Aging is a complex phenomenon, a sum total of changes that occur in a living organism with the passage of time and lead to decreasing ability to survive stress, increasing functional impairment and growing probability of death. There are many theories of aging and skin remains the largest organ of the study.
Skin aging is described as a consequence of intrinsic and extrinsic factors.
The most common amongst visible signs of skin aging are wrinkles and there are various therapies including anti-aging cosmeceuticals, sunscreens, chemical peeling, injectable agents, such as botox, fillers, autologous fat grafting as also few surgical procedures have been used.
Given that the skin is our largest organ and certainly the most visible one, most of us would agree that taking care of it properly is important. We are at present in the middle of a minimally invasive, no downtime, socially convenient, quick recovery, cost-conscious revolution. Peopleare seeking easy, pain-free methods of appearing youthful and healthy without the problems of invasive cosmetic surgery. Up to the 1980s, the famous and privileged were the only segments of the population considering cosmetic enhancement. The procedures were limited to surgery and deep acid peels. The introduction of wrinkle fillers and botulinum toxins, and use of creams containing exfoliating agents heralded the onset of the nonsurgical era, providing low risk, effective but subtle enhancements.
Effective skin care is one of the most neglected areas in cosmetic medical practice. Although Doctors have been convinced of the benefits of sunscreens and moisturizers, the concept of skin rejuvenation using creams and lotions is viewed with a high degree of skepticism.
In the eighties the publishing of the discovery that that sun-damaged skin could be rejuvenated using trans-retinoic acid, a vitamin A derivative by Dr Albert Kligman, led to Retinoic Acid being given approval as a topical prescription only product for photodamged and aging skin. Today use of these creams in combination with depigmenting cream have become an effective method for non-surgical skin rejuvenation.
Skin rejuvenating cream programs
Skincare is an essential part of cosmetic practice. It is understood that static lines can be addressed with fillers and dynamic lines can be addressed with botunilum toxin. But the benefit of these treatments would be enhanced if the rest of the skin is smooth, moist, evenly pigmented and radiant.
The objective of having these skin attributes would also be achieved in people who do not have lines but just aspire for a fresh and radiant look.
Medically approved skincareregimen, recommended by the doctor as part of a homecare program involves using cleansers, creams, gels and sunscreens in a particular order to achieve a rejuvenating benefit for the skin.
Conditions that respond to the skin rejuvenating program
This program is deal for people who have
- Early aging signs on the face,
- Dull looking skin,
- Irregular pigmentation,
- Dry skin,
- Fine lines,
- Acne etc.
Components of skin rejuvenating programs
Alpha hydroxy acids
Alpha hydroxy acids (AHAs) are exfoliators and moisturizers commonly found in many different concentrations in skincare products. Alpha hydroxy is the name for a group of acids that are derived from foods, such as glycolic, lactic, maleic and tartaric acids, which decrease thickness of the epidermal layer of skin. These acids also have some impact on the collagen density and help to increase the thickness of dermis. Prescription creams have much higher concentration of these acids as compared to over the counter products. .
Retinoids are used in topical treatment of photo-aged skin, as it appears to increase the rate of cell division and improves wrinkling, coarseness, hyper pigmentation and roughness associated with over exposure to the sun. It repairs photoaged skin by inhibiting collagenase and improving dermal vasculature, while also stimulating new collagen deposition, it promotes the down growth of rate ridges, restoring the undulating dermo-epidermal interphase and improves the skin’s water barrier properties.There is overwhelming evidence supporting the efficacy and safety of topically applied retinoids in the treatment of photodamaged skin.
Patients must be thoroughly educated on the correct use of retinoids. A gradual increase in frequency of application is advised to enable tolerance to establish. We start with the lowest dose which is usually applied at night or twice weekly to start, increasing to every night over 4–6 weeks. Commonly one can expect some mild redness and scaling but this subsides with use of additional moisturizer. The full impact may take months after which one can be on a biweekly maintenance dose.Retinoids should not be used in pregnancy. The most important instruction to patient who is using topical retinoids is – to never be without sun protection during the daytime – whether one is indoors or outdoors.
Vitamin C can accelerate wound healing; it is a potent antioxidant that protects fatty tissues from oxidation damage and plays an integral role in elastin and collagen synthesis. It is capable of controlling inflammatory responses associated with UV exposure. Topical Vitamin C is commonly incorporated into skin products because of its stimulatory effect on collagen synthesis, its ability to regenerate vitamin E and an antioxidant effect. It has also been found to inhibit tyrosinase and so reduce areas of hyperpigmentation. There is some protection from UV radiation and improvement in some inflammatory skin conditions due to its antioxidant effects.
Various studies have shown some improvement in photodamage.
Vitamin E has significant moisturizing properties, anti-inflammatory effects and may provide protection from UV damages. It acts as an antioxidant and inhibits the formation of lipid peroxides and thus prevents skin aging. It is known to improve decreased function of the sebaceous gland and ameliorate excessive pigmentation in the skin. Preclinical studies showed topical vitamin E protects against UVB-mediated damage. It is commonly incorporated into cosmetic and cosmeceutical preparations.
In medical cosmetic practice, we must recommend products that have proven ability to improve damaged skin. Moisturizers are major adjuvants to exfoliating agents and help to approach the problem of aging skin in a holistic manner.
Hydroquinone is a POM in the UK, but is banned OTC in Europe because of exogenous ochronosis, a severe hyperpigmenting damaging side effect. It is, however, the most effective depigmenting product available that inhibits tyrosine production. Recommended use is for 4–6 week periods every 12 weeks, response-dependent. Azelaic acid and kojic acid are alternatives.15 Kligman developed a formula containing hydroquinone, retinoic acid and prednisone which is useful in difficult cases but very unstable with a short shelf life of under four weeks.
Sunscreens are essential for skin health and rejuvenation. Recent advances in formulations have made products easier to apply and more cosmetically appealing. Sunlight penetrating the Earth’s atmosphere exposes us to UVA and UVB ranging from 290–400 nm. Sunscreens are labeled with an sun protection factor (SPF) number which is only a measure of UVB protection. UVA has a longer wavelength than UVB and goes deeper into the skin, causing damage in the dermis. At this time there is no universally agreed method of labeling for UVA protection.
Most products now contain two types of ingredients:
(a) Reflective agents, for example, zinc oxide or titanium dioxide. They are inert, unlikely to cause any allergic reaction and simply reflect the UV light; and
(b) Chemicals that absorb and react with sunlight to render it harmless.
Common ingredients are avobenzone, oxybenzone, and octylmethoxycinnamate. These cover most of the wavelengths but no sunscreen provides 100% protection. In the future, increasingly powerful antioxidants will be added into products so that, in theory, damage is repaired as it arises. To encourage compliance, moisturizers combined with SPF are usually recommended. Daily application is required and not only to the face but neck, hands, and décolleté. Men should be reminded to cover their bare heads and tops of ears.
Holistic approach to skin rejuvenation
The introduction of increasing numbers of nonsurgical options for facial rejuvenation has revolutionized the field of skin aesthetics. But there are many intrinsic and extrinsic factors which impact the skin of an individual.
We know that our lifestyle has significant impact on our skin and we try to relay this information to the patient during the consultation. But when it becomes a part of skin care program the patient understands his/her responsibility in achieving the goals and accordingly compliance is better. The doctor can make recommendations but not supervise daily applications of topical agents. The important factors and advice that need to be addressed include: sun exposure, tan bed usage, smoking, stress, diet, and lifestyle issues.
The best results are achieved when we combine the cream program with lifestyle modification (quit smoking, follow healthy diet, exercise regularly, sleep adequately etc), and occasional peels and microdermabrasion.