Managing Healthy Skin
From early on, we learn that having a smooth, clear complexion is an attribute of physical attractiveness. However, as we age, maintaining that healthy glow becomes more difficult. The face is the most exposed part of the body, vulnerable to the damaging rays of the sun, and a harsh contaminated environment. The face is also subject to acne, rashes, allergic reactions, and injuries that may leave permanent scars.
A number of non-surgical “refinishing” treatments are available for individuals who want to eliminate or soften imperfections of their facial skin and achieve a clearer, fresher look. These treatments include glycolic acids (sometimes called “fruit acids”), which are derivatives of food substances blended into facial preparations and are used to eliminate rough or dried surface skin. Retin-A®, a vitamin A acid, changes the cellular metabolism of the skin’s wrinkles and blotches from sun damage. Retin-A® rebuilds collagen and elastin in skin, and is an extremely beneficial topical treatment. Topical antioxidents scavenge the cell damaging free radicals generated by sun and other pollutants.
What to Expect from Skin-Surface Treatments
“Surface-repair”, home care, topicals, and in-office treatments can enhance your appearance and give your skin a smoother, fresher look, but they won’t remove deep scars and flaws or prevent aging. These treatments should not be thought of as mini-facelifts. Generally speaking, Retin-A® and glycolic acid treatments offer less dramatic results than surgical approaches such as deep skin resurfacing procedures like CO2 laser or deep chemical peels.
Planning for the Treatment
Whether you’re planning a surgical or nonsurgical skin treatment, it’s important that you find a physician or a paramedical aesthetician supervised by a physician who has training and experience with a variety of skin management techniques. You’ll want a physician who can give you the best possible single treatment or treatment combination.
In your initial consultation, be open in discussing your treatment goals with your physician or aesthetician and don’t hesitate to ask any questions or express any concerns you may have. Your physician or aesthetician should be equally open with your choice of treatment options based upon your age, skin condition, and previous plastic surgeries. Your medical history and skin history will be reviewed at your consultation.
Aging/Photoaging
Sun is by far the worst enemy of the skin. The sun creates free radicals, which cause cell damage. Cell damage eventually results in the destruction of collagen and elastin and alters DNA, eventually resulting in skin cancers. Repetitive exposure to the sun is the number one cause of premature aging and skin cancer.
Aging defines the natural order of life, that matter changes with time. Extrinsic aging is due to outside influences on the skin’s health. The best example of this is sun exposure. Most scientists now believe that 90% of aging is due to extrinsic factors. Intrinsic aging is the part of aging that is due to the actual passing of years, wearing out of the body and hereditary factors. Family history and ethnic background do, to a large degree, govern intrinsic skin aging.
Photoaging changes can occur prematurely for individuals depending upon skin type and the amount of sun exposure. There is a long delay between sun exposure and clinical photo damage. About 80% of sun exposure occurs before age 20, yet the skin changes caused by sun damage usually are not obvious for another 10-20 years. The earliest signs of photo damage may be blotchy pigmentation, fine lines, and a yellowish or sallow discoloration. The skin never forgets an injury. Childhood ultraviolet injury, i.e. sunburns, have been associated with a variety of adverse affects that appear later in adulthood. The most dangerous is the association of sun burns with malignant melanoma. These changes occur in distinct layers of the skin, the stratum corneum, epidermis and dermis. The thickening of the stratum corneum gives rise to a rough, leathery appearance. The epidermis becomes thinner with the appearance of atypical epidermal cells. The number of melanocytes change and their distribution becomes irregular. Photodamaged dermis is markedly altered with thickened elastic fibers, altered collagen and decreased ground substance or mucopolysaccharides.
There are many factors that influence aging. Elastosis, which means loss of the elasticity, is a significant factor in gravity’s effects on aging tissue. Expression lines are dynamic facial lines caused by repetitive movement. Raising the eyebrows, frowning, and smiling will eventually cause a crease to occur, just as pants will wrinkle the more you wear them. Smokers will inevitably get smokers lines around the mouth and eyes. Sleep habits, such as sleeping on one side or directly on the face, will eventually create lines and elasticity changes. These are all examples of intrinsic aging changes.
As time progressives, the muscles, fat, and skin of our faces undergoes structural changes. The amount of fat in the subcutaneous layer decreases with age. The skin of the face is stretched back and forth over a lifetime, causing an “enlarging” of the skin, and enhancing the gravitational changes.
Prevention of skin aging includes an excellent diet and regular exercise. Good health habits will help the body to nourish the skin better and therefore help fight aging. Avoiding excess alcohol will also help the body to function better. A regular aerobic exercise program and a well-balanced, healthy diet can certainly help an individual live longer and better. A diet rich in antioxidant foods, or use of antioxidant supplements such as Vitamin C and E help protect body tissues, including the skin, from free radical damage, reducing the sign of aging. Good sleep habits allow the body time to regenerate tissues and repair damaged cells. Avoiding high amounts of stress certainly helps to avoid premature aging not only of the skin, but also other organs of the body.
Chemical Peel Skin Resurfacing Procedures
Chemical peel consists of the application of a chemical solution, usually an acid, to the skin of the face or body. A chemical peel can be superficial, medium depth, or deep in terms of the levels of the epidermis and dermis treated. The goal of the chemical peel is to make the skin look smoother with a more regular color, but still leave the skin looking as natural as possible. Chemical peel is most commonly performed for cosmetic reasons. It may also however remove precancerous skin growths.
Alpha-Hydroxy Acids (AHAs), such as glycolic, lactic or fruit acids are the mildest of the chemical peel formulas and produce light peels. These types of peels can provide smoother, brighter looking skin with just a few superficial treatments and very little, if any, down time. These lighter peels are considered more complexion peels. They make the skin look brighter and fresher by stimulating exfoliation (cell turnover) and therefore must be repeated at varying intervals to maintain the effect. Repeated treatments can help to further improve the texture and overall health of the skin. They can also reduce the effects of aging and sun damage, including fine wrinkling and pigment irregularities. A topical skin maintenance program along with regular chemical peels is mandatory to achieve and maintain optimal results in terms of skin appearance and skin health. The advantage of light peels is that they minimally disrupt your schedule and you can look reasonably normal within a few hours or days. Make-up can be worn the same day and you can easily go back to work the same day. For patient’s who have deeper or more severe problems, a medium depth chemical peel may need to be performed with trichlorocetic acid, TCA for short. Fine surface wrinkles, superficial blemishes, and pigment problems are commonly treated with TCA. The Biomedic Pigment Peel Plus is a medium depth chemical peel typical of this type of treatment.
Specially trained and medically supervised paramedical estheticians perform both superficial and medium depth chemical peels in my practice.
Topical Antioxidants
Free radicals are an important factor in the aging process, including aging of the skin. Topical free radicals scavengers, called antioxidants help neutralize free radicals before they can attach themselves to cell membranes, eventually destroying the cell. Chronic irritation to the skin by sun, pollution, smoking, chemical exposure, and other inflammations lead to cumulative damage to cells by free radicals. This results in the formation of self-destruct skin enzymes such as hyaluronidase, elastase, and collagenase which cause the break down of collagen and elastin fibers and the reduction in the strong supportive effects of hyaluronic acid.
Antioxidants work by supplying electrons to unstable free radical oxygen atoms, which need these electrons to become stable. Cell membranes have an excess of electrons. They can provide electrons to free-radical oxygen atoms, but are severely damaged in the exchange. Antioxidants supply electrons, neutralizing the free radical atoms before they have a chance to attach to cell membranes.
Free radicals occur in normal body cellular and physiologic reactions. Free oxygen atoms are given off as a result of various chemical reactions within the body. Smoking, alcohol, stress, and sun exposure also contribute to significant additional free radical production.
Both extrinsic and intrinsic aging is the result of damage to cellular components by free radicals, which cause oxidation of proteins, lipids, cross linking of proteins and damage to DNA. The cumulative effect of free radical activity which is generated by the normal metabolism of the cell, as well as normal exposure to radiation and toxins, eventually results in a cell that can no longer function. We now know from extensive scientific research that diverse diseases such as heart disease, arthritis, Alzheimer’s, Parkinson’s and various cancers are initiated by free radical damage.
The chief defense against free radical damage is antioxidants. Antioxidants are molecules, many of them naturally occurring substances such as Vitamin C and Vitamin E, that block the damaging reaction of reactive oxygen species, i.e. free radicals. Alphalipoic acid is a unique antioxidant that is both water and fat-soluble. Antioxidants are also important in the repair process and are preventative of DNA damage occurring from free radical exposure.
Inflammation is an integral part of the aging process. Inflammation is created and perpetuated by free radical reactions.
The antioxidants Vitamins C, E and alphalipoic acid may also work synergistically to reduce the amount of photo aging caused by ultraviolet exposure to the skin by inhibiting inflammation and the inflammatory cascade that is stimulated by free radical damage caused by sun exposure.
Retin-A® (Tretinoin or Retinoic Acid)
In general, Retin-A® is most effective in patients who have fine facial wrinkles, or blotchy pigmented areas caused by sun damage. Patients who are planning to have a chemical peel are instructed to use Retin-A® as part of the preparation for the peel. Retin-A® thins the skin’s outer layer, allowing the acid solution used in a chemical peel to penetrate more deeply, evenly and predictably. It also stimulates skin cell turnover (exfoliation) so skin healing and the outcome from a chemical peel is more efficient and predictable. Under the microscope, Retin-A® has been shown to “reorganize” the skin by reestablishing a more normal epidermis, increasing new blood vessel formation, increasing collagen production, and generally improving damaged skin.
Although no serious medical problems have been associated with Retin-A®, it is possible that its use could result in temporary skin irritation and redness. If this happens, a milder formulation may be recommended. Retin-A® is not recommended for pregnant women or nursing mothers, because its effects on the fetus and nursing infants are still being studied.
Your initial instruction on the application of Retin-A® will include a lesson on how to begin your skin-care routine at home. After you wash your face thoroughly, a small amount of Retin-A®, in either cream or gel form, is rubbed over your face and nose. A gentle formula will be used at the beginning, especially if you are younger or have a fair complexion. You will be switched to a stronger formula after your skin becomes accustomed to usage.
Only a very small amount of Retin-A® – a pea-sized dab – is needed to cover the entire face. You will be instructed to apply Retin-A® every 3rd or 4th night before you go to bed. Because Retin-A® is drying to the skin, a moisturizer is also recommend once or twice a day. At periodic follow-up visits, your aesthetician may adjust the strength of your prescription or its frequency of use. To maintain the benefits of Retin-A®, it must be continued indefinitely.
Because Retin-A® thins the outer layer, you will need to consistently use a sun block to protect yourself from ultraviolet light, and you may have to discontinue using certain products or cosmetics on your face.
Although the degree of change varies from person to person, with continued use of Retin-A®, you will begin to see subtle improvements in the texture and tone of your skin. Retin-A® users notice a rosy glow during the beginning months of use, followed by the softening of fine lines and the shrinking of large pores. After about six months, many Retin-A® users report that wrinkles are less visible and that age spots have faded significantly.
Sun/Ultraviolet Rays/Sunscreens
The aging, wrinkling and skin cancer inducing effect of ultraviolet radiation of the sun is recognized as an important health consideration, and ultraviolet absorbers or blockers are an effective preventative. The suntan that became fashionable in 1920’s, suggesting an image of leisure and affluence has become much less important to the health conscious consumer, as the adverse health considerations have become known. Skin care has become the key, whether the effect is to prevent sunburn, prevent skin cancer or premature aging of the skin.
There are three general categories of ultraviolet radiation, UVA, UVB, and UVC. UVA radiation has a wave length in the range of 320-400 nanometer, is capable of tanning the skin with only very weak reddening (erythema).It falls more evenly during the day than does UVB radiation. It is known to inhibit the DNA repair process of damage that is caused by UVB radiation. It is also implicated as a causative factor in cataracts of the lens of the eye. UVB radiation has a wavelength of 290-320 nanometers, is the major cause of sunburn and also stimulates the tanning response. It is concentrated more at mid-day, approximately two hours either side of the noon hour. Maximum erythema effect occurs at 308-311 nanometers. UVB radiation is known to cause cell mutations. UVC radiation has a wavelength of 200-290 nanometers, and has a germicidal and erythemal effect, but does not reach the earth’s surface.
Ultraviolet rays are high energy rays that are capable of deranging the molecular structure of DNA at a cellular level. UVA penetrates the skin more deeply, causing changes in blood vessels and premature aging. Overexposure to UVA can cause long term eye damage, and aggravation of various allergies or skin conditions. UVA and UVB actually enhance the effect of one another synergistically. They are potentially a lethal cancer producing combination. UVB damages the skin, while UVA interferes with the body’s ability to repair the damage at a cellular level. This then causes cell mutations because of the alteration of genetic information in molecular DNA, hence abnormal cells which grow out of control, i.e.: cancer cells. Exposure to UV radiation clearly has an adverse and dangerous effect on the body’s immune system.
A suntan is actually a reaction to injury, whereby special cells called melanocytes release granules of protective melanin pigment, which absorbs and scatters subsequent doses of ultraviolet rays. In the face, most of what we think of as skin aging is actually accumulated sun damage. The relentless, cumulative, everyday exposure to UV radiation is much more dangerous than the occasional sunburn! Tanning booths are a potential source of excessive ultraviolet radiation. The UVA rays used may be upwards of 100 times stronger than natural sunlight. The lighting has up to 5 percent UVB contamination, with intensities of both UVA and UVB that are dangerously high. There is strong evidence that UVA exposure in the tanning industry is harmful to your health.
Sensitive Skin & Rosacea
Sensitive skin is very thin, fragile looking and pink colored. Because of sensitive skin’s thinness, the blood vessels and nerve endings are much closer to the surface. This is why this type of skin reddens so easily, and also why it becomes irritated by cosmetics and surface treatments more easily. Sensitive skin will often react to internal factors such as eating spicy foods, and stimulants such as caffeine, tobacco or niacin. These substances are called vasodilators. Vasodilators dilate the blood vessels, making more blood flow through surface skin vessels. This dilation often shows up in the skin of sensitive skinned individuals as red blotchy patches.
It is extremely important to protect the barrier function of sensitive skin, which in general does not have a natural barrier function that is as effective as that of normal skin. Decreased barrier function results in a more permeable epidermis, and irritants are more likely to cause inflammation because it is easier for them to penetrate the skin surface, where they come in contact with poorly protected nerve endings. If skin is already irritated because of a diminished barrier function, it is much more likely to react to skin care products and cosmetics.
Rosacea is a type of sensitive skin. Rosacea is a condition of the skin in which it turns red very easily, known as flushing. Rosacea normally affects persons older than 30 years of age, but can appear as early as the 20’s or as late as 70-80 years of age. The sudden rushing of blood to the face can stimulate sebaceous glands and irritate follicles causing large red papules and pustules to form in the cheek, nose and chin areas. When pustules and redness occur in a person with rosacea this is known as a flare of rosacea.
Even though many aspects of rosacea may closely mimic the description and characteristics of acne, it is a completely separate entity. It is often difficult to diagnose rosacea because the lesions so closely resemble acne. Rosacea is much more prevalent among females, but when men do get rosacea, it is usually far more severe.
Rosacea is a progressive skin disease that must be taken seriously. Most recent research indicates that the cause of rosacea may involve a variety of possibilities and factors that cause or exacerbate the condition. One thing that is absolutely certain, cumulative sun exposure and the resulting sun damage always plays a role in flares of rosacea.
Important Concepts: Rosacea is not curable. Rosacea is treatable and can be controlled. Rosacea is varied and complex. Treatment requires dedication and perseverance. The patient must be compliant and flexible in treatment options.
In general, patients should avoid all known irritants and sources of local irritation. A broad-spectrum sunscreen is an absolute must. Topical prescription products should be in a non-alcohol base.
Rosacea appears to respond extremely well to a combination of azaleic acid, glycolic acid, and salicylic acid. Patients report a lessening of redness and fewer lesions. Additional treatment options may include intermittent oral and topical antibiotics. Investigational treatments include utilizing oral antihistamines to decrease the inflammatory cascade.
Pulse Dye Vascular Laser is an effective new treatment for rosacea. By reducing the blood vessels of rosacea, flushing and flares are significantly reduced in frequency and severity.Rosacea is not curable but it is treatable and can be controlled.
Acne
The most common form of acne is called acne vulgaris. This type of acne is often associated with teenagers. Almost all teenagers have some acne. That is because at the onset of puberty, teens undergo surges in hormone production causing a stimulation of the sebaceous glands, which produces an overabundance of sebum. This waxy substance can block the skin pores causing open or closed comedones. Infection in closed comedones caused by the common skin bacteria P-acnes then causes infected skin pores called pustules (pimples).
Acne is graded on its severity on a 4-point scale. Grade 1 acne is mostly open and closed comedones with an occasional pimple. Grade 2 has many more closed comedones with occasional pimples. Grade 3 acne is thought by most people as typical teenage acne. It involves a large number of open and closed comedones and inflammation and redness as well. Grade 4 acne is commonly referred to as cystic acne, with many deep cysts, subsequent scarring and scar pit formation.
Scars form when the skin attempts to heal itself, producing collagen, which may overgrow, producing a raised, red type of scarring. When “acne pit” scarring occurs, there is actual destruction of tissue in the inflammatory process that then causes a large or small depression.
Hormonal fluctuations, specifically male hormones called androgens is the mechanism that causes stimulation of sebaceous glands. The sebum and cell debris then block skin pores that subsequently causes inflammation, cell build up and full-blown infection due to the P-acnes bacteria. Testosterone is the male androgen that converts to dihydrotestosterone (DHT), the main form of the male hormone that switches on the oil gland.
Premenstrual acne flairs in women is often referred to as adult onset acne. This type of acne can also be caused by comedogenic cosmetics, stress, and hereditary acne factors, although hormones probably play the most significant role in adult female acne. Androgen flares in the blood stream cause this type of flare-up in adult onset acne. Premenstrual flares are caused by a sudden predominance of androgen, which corresponds to the decrease in estrogen during the normal menstrual cycle. The elevation in androgen is more related to a decrease in overall estrogen levels in the blood stream versus a significant rise in androgen production so that this is more of a relative type of change.
Sun exposure although it may have an immediate drying effect on acne lesions, actually damages the skin further causing more cell build up within the pores and increasing the risk of acne flare-ups later.
Over cleaning is an important factor in the aggravation of acne symptoms. Repeated exposure to detergents and facial cleansers can aggravate the condition, causing enough irritation to precipitate active acne, and bringing forth other sensitivities as well. Over cleaning over stimulates the sebaceous glands so that they actually produce more sebum and therefore increase the risk of active lesions.
Acne treatment to control flare-ups and scarring clearly does need to include a dedicated cleansing regime, but with appropriate cleansing agents and the avoidance of comedogenic topical products that may aggravate the problem.
Skin treatments may also be recommended to unblock the pores and remove the sebum. This would include light alpha hydroxy acid peels with both glycolic and salicylic acid. Other measures needed in certain cases may include long-term treatments with topical or oral antibiotics to control skin bacteria.
Retin-A®, a prescription drug is commonly used to treat severe acne. Its use is described elsewhere, but suffice it to say as with any other topical skin treatment there may actually be an increase in acne lesions in the early use of Retin-A® due to the deep action of the medication. Positive results should be noticed after 2-3 weeks of treatment, but it may take several months before significant, definite benefits are seen.
Acne is one of the most frustrating skin diseases to treat, both for the aesthetician and the physician overseeing that treatment. The patient must be compliant, educated, and motivated to obtain the most effective improvement in their acne symptoms.
Hyperpigmentation
One of the main signs of photoaging is hyperpigmentation. It is one of the main concerns of sun-damaged patients in terms of dealing with irregular, scattered pigmentation. It can be very difficult to manage depending upon the depth of the pigment. Hyperpigmentation is primarily due to sun exposure but can also be related to changes in hormonal activity, particularly in female patients, that results in over activity of the melanocytes in the skin.
The melanocytes, which are the cells that produce melanin, are located in the lower epidermis or the upper dermis. Melanin is stimulated by sun exposure as a protective mechanism to reduce UVA/UVB radiation penetration into the deeper layers of the skin. Melanocytes can also be stimulated by hormonal fluctuations, exposure to chemicals causing inflammation, injuries to the skin including deep skin resurfacing and various forms of topical skin irritation or inflammation, including acne. The hyperpigmentation associated with chronic acne is called post inflammatory hyperpigmentation and is due to chronic irritation from infected acne lesions.
Three types of products and therapy are effective in reducing skin pigment. These are chemical exfoliation, melanin suppressive agents, and sunscreens. Normally, a combination of modalities needs to be used in treating hyperpigmented, photodamaged skin.
Chemical exfoliants including alpha hydroxy acids and Retin-A® are both utilized to stimulate cell turn over, therefore evening out the melanin deposition in the epidermis. Chemical exfoiliants remove dead surface cells containing melanin, therefore helping to fade the skin. They also clear hyperkeratonized areas of cell build up on the skin surface, enabling more effective skin treatment with other topical products.
Melanin suppressive agents interfere with the chemical process of melanin production. Many inhibit tyrosinase, an enzyme that is used to convert the amino acid tyrosine, into melanin. Various other skin lightening agents including kojic acid, some antioxidants and azelic acid are less effective in melanin suppression, but may be adjunct treatments or primary treatments depending upon skin sensitivity. The most commonly used topical melanin suppressive agent is hydroquinone, which is generally applied to the skin in 4%-10% prescription formulations. Drawbacks to hydroquinone include its irritative and drying properties as well as possible skin sensitivities that may develop with its use. It is a strong oxidant, which means it neutralizes and turns darker fairly quickly on exposure to oxygen. It must therefore be carefully manufactured and added to topical vehicles such that it remains effective, yet does not discolor.
Broad-spectrum sunscreens or sun blockers, which limit UVA UVB penetration to the skin, are critical in the treatment of hyperpigmentation. It is counter productive to attempt to lighten hyperpigmentation and continue to expose the skin to the primary factor in the cause of hyperpigmentation, chronic sun exposure.
Actinic/Solar Keratoses
Actinic/Solar Keratoses are rough areas of damaged skin, characterized by dysplastic cell growth. Dysplastic means abnormal cell growth. Actinic keratoses are frequently found on the faces of individuals who have had chronic sun exposure. They are most prevalent in light-skinned individuals. They are red patches of skin that can be crusty, scaly, and rough to the touch. Because they are dysplastic in nature, they are considered to be precancerous. Actinic keratoses can be treated in a number of ways. Cryosurgery (freezing with liquid nitrogen), or deep spot chemical treatment, versus superficial cautery type techniques treat these superficial lesions. They can also be treated with superficial chemotherapy using a drug called Efudex.