Skin Care Overview
Just a few years ago, having beautiful skin was a combination of good genes, “hope-in-a-jar” face creams, and invasive surgery. Recent advances in pharmacology, cell biology and directed energy have enabled many treatment options to restore and maintain a healthy, youthful appearance with a minimum of discomfort and downtime.
Good skin care begins with the basics. Aging takes it’s toll on everyone, some sooner than others, so the first step is to slow down the aging process in your skin. A healthy lifestyle and regular exercise provide an infrastructure for maintenance and repair of the skin. The role of dietary supplements such as vitamins, minerals, herbal preparations, and antioxidants given an otherwise healthy, balanced diet) is unclear, but as a rule they won’t hurt and may indeed help.
Hydration and humidity are critical yet often overlooked elements of skin care. Cooler weather brings lower humidity and higher wind speeds, both of which increase water loss through the skin. Adequate water intake and humidification of the home will help prevent dry, itching and flaking skin especially during the heating season.
By far, the most damaging influence on the skin, especially the facial skin, is exposure to ultraviolet (UV) rays from the sun. UV radiation comes in three forms:
- UVA long wave – present even on cloudy days
- UVB short wave – worse in the summer, on sunny days and in the midday hours
- UVC – blocked by the Ozone Layer
The shorter wave UVB damages the upper layers (epidermis) of skin, and is the primary cause of tanning, sunburn, and skin cancer. UVB is partially blocked by clouds and the atmosphere, which is why one is less likely to burn in cloudy days, in the winter, or in more northern climates. In contrast, longer wave UVA rays penetrate through the clouds and atmosphere, and even window glass, to penetrate deeply into the skin. This damages the connective tissue within the skin (collagen and elastic fibers), as well as the blood vessels in the delicate upper dermis. UVA as the primary cause of photoaging.
Most “drugstore” sunscreens are primarily UVB blockers, and while they protect from sunburn and reduce the incidence of most skin cancers with proper use, they are less effective at protection from UVA. By preventing sunburn, UVB blockers may actually increase UVA exposure by allowing people to spend more time in the sun than they would without protection. The only effective (transparent) UVA blocker currently available in the U.S. is submicron Zinc Oxide (also known as micron zinc, micronized zinc, Z-Cote, etc.). This agent is often combined with other sunscreen ingredients, notably titanium dioxide and octylsalicylate to provide cosmetic “elegance” and/or additional protection.
Facial skin loses about 1% of its collagen and elastic fibers per year after age 25, and chronic sun exposure can increase this loss markedly. Darker skinned individuals have a “built-in” sunscreen, but they have only a 10 year advantage over those that are fairer-skinned. Sun exposure is cumulative — the UV rays will damage your skin whether you’re napping on the beach with a tropical drink or working with a crew laying railroad ties.
Good “sun sense” especially in childhood and young adulthood, will not only reduce the chances of skin cancer, but pay huge dividends in the appearance and texture of the skin later in life. One should apply a quality sunscreen containing at least 4.5% Zinc Oxide no less than every 2 hours when the sun is in the sky, regardless of the season or weather conditions, even when driving or sitting in near a window. If direct or reflected exposure is unavoidable, protective clothing, including a hat with at least a 3 inch brim, should be worn as well.
Like a permanent weight loss plan, saving your face may require changes in habits and lifestyles, but without good “sun-sense”, all the time, money, and heartache spent on other treatments will be an exercise in futility.
The principal function of the skin is to act as a two-way protective barrier. The epidermis is the outermost laser of skin, constantly producing new cells which are gradually shed at the skin’s outer surface. This non-living outer layer (stratum corneum) is the skin’s first line of defense and can thicken with advancing age, disease, or exposure to sunlight, giving the skin a dull, thickened, “leathery” appearance, often with clogged pores and fine wrinkling. Exfoliation is the process of reducing excess non-living skin cells, which lets the natural beauty of the skin show through, unblock pores, and reduce the barrier function of the skin just enough to allow better penetration of topical preparations. Increased skin cell turnover stimulates collagen production, increases skin thickness and improves skin tone. Exfoliation can be chemical, mechanical, or a combination of both.
Mechanical exfoliation can be as simple as a “buffy” pad, loofa, or scrub, which may be “low-tech” but effective when strong exfoliation is needed. On the delicate facial skin, however, microdermabrasion is the treatment of choice, offering controlled, gentle exfoliation with stimulation of the skin. The process involves a diamond tipped suction wand that can remove the top layer of dry skin cells without injuring the skin. The treatments at the PURE MedSpa do not use any crystals or “sandblasting” of the skin.
The advantage of microdermabrasion over other mechanical exfoliation methods is controlled stimulation without irritation. Microdermabrasion is a good way to “jump start” the exfoliation process in patients who have many clogged pores, thick, weathered skin, and is often performed at monthly or quarterly intervals for maintenance.
Chemical Exfoliation is usually performed with Alpha-hydroxy Acids (AHA), which are mild organic acids derived from various sources such as sugar cane, milk, and fruit. The most commonly used are glycolic and lactic acids, which dissolve the lipid bonds that bind together non-living skin cells in the outer layer of the skin (stratum corneum). AHA’s also help the living layers of the skin thicken and retain water, thereby “plumping” the skin and decreasing fine wrinkling. A thinner stratum corneum also means improved clarity of the skin, and better absorption of other topical agents, such as “bleaching” creams, retinoids, antioxidants, etc.
Low concentrations of AHA’s are available in a variety of consumer skin care products. Products with a higher concentration (more acidity) are more effective, and are available only from licensed practitioners. High concentrations of AHA are the basis for light, or “lunchtime” peels, and are often combined with herbal or fruit extracts (“pumpkin peel”, “blueberry peel”, etc.). As the concentration of AHA increases, so does the incidence of side effects such as redness, irritation, blistering and peeling, and increases the likelihood of sun damage and discoloration in patients who do not use sunscreen.
A typical exfoliation regimen for a new patient would consist of daily home use of an alpha-hydroxy lotion for 2 weeks, followed by a light peel or microdermabrasion. Results can be achieved more quickly by utilizing a series of microdermabrasions and/or light peels performed every 2 weeks for a total of 4-6 treatments, with occasional “maintenance” treatments as needed. Regular use of an AHA at home is essential.
Formerly the domain of department store cosmetic counters, topical treatments are coming of age due to a better understanding of the physiology and pharmacology of the skin. Despite the myriad of skin care products on the market, all of these products fall under just a few categories: Moisturizers, sunscreens, exfoliants, retinoids, antioxidants, bleaching agents, cell growth factors, and “herbal/other”.
Moisturizers are preparations that relieve the signs and symptoms of dry skin. If the skin is not dry, such as in the summer months, or in patients with oily skin, a moisturizer need not be used for it’s own sake. A thick, occlusive moisturizer may be suitable for dry, chapped hands, but may clog pores on the face. Facial moisturizers should be humectant, or water binding, to increase the water content of the non-living outer layer of the skin.
Exfoliants containing AHAs may be used on a daily basis, or less frequently if the skin becomes irritated. Percentages of AHA listed on the label can be misleading. The best way to judge an AHA preparation is by it’s acidity, or pH, which is rarely, if ever, listed on the label. Preparations with a low pH are more acidic, and therefore more effective, but more likely to cause irritation. AHA products with a pH higher than 4 are ineffective exfoliants; those with a pH of less than 3 are only available from skin care professionals. Beta Hydroxy Acid (BHA) is often included in exfoliant products, especially in those intended for use in acne-prone skin.
A water-based alpha-hydroxy lotion of appropriate strength should be applied daily in the morning immediately after cleansing. Scrubbing with abrasive cleansers is neither necessary nor recommended. Some stinging or redness is expected at first, but will improve as the skin adapts to the AHA. If redness or irritation recurs as other skin care treatments are added (such as bleaching agents, retinoids, etc.), or as exfoliation progresses, a milder AHA can be used, or the frequency of application can be decreased.
Retinoids include the well known prescription medications such as Retin-A, Renova, and Avage, and over-the-counter agents such as retinol (vitamin A) and retinyl palmitate. Retinoids act on the DNA of the living layers of the skin to reverse the signs and symptoms of sun damage and skin aging. All retinoids may cause dryness, redness, and irritation of the skin, and all must be used for months before the beneficial effects are realized. Over the counter agents such as retinol (vitamin A) and retinyl palmitate have no activity until they are converted in the skin to retinoic acid (Retin-A), hence, they are less irritating, than the prescription retinoids.
Because retinoids are broken down by bright light, they should always be applied in the evening, and because retinoids make the skin sun-sensitive, a sunscreen with at least 4-5% zinc oxide should be used regularly. Retinoid creams should be applied regularly but sparingly-a pea-sized “dab” of cream is enough for the entire face. Irritation and redness is not unusual in the first few months, and the frequency of application can be increased gradually. The full beneficial effects of retinoid treatment may not be realized for 6 to 12 months. Despite these disadvantages, retinoids are the single most effective class of topical agent for reversing the signs of aging, sun damaged skin.
Bleaching Agents are often used to correct irregular pigmentation and brown spots. Contrary to what their name implies, these agents don’t really use a “bleach” (such as that in Clorox®) to lighten the skin, but rather block the formation of melanin, the most common skin pigment. If the bleaching agent is discontinued, the pigment will return. Hydroquinone, kojic acid, and arbutin are the most commonly used compounds – all are more effective (but potentially more irritating) in higher concentrations. Using bleaching agents without aggressive sun protection is a recipe for failure.
Antioxidants are a diverse group of chemical compounds that have evolved over billions of years to allow life to flourish in the presence damaging UV light and an oxygen-containing atmosphere. Energy released by normal cellular metabolism is contained and controlled by antioxidants, much as the energy released by an automobile engine is contained and controlled by the cylinder walls, valves, transmission, etc.
The most used topical antioxidant is Vitamin C (L-Ascorbic acid, L-ascorbate), essential for collagen synthesis and UV protection. Vitamin C is rapidly broken down by sunlight, and is regenerated by vitamin E. In order to be absorbed through the skin effectively, Vitamin C must be very acidic, and such formulations may be irritating, especially in patients with dry, sensitive skin.
There are many other antioxidants available, both as ingredients in skin products and as oral supplements. There’s no question that inflammation and oxidation play a crucial role in disease and aging, and many compounds that influence these processes have been extensively studied in the laboratory.
The latest topical antioxidants are well-absorbed through the skin and have been shown to reduce the appearance of fine lines and wrinkles, decrease skin roughness, and even out skin tone. These include idebenone, ferulic acid, alpha-lipoic acid, and Coenzyme Q10.
Cell Growth Factors
Herbal and botanical ingredients have been used to improve the appearance of skin since time immemorial, and although the role of botanical substances in medicine is well known, the effect of these substances used on the skin is less clear. They are most often used in “natural” or “holistic” skin care preparations for their scent and feel, as well as for marketing purposes. In most cases there’s little scientific basis for their efficacy, with little or no standardization of dose or concentration, and some of these substances may cause sensitivity, allergy, or dermatitis. The decision to use such preparations is best left to individual preference.
A “Typical” Home Skin Care Regimen
- A gentle, hydrating cleanser
- Alpha hydroxy lotion
- Calming/bleaching agent (if necessary)
- Moisturizer (if necessary)
- Sunscreen (5% transparent Zinc Oxide)
Sunscreen should be reapplied every 2 hours when the sun is up, regardless of weather or season-a “foundation” or moisturizer containing sunscreen is not adequate protection!
- Gentle hydrating cleanser
- Retinoid cream/lotion
- Moisturizer (if necessary)
When in doubt, “thinner” preparations should be applied first, and sunscreen is always applied last!
Botulinum Toxin (BOTOX® and DYSPORT®)
The immense popularity of botulinum toxin (botulinum toxin type A — Botox® and Dysport®) is well deserved. Properly administered, botulinum toxin will dramatically improve facial wrinkles quickly and safely without any significant risk or downtime.
Botulinum toxin is a neuromuscular paralyzing agent which prevents the movement of muscles which fold the skin surface above. After injection, Botox® interferes with the nerve ending involved in the transmission of impulses to the muscle; the botulinum toxin is totally eliminated from the system in a few days. Then, as the nerve endings repair themselves, movement returns, usually after 10-12 weeks. Increasing the dose of botulinum toxin may increase the number of nerve endings affected (which may be necessary in individuals with “bulky” muscles), but will not make the effect “last” any longer!!
The treatment goal is to improve the appearance of wrinkles caused by movement, in areas where the movement won’t be missed by the patient. Botulinum toxin is usually used on the upper third of the face (forehead, brows, crow’s feet), and rarely around the mouth, another common location for wrinkles. During the 3 months or so that the wrinkles are not being “wrinkled” by constant movement, normal, or “physiologic” collagen remodeling will repair the damaged collagen in the wrinkle, “filling it in”, so to speak. The underlying muscles also become weaker from disuse. The net result is that, even though movement may return after 3 months, the wrinkles will be improved for some time after the movement has fully returned.
With repetitive Botox® or Dysport® treatments, the lines and wrinkles will gradually improve, even without other treatment, and the interval needed to maintain the improvement become longer! With proper sun protection (to prevent further damage to collagen and elastic tissue), topical treatments (to improve the environment for new collagen production), and treatments to stimulate new collagen and elastic tissue production (such as IPL/laser treatments), truly remarkable results can be achieved, without significant risk or downtime. Most patients will only need treatments twice or 3 times a year to maintain the improvement.
Contrary to what’s commonly portrayed in the media and advertising which exploits the popularity of BOTOX® (Stri-Vectin, “Faux-Tox”, “No-Tox” and “Bo-hylurox”, among others), proper use of botulinum toxin type A (Botox® or Dysport®) will not “make your face look like a mask” or leave you “numb” or “paralyzed”. The treatments are extremely safe and effective, especially when compared to common household medications like Tylenol, aspirin and cough and cold preparations which contribute to hospitalization and mortality every year in the U.S.
Injectable filler materials are all similar, in the sense that they mask, rather than truly correct or repair, the wrinkles, defects and hollows for which they’re so commonly used. Although there are number of injectable filler materials on the market, the most commonly used are collagen and hyaluronic acid derivatives.
Injectable fillers may vary in consistency from thin (Belotero), to thick (Juvederm Voluma). As a rule, thinner materials are used in the upper layers of the skin for fine wrinkles and lines, such as the upper lip, and thicker materials are injected deeper for larger, deeper lines such as the nasolabial folds on either side of the nose. Some very thick materials (Perlane, Juvederm Voluma, Radiesse) are intended for use under the skin for correction of hollows and volume loss.
All injectable fillers may cause the usual side effects associated with injection, such as pain, bruising, and tenderness at the injection site.
Hyaluronic Acid Gel (Restylane, Belotero, Juvaderm) is prepared from hyaluronic acid, a sugar-like molecule that the skin uses to bind water, collagen, and elastic fibers, and which is a major component of mucus. Restylane is the best known of the hyaluronic acid gels, and has been used worldwide for almost a decade. However, Dr. Summers recommends Juvederm over Restylane because Juvederm will last several months longer and Juvederm appears to induce slightly less swelling than Restylane.
Sculptra is composed of L-polylactic acid microcrystals. This is a polymer of a natural substance, lactic acid, and has been used worldwide in absorbable sutures for over 25 years, with an outstanding safety profile, and for 9 years outside the U.S. for the correction of lipoatrophy (fat loss). Unlike other fillers, Sculptra is injected in the lowest layers and just under the skin. The microcrystals of polylactic acid induce collagen production over the course of a month, correcting the defect. Usually at least 2 treatments are needed about a month apart, and the correction lasts over 2 years. Touch-up treatments can be given as needed to maintain the results.
Sculptra is supplied as a powder, and must be mixed with saline at least 2 hours before the treatment session. Discomfort during injection is easily managed with topical anesthetic applied at least an hour before, and by adding small amounts of anesthetic to the Sculptra solution before injection. The treated areas may be somewhat bruised after injection, but in most cases a dramatic improvement is visible immediately. Massaging the injected areas ensures even spread of the Sculptra solution. Over the following day or so, the saline in the Sculptra solution is reabsorbed and the defect will return. Then, as the Sculptra induces new collagen formation, the defect will gradually “fill in” over the course of 4-6 weeks and repeated treatments can be performed as needed.
Radiesse consists of calcium microspheres suspended in a gel. It is used to fill in deep lines and hollows, and add volume to various facial regions. Having injection experience since 2002, Dr. Summers was the first plastic surgeon to offer Radiesse injections in the region and he has extensive experience with this material. As the gel dissolves, the spheres stimulate collagen formation. Treatment is best carried out in stages and injections should not be done in the lips. Visible benefits last about 12-18 months.
Permanent Fillers include substances such as silicone, Artecoll/Artefill, and polyacrylamide gel. Although the idea of a “permanent” filler may sound attractive, these materials may shift, clump, or cause inflammation or infection, sometimes many years later, and cannot be removed except by surgery. Therefore, Dr. Summers does not consider these substances safe and they are not available at the Maryland Plastic Surgery Center.
“Minimally Invasive” Treatment Options
Almost all of these treatments involve the use of directed energy. Although there is a wide and sometimes confusing array of devices available, they are all designed to stimulate new collagen and elastin formation, or to remove unsightly lesions, including spots, redness or veins, or unwanted hair.
The goal of minimally invasive therapy is to target the problem, whether it be wrinkles, spots, loose skin, etc., while causing minimal or no injury to normal tissue. Different techniques are used to accomplish this goal, including selecting the proper wavelength (color), intensity, and duration of energy, and adequate cooling of the skin, when necessary.
The depth of a particular skin problem is a major element in choosing the best minimally invasive therapy. For example, splotchy pigmentation and redness are typically closer to the surface, while wrinkles are from loss of collagen and elastin in the middle layers. Laxity and sagging skin involve the collagen in the deepest layers of the skin, as well as the underlying fat and muscle lining.
“Photofacial” is a term used to refer to laser or light-based treatments for redness and pigment irregularities in the upper layers of the skin. Photofacials are often performed with IPL (“Intensed Pulsed Light) machine, multipurpose devices resembling large flashbulbs that use broadband light to target red and brown pigment in the skin. Typically, a series of 4-6 treatment sessions are performed at monthly intervals. Because IPL light is readily absorbed by normal skin pigment, skin cooling is critical, and blistering may occur in patients with darker skin. Patients with olive or darker complexions may be treated with lower energy levels and a skin lightening cream may be used to reduce the risk of hyperpigmentation.
True lasers may also be used to treat redness, brown spots, and abnormal pigmentation. Typically, “green-light” lasers are as effective as IPL devices, with fewer treatment sessions and expense. Longer wavelength red and infrared lasesr offer the option of treating these problems effectively in patients with darker skin.
Pros: Effective for redness, “broken veins”, discoloration, superficial collagen remodeling.
Cons: Multiple treatments usually needed for best results, minimal effect on lines and wrinkles. Results and safety to a large extent operator and device dependent.
“Non-ablative” Laser treatments have become popular over the past few years. As the name implies, these lasers and related devices stimulate new collagen formation without damaging the outer layer of the skin. As a result, there’s little or no risk or downtime during the treatments. These devices stimulate blood vessels to induce collagen remodeling. “Non-ablative” lasers have also been used to treat active acne as well as acne scarring with good results.
Non-Ablative laser resurfacing usually involves 4-8 treatments given 2-4 weeks apart. Most patients will experience an improvement in skin texture and “feel” beginning 6-8 weeks after the first treatment and continuing up to a year afterwards. Experience with these lasers has shown that improvement of fine wrinkles is mild to moderate in most cases, and most apparent around the eyes, forehead and cheeks, and much less so around the mouth and upper lip. A very few patients will experience no improvement, and a very few a dramatic improvement in the appearance of wrinkles.
Pros: Quick, easy, no downtime, no or minimal discomfort during treatment.
Cons: Multiple treatments needed for best results, results are typically modest and variable, may take months to see full effect.
“Fractionally Ablative” laser resurfacing (e.g. Fraxel) is the newest option in skin rejuvenation. Rather than removing the entire skin surface in a single procedure, as with traditional laser resurfacing, dermabrasion, or deep chemical peels, the laser places a regular pattern of microscopic “spots”, separated by areas of normal skin. Each individual spot is smaller than the diameter of a hair, so there is no visible wound created. Mild redness and/or swelling, followed by mild peeling may occur for up to a week afterward. Multiple sessions, each treating about 25% of the skin surface, can be performed 1-4 weeks apart for a total of 8 treatments.
Mild discomfort during treatment can be managed by topical anesthetic ointment applied an hour or so before and a short-acting local anesthetic for sensitive areas. Most patients notice an almost immediate improvement in discoloration and skin texture, although collagen remodeling taking place weeks or months after the treatment session induces smoothing of wrinkles and in some cases mild tightening of the skin.
Fractional laser resurfacing is very effective for the treatment of sun-damaged skin, acne scarring, stretch marks, and many other conditions with little to no downtime.
Pros: Fast Recovery, Minimal downtime. Effective for restoring texture, color, radiance to sun-damaged and dyspigmented skin. Noticeable improvement soon after first treatment. Very effective for acne scarring. Can be used on any area of the body. Aggressive treatments (fractional CO2) are effective at reducing even deep lines.
Cons: Multiple treatments necessary for best results. May take months to see full effect of treatment. Several days of “downtime” are required for aggressive treatments.
Radio-frequency Skin Tightening is used to selectively heat the deep layers of skin collagen, inducing collagen repair and tightening. Although sometimes called the “lunchtime facelift”, the procedure is most appropriate for younger patients showing the first signs of skin laxity. Patients with significant laxity or loose skin will not experience the same improvement obtained from surgical lifting.
With current equipment and treatment protocols, the procedure is much less uncomfortable than before, and most patients will experience noticeable results after a series of treatments.
Pros: Very safe, non-invasive, quick recovery.
Cons: Results take months to become apparent.
Infrared Skin Tightening uses infrared light to heat the deep layers of the skin to induce collagen repair and tightening, while protecting the epidermis during treatment by direct contact cooling.
Pros: Safe, non-invasive, no downtime.
Cons: Multiple treatments necessary for best results.