TREATMENT OF AGEING SKIN

DR MIKHIN GEORGE THOMAS

• Continuous ongoing dynamic chronological process

• Irreversible process

• Visible and its social impact

• Life expectancy on the rise

Types of ageing
• Intrinsic ageing

Genetics

Cellular metabolism

Hormone

Metabolic processes
Intrinsic ageing
. Fine wrinkles.
. Thin and transparent skin.
. Loss of underlying fat leading to hollowed cheeks and eye
sockets with noticeable loss of firmness on the hands and
neck.
. Bones shrink away from the skin as a result of bone loss,
which causes sagging skin.
. Dry skin with pruritus.
. Inability to sweat sufficiently to cool the skin.
. Greying hair eventually turning white.
FACTORS CAUSING AGEING IN FACE
FACTORS
Gravitational force
Depletion of subcutaneous fat
Subcutaneous fat accumulation
Resorption of bone and cartilage
AREAS OF THE FACE AFFECTED
Upper and lower eyelid, cheeks,
neck
Forhead, periorbital, buccal, inner
line of nasolabial folds, temporal
and perioral areas
Submental, around jaws, outer
lines of nasolabial folds, lateral
malar area
Maxilla, mandible and frontal bone
EXTRINSIC AGEING

CHRONIC LIGHT EXPOSURE

POLLUTION

 IONIZING RADIATION

CHEMICALS

TOXINS
GLOGAU’S
THE THEORIES OF AGING

• Cross-linking theory of aging

• Wear and tear theory of aging

• Free radical theory of aging

• Somatic mutation theory of aging

• The pacemaker theory of aging

• Genetic theory of aging

• Cumulative endogenous damage- free radical theory

• Genetic determinants- telomeres

• Changes in sex hormone levels

• Altered cytokine levels- TGF beta 1

KEY FEATURES
• Epidermal hyperplasia and dysplasia

• Dermal thickening

• Solar elastosis

• Actinic vasculopathy

• Dry, coarse and lax skin

• Actinic keratoses

• Malignant tumors
Ageing in the Indian skin
• Complex and variable in color

• Better equipped for protection

than western skin

• Less chance of skin changes and

malignancy due to photodamage

Approach
• Evaluation of patient

• Preventive management

• Medical management

• Combination treatment

• Surgical management

• Cosmeceuticals
EVALUATION

• Individualized
• Attitude, racial, cultural, ethnic backgrounds
• Psychological outlook
• Limitations of procedures to be explained
• Clinical signs of ageing to be documented
• Appropriate consent and photographs to be taken
Preventive strategies
• Eating fresh fruits and green leafy vegetables

• Regular exercise

• Adequate sleep

• Avoid strong sun and wind

• Avoid smoking and excess of alcohol

• Avoid stress
SKIN CARE

• Healthy and functioning skin barrier

• Daily skin care may increase skin regeneration, elasticity,

smoothness, and thus temporarily change the skin condition
PHOTOPROTECTION
• DNA photodamage and UV-generated
reactive oxygen species (ROS) are the
initial molecular events.
• Wrinkles and pigmentary changes.
• Sunscreens- SPF of 15 or higher.
• Sun-protective clothing- ultraviolet
protection factor (UPF) of 50+ and reportedly
blocks 98% of ultraviolet A and B.
• Sun avoidance

• Patient education- avoid midday sun exposure

• Participate in outdoor activities early or late in the day

• Seek shady, covered areas rather than direct sunlight

Moisturizer

• Maintains hydration of skin

• Decreases fine wrinkles

• Decreases roughness of skin

• Usually combined with sunscreen

MEDICAL MANAGEMENT
Topical retinoids
• Cordero (1983)
• Kligman, Grove, Hirose, and Leyden- (1986).
• Surface roughness, dyspigmentation, and fine wrinkles- most
improved
• Due to effects on the dermis- increased collagen type I in photoaged
skin
• 0.05% or 0.1% cream
• Increases epidermal thickness

• Promotes dermal collagen production

• Reduces its degradation

• Inhibits UV-induced matrix metalloproteinases

Side effects

• Erythema

• Peeling

• Burning sensation
ANTIOXIDANTS
(1) directly neutralize FRs

(2) reduce the peroxide concentrations and repair oxidized membranes.

(3) quench iron to decrease ROS production.

(4) via lipid metabolism, short-chain free fatty acids and cholesteryl
esters neutralize ROS.

systemic antioxidants- vitamin C, vitamin E, carotenoids, trace

elements copper and selenium.
• Topical vitamin C 5% cream- improvement in the appearance of
photoaged skin with regard to firmness, smoothness, and dryness
and stimulates the collagen-producing activity of the dermis

• N-acetyl cysteine (NAC)- converted to glutathione, an endogenous

antioxidant.

Prevents UV induced extracellular signal-regulated protein kinase

(ERK) activation and subsequent up regulation of matrix
metalloproteinase (MMP)s which prevent collagen breakdown.
• Idebenone, a synthetic analog of coenzyme Q10 with potent
antioxidant activity- reduces the skin roughness, increases hydration,
reduces fine lines

• Genistein- isoflavone and the major active constituent in soybeans

has well documented potent antioxidant activity

• Green tea polyphenols- increase the minimal erythema dose,

decreases the number of Langerhans cells and reduces DNA damage
in the skin.
Hormonal replacement therapy

• LACK OF HORMONES

• Skin dryness

• Decrease in skin firmness and elasticity.

• Oestrogens - synthesis, maturation and turnover of collagen,

increase the synthesis of hyaluronic acid, and promote water
retention
HRT

• Increased skin surface lipids

• Increase in epidermal hydration and elasticity

• HRT beneficial in both UV-exposed and non-exposed sites

• Increases in both skin collagen and thickness during HRT

5-Flourouracil

• 5- flourouracil (5-FU) when applied topically- increase the levels of

type1 procollagen mRNA and protein, thus increasing the collagen
synthesis.

• For patients unwilling to undergo costly laser resurfacing procedures

• For those with actinic keratoses

IMIQUIMOD

• Immune modulator

• Wrinkle reduction

• Improvement in dyspigmentation.

• The epidermal changes characteristic of aging skin like atrophy and

atypia were diminished after therapy

• Dermal changes were not noticed.

Surgical management
Non invasive
• Low energy ablative lasers
• Nd: YAG laser
• Infrared laser therapy
• Radiofrequency
• Intensed pulsed light
• Endermologie
NONABLATIVE SKIN REJUVENATION
• “SUBSURFACING”

• Low risk

• Selective, heat induced denaturalization of dermal collagen that leads

to subsequent reactive synthesis.

• Type I- ectatic vessels and erythema, irregular pigmentation, and

pilosebaceous changes

• Type II- improvement of the dermal and subcutaneous senescence

• Lasers- 532-, 585-, 595-, 755, 800-, and 1064-nm wavelengths

• IPL systems- filtered light

• Pulsed dye lasers (PDL)- oxyhemoglobin as the primary chromophore are now
employed for Type II photo rejuvenation only
• Release of inflammatory mediators and GF into the interstitium
followed by stimulated fibroblast activity

• Initiation of tissue repair

• Enhanced collagen and elastin neoformation replacing the originally

damaged elastic tissue
ENDERMOLOGIE

• Noninvasive mechanical body-contouring used in the treatment of

cellulite.

• Cellulite-affected skin is sucked between the rollers and kneaded for

approximately 34-45 min.

• This temporarily reduces the appearance of the cellulite

• Short lived
Monopolar RF

• Electric current

• Generates heat through resistance in the dermis and as deep as the

subcutaneous fat, with proprietary cooling of the epidermis.

• Skin tightening and immediate collagen contraction with a single

treatment.

• Patient selection- early laxity of forehead, neck skin.

MINIMALLY INVASIVE

• Chemical peels

• Platelet rich plasma

• Microdermabrasion

• Botulinum toxin

• Fillers

• Fractional photothermolysis
CHEMICAL PEELS

• Chemical ablation of defined skin layers

• Induce an even and tight skin as a result of the regeneration and

repair mechanisms after the inflammation of the epidermis and dermis

 Medium-depth peels
• coagulation of membrane proteins
• destroy living cells of the epidermis
Superficial peel
• depending on the concentration, the
dermis.
• Target the corneosomes

• Cause desquamation
Deep peels
• Increase epidermal activity of
• coagulate proteins and produce
enzymes complete epidermolysis

• Lead to epidermolysis and exfoliation • restructure of the basal layer and

restoration of the dermal architecture
MECHANISM OF CHEMICAL PEEL

• Increase in collagen content, water and GAG in the dermis.

• Improvements in skin elasticity and wrinkles after chemical peeling

can be attributed to increase of col-1 with or without col-3

• Dense rearrangement of collagen fibers

MICRODERMABRASION

• Skin surface is abraded with rough aluminum oxide or sodium

chloride crystals

• Principle- superficial trauma which damages the skin barrier which

repairs within 24 h and also stimulates the fibroblasts to produce
collagen

• bleeding, infection and hyperpigmentation

The depth of peeling depends not on the substance used only, but on its
concentration, pH of the solution and time of application
AUTOLOGOUS PLATELET-RICH PLASMA
• Platelet-derived growth factor (PDGF)

• Transforming growth factor (TGF)

• Vascular endothelial growth factor (VEGF)

• Insulin-like growth factor (IGF)

• α-granules of concentrated platelets activated by aggregation inducers

• Induce the synthesis of collagen and other matrix components by

stimulating the activation of fibroblasts
BOTULINUM TOXIN
• Dr Alan Scott
• Neurotoxin used to paralyze various muscle groups of the face for cosmetic
improvement of wrinkles.
• Glabella, forehead, and periocular regions
• Neuromuscular inhibition of acetylcholine
• 3 to 6 months
• Pain, bruising, and paralysis of the nerves that control eyelid function
Two main serotypes

• Botulinum toxin type A (BTX-A)

• Botulinum Toxin Type B (BTX-B)

• Type B botulinum toxin (BTX-B)- shorter duration of effect than BTX-A

• Used if therapeutic resistance is observed to BTX-A.

Indications for Botox
• Forehead lines

• Glabellar lines

• Crow’s feet

• Bunny lines

• Perioral wrinkles

• Platysmal bands

• Dynamic wrinkles respond better than fixed wrinkles.

Contraindications

• Injections in patients with peripheral motor neuropathic diseases or

neuromuscular functional disorders.

• Coadministration with aminoglycoside antibiotics or other agents that

interfere with neuromuscular transmission.

• Treatment of patients with inflammatory skin disorders at the

injection site.

• Pregnancy and lactation

COMPLICATIONS

• Pain

• Edema

• Erythema

• Ecchymosis

• Headache and short-term hypesthesia

 SOFT TISSUE FILLERS

• Products injected within or beneath the skin to improve its physical

features by soft tissue augmentation
Categories of dermal fillers

• Autogeneic- fat, autologous plasma, autologous collagen

• Allogeneic- human cadaver tissue, human fibroblast cell culture

• Xenogeneic- collagen, usually derived from bovine or porcine sources;

hyaluronic acid products derived from animal sources or the results of
bacterial fermentation

• Synthetic products, e.g. silicone, polymethyl methacrylate,

hydroxyapatite, carboxy cellulose, poly-l-lactic acid, polyacrylamide
HYALURONIC ACID

• Natural hyaluronic acid has a half-life in tissue of only 1 to 2 days

• Undergo aqueous dilution and enzyme degradation in the liver to

carbon dioxide and water.

• The duration of effect for hyaluronic acid fillers ranges from 3 to 12

months
• Staphylococcus equine fermentation

• Space filling

• Lubrication

• Shock absorption

• Protein exclusion

• Regulator of cell proliferation

• Temporary

• Semi permanent- lasting between 1–2 y

• Permanent materials- lasting longer than 2 y.

MECHANISM OF ACTION

• Stimulate fibroblasts to express collagen-1, MMP-1 and tissue

inhibitor of matrix metalloproteinase-1 (TIMP-1)

• Participate in wound healing

• Modulation of inflammatory cells

• Interaction with proteoglycans of the extracellular matrix

• Scavenging of free radicals

INDICATIONS OF DERMAL FILLERS
• Depressed scars: Post-surgical, traumatic, post-acne or other diseases

• Wrinkles and folds

• Lip sculpting

• Enhancement of facial contour

• Periocular melanoses and sunken eyes

• Dermatological diseases: angular cheilitis, dermal atrophy, AIDS

lipodystrophy
CONTRAINDICATIONS

• Keloidal tendency

• Hypersensitivity to products as demonstrated by positive skin testing

• Unrealistic expectations

• Patients with autoimmune disease

COMBINATION APPROACH

• Sandwich procedure: Here a layering technique, where one product is

injected above the other in different planes for a better esthetic effect

• Botulinum toxin: Injecting botulinum toxin 1 week prior to soft tissue

augmentation in the areas to be treated results in a synergistic effect

• It reduces the amount of product required for correction .

• Helps to increase the longevity of the filler in the treated area.

 LASER PROCEDURES
• Ablative laser resurfacing is considered to be the gold standard to
improve clinical features of the aging face and generally refers to
treatment with a carbon dioxide laser (10,600nm)
• It improves fine and some coarse wrinkles and overall dyspigmentation

• Lightens dark under-eye circles

• Generally improves the texture of skin

• This procedure works by vaporizing the epidermis and portions of the

papillary dermis so that neocollagenesis can occur
ABLATIVE
• Epidermal ablation

• Collagen shrinkage

• Stimulation of neocollagenesis

• Extensive dermal remodeling

• Regeneration of cellular organelles and intercellular attachments

• Persistent erythema, hypo- or hyperpigmentation, infection or scarring

Fractional laser skin rejuvenation

• Creates microscopic zones or columns of thermal damage surrounded

by healthy tissue

• Facial rhytides, photodamaged skin and scarring

• Triggered by motion across the skin- described as a ‘rolling’ laser

system.
Non-laser skin surface rejuvenation

• Recent development

• High surface energy generated with nitrogen gas released at high

velocity

• In research
Skin surface cooling
• To reduce undesirable thermal injury to epidermis

• There are three main types of tissue cooling:

1 Cold air convection -directed on to the area prior to and during treatment

2 Contact cooling - laser or light tip itself is cooled and thereby cools the
skin surface

3 Cryogen spray cooling - frozen gas is sprayed on to the skin just prior to,
and with some lasers during, the delivery of the laser light
Adipose-derived stem cells- new therapeutic
modality
• Stem cells are undifferentiated cells, which have the important properties of self-
renewal and differentiation

• Adult stem cells have variable reproductive properties and potentials

characteristic of embryonic stem cells

• Adipose-derived stem cells (ADSC) that are easily obtained from subcutaneous fat
tissue have the relative advantages of accessibility and abundance

• wrinkles are reduced by increasing dermal thickness and collagen density after
ADSC injection into photodamaged aged skin.
Mechanism for anti-ageing effect of
ADSC
• Paracrine effect -secretes variable cytokines that modulate extracellular
matrix remodelling, angiogenesis and antioxidant effect

• The other is a possibility of variable differentiation, which means that

injected ADSCs were differentiated to another type of cells such as
fibroblasts and endothelial cells
COSMECEUTICALS

• Cosmetic products

• Biologically active ingredients

• Available without a prescription