period with the use of multiple therapies that work together.
You must research all your medications that can cause or increase pigmentation such as high dose estrogen therapy as in birth control pills, and estrogen replacement agents, Dilantin (a seizure medicine), and cosmetics with oxidized linoleic acid and any salicylates. Then decide that you must always protect your skin from that time forward.
Consider bronzer and facial self tanners, including lines from Lancome, Estee Lauder, Chanel and Neutrogena, if you must have 'color'. Next there are several options to address severe pigmentation disorders. Daily Retin A or Vitamin A Derivatives, with a Fruit Acid/B1 combo agent such as physicians choice pigment gel, and azelex (azelaic acid) at night. Kligman's formula available as a compounded agent by most pharmacies, is composed of a bleacher, Retin A and a low concentration but potent cortisone ingredient. Moving up the line, we can employ high level Glycolic Acid peels of 70-99%, frequent low level TCA peels (15-25%). Modified Jessner's (salicylic Acid, Citric Acid, Lactic Acid) or PCA Peel (Mixed Fruit Acid, Citric Acid, Lactic Acid, Salicylic Acid and Kojic Acid) at 3 week intervals. This problem is never completely resolved but it can be controlled. It must be managed with the use of strong sunscreens, a home care regimen that is well tolerated, and a constant review of all medications either consumed or applied to the skin.
8. What about my deep wrinkles? I also have sun damaged skin and I used to smoke a great deal.
The level of treatment necessary to reduce deep wrinkles demands a deeper action for this more pronounced effect. However, the skin will react more vigorously leading to substantially more swelling, bruising, and recovery time. There may be skin drainage or frosting for 7 to 10 days, and a red or pink discoloration to the skin that can last 2 to 8 months. This must be an acceptable tradeoff for a more pronounced effect in long run.
Deep chemical controlled resurfacing and laser-assisted resurfacing are equally effective for modest to medium wrinkles and there may be little change in pigmentation at the medium treatment ranges for Fitzpatrick Skin Type I-III. For severe wrinkles deep chemical resurfacing may give the most pronounced results, at a lesser risk of scarring although the skin may appear a bit more pale, as it can from use of the laser.
Some disadvantages to Laser Resurfacing include, cost that is 2-3 times that for Deep Chemical Resurfacing, a slightly higher incidence of scarring and increased pigmentation, prolonged redness and pinkness in those candidate individuals who have a need for deep resurfacing, and loss of pigmentation. The requirement for sedation or general anesthesia for a major laser resurfacing brings forth the fact that the laser is more uncomfortable especially around the lips and lids. Motion by anxious patient can be deleterious, thus proper eye shields are imperative. Usually moist saline gauzes are placed around the lids and lips. If performing resurfacing around the eyelid margins, it will be necessary to use a metal lid shield (not plastic) or heavy saline soaked gauze. If major facial laser resurfacing is used 1 prefer general anesthesia, to make the patient the most comfortable. Special precautions with the use of laser that are not required with the use of deep chemical resurfacing.
Chemical Resurfacing may require sedation or general anesthesia in some cases, yet there is very little hazard to the patient and operator during the course of chemical resurfacing.
9. What can be done for sun spots and roughness on my neck, arms and hands?
Care Care has to be exercised when resurfacing the extremities, since they have limited regeneration potential when compared to the rapid healing of the face. I prefer to use TCA (or TCA acid) a chemical agent that is applied in predetermined concentrations, in a brisk application technique, to create a limited exfoliation, or frost, which loosens the upper coarse layers of skin. The shedding process takes more time, such as 4-10 days and should be done in stages for some individuals. Since there is a brown frost that forms on the resurfaced areas, it may be unsightly for a longer period of time before it sheds.
Cover clothing and sunscreen is mandatory. Sunscreens and a basic fruit acid body cream regimen is then continued. One can also use a PCA or Jessner's (salicylic acid, lactic acid and citric acid) peel, or a serial glycolic acid peel program.