Introduction
People's faces reflect the effects of age and exposure to the elements - sun, wind, cold, and so on. These effects are commonly called 'photoaging". The signs are well known: wrinkles, roughness and dryness, irregular pigmentation, small dilated blood vessels (telangiectasia), sallowness, and brown spots. Risk factors for photoaging include having a fair skin, ease of getting sunburnt, sunburns before the age of 20, smoking, and advancing aging.

Some photoaging changes (e.g. wrinkles and telangiectasia) are associated with an increased risk of actinic keratosis, which, if left untreated, can progress to one type of skin cancer. So it's important to pay attention to photoaging, not just for cosmetic reasons.

Because aging skin is less attractive than a youthful appearance, the public is bombarded with remedies offering immediate improvement. Many such claims are false. Dr Robert Stern of the Department of Dermatology, Beth Israel Hospital, Boston, has published a review of effective treatments in the New England Journal of Medicine that should help people find their way through the mass of available approaches. Here's a summary of his views.

Prevention of photoaging
Protection from the sun at any age will reduce the risk of actinic keratoses and squamous-cell cancer, and will halt the progression of photoaging changes. Correct application of sunscreen (enough, often enough), with an SPF number of 15 or above, will have the same effect as adequate shade or sun-proof clothing.

Exfoliants and moisturizers
The creams and lotions promoted for improving the appearance of aging skin often contain alpha and beta hydroxy acids. At low concentrations (4% to 12%) they can act as moisturizers, but at higher concentrations they have a "peel" effect, and are irritating. Their use allows 20% more ultraviolet B light through the skin, so sunscreen must be used along with the hydroxy acids. There's no evidence that expensive creams are any better than cheap ones.

Retinoid creams
Two of these derivatives of vitamin A - tretinoin and tazarotene - have been approved by the FDA for improving the fine wrinkles and pigmentation of aging, and reducing roughness (tretinoin) or brown spots (tazarotene). They are sometimes irritating in the concentrations necessary to be effective. There's no evidence that other vitamin A derivatives (e.g. retinol and retinaldehyde) are effective in photoaging problems.

Fluorouracil cream
Fluorouracil may be used for clearing actinic keratosis, having a similar but less complete effect as cryosurgery (freezing the lesions with liquid nitrogen). It has to be applied twice a day for 3 weeks, and the results are like those of a medium-depth chemical "peel", i.e. there is substantial irritation for some weeks afterwards.

Facial rejuvenation
There are dozens of approaches available to treat the ravages of time. The table below lists the major ones that are known to be effective.

Note that only collagen and hyaluronic acid are recommended as skin fillers, although there are more than 40 substances reported to have been used. Silicone injections are not approved, and should be avoided.

Microdermabrasion is popular and relatively cheap. Its effectiveness is based on anecdotal reports - data from clinical trials are not available.

Conclusions
Protection from the sun is the first line of defense against photoaging. Tanning (natural or artificial) should be avoided. A dermatologist can tell you if your photoaging has resulted in actinic keratoses, which can be treated by cryosurgery (freezing) if there aren't extensive lesions. Otherwise, numerous actinic keratoses should be treated by fluorouracil cream. Retinoid creams are good for benign photoaging changes, but they require a prescription. Over-the-counter hydroxy acid preparations may help to a limited extent.

Facial appearances can be improved if you have the money and the patience. Many carry some risks (see table above), and most require re-treatment at regular intervals. It's a matter of personal choice rather than a question of good health.

Source:
Treatment of photoaging RS. Stern, N Engl J Med, 2004, vol. 350, pp. 1526--1534