Summarized by Robert
W. Griffith, MD
October 1, 2004
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.
| Indication |
Procedure |
Risks/Disadvantages |
| Wrinkles |
Ablative laser treatment |
Infection, scarring, pain, change in pigment |
| Non-ablative laser |
Not very effective |
| Microdermabrasion |
Infection, scarring, pain, change in pigment |
| Botulinum toxin (Botox) |
Headache, bruising, drooping eye-lid, re-treatment
needed 4-monthly |
| Skin filler - collagen or hyaluronic acid |
Bruising, pain, local allergic response, re-treatment
needed |
| Chemical peel |
Infection, scarring, pain |
| Face-lift, eye-lid surgery |
Infection, scarring, expensive |
| Pigmentation |
Cryosurgery |
Maybe lack of pigment afterwards |
| Laser treatment |
Maybe lack of pigment afterwards |
| Dilated vessels |
Laser treatment |
Bruising, maybe lack of pigment afterwards |
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
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