ARTICLE
Auteur(s) : Brigitte Dreno1,
Tanja Fischer2, Elisabetta Perosino3,
Florence Poli4, Miguel Sanchez Viera5
1Unité de cancérologie cutanée, Hôtel-Dieu, Place
Alexis Ricordeau, 44093 Nantes cedex 01, France
2Bertini Strasse 4, 14 469 Postdam, Germany
3V. Cesare Parese 300, 00 144 Roma, Italy
42, rue du Cherche Midi, 75 006 Paris, France
5Centro de Dermatologia, Cosmética y Láser, Menendez
Pelayo 67, 28009 Madrid, Spain
accepté le 21 Février 2008
Perception [1] of skin ageing and wrinkles is increasingly a
reason to consult a dermatologist; the history of dermatology shows
that aesthetic treatments have been used since ancient times [2].
Skin ageing may be physiological and/or a result of photoageing.
Although all organs age, the skin is the only organ that is
confronted with photoageing, which is also associated with the
development of skin cancers. Dermatologists therefore need to
consider both of these problems when caring for ageing skin and it
would be a mistake to regard skin ageing as a simple problem of
looks (aesthetics). To provide comprehensive management of ageing
skin, it is essential to make a thorough diagnosis before any
therapeutic decision is made. This involves assessing the intensity
of intrinsic and extrinsic signs of skin ageing, identifying the
existence of actinic keratosis skin lesions, which indicate
depletion of an individual’s “solar capital”, and detecting the
presence of skin carcinomas. At this stage it is also important to
assess a patient’s skin sensitivity, which is not always related to
the phototype. The most appropriate treatment(s) may then be
offered to the patient. This comprehensive approach to care
requires knowledge of the mechanisms of skin ageing and the
advantages and drawbacks of the different therapeutic approaches
available, in order to arrive at the best therapeutic strategy and
to meet patient expectations. There are very many different
therapeutic approaches, and in the context of work by a group of
European experts it seems appropriate to propose a therapeutic
strategy for the overall management of skin ageing to help
dermatologists in their daily work with patients. This therapeutic
strategy is based both on an analysis of the literature and the
personal experience of the experts.
Physiopathology of skin ageing
The mechanisms of skin ageing involve intrinsic and extrinsic
factors [3].
Intrinsic factors are hereditary, and comprise the skin
phototype, which is responsible for natural photoprotection, and
the bone structure, which plays a role in tissue resistance and the
distribution of facial fat [3]. Six phototypes have been defined to
date [3] (table 1). The skin is an organ
that is affected by hormones, especially oestrogens, androgens and
progesterone.
Modification of the hormonal balance at the menopause also plays
a role in skin ageing.
Extrinsic factors are mainly UV radiation, which is a major
cause of skin ageing [4] and also of actinic keratoses, skin
carcinomas and melanomas. A distinction must be made between UVA
and UVB radiation. UVB only penetrates the epidermis and acts
directly on cellular DNA, causing mutations. UVA is less energetic
and has a less direct effect on DNA; nonetheless, it is harmful
because it forms free radicals that lead to major cell damage.
Approximately 50% of the effects of UV radiation are related to the
formation of free radicals [5]. UVA also penetrates deeper into the
dermis and so plays a major role in skin ageing. UV radiation
causes many structural changes (figures 1A and B) in the
skin [3, 5]:
- – Thickening of the corneal layer in the short term
(UVA), but in the long term it leads to a thinning of the
epidermis, and a tendency for epidermal ridges to disappear.
- – An increase in the production of melanin by
melanocytes. Over time, this production becomes uneven. This is
related to the fact that some melanocytes stop producing melanin,
the quality of the melanin grains produced decreases, and the
distribution of the grains in the surrounding keratinocytes becomes
uneven [6].
- – Melanocytes may develop an abnormal morphology.
- – Collagen and dermal elastic fibres decrease. The
action of UVA on the extracellular matrix is very complex and
involves the activation of metalloproteases (MMP) and certain
cytokines (interleukin 1, TNF-α, TGF-β) and the inhibition of TIMPs
(MMP inhibitor enzymes). This results in a loss of collagen and
elastic fibres and leads to a decrease in their synthesis and
deterioration in their quality (decrease in type I collagen).
- – UV radiation enhances angiogenesis by increasing
Endothelial Growth Factor and inducing vascular dilation and
telangiectasia.
- – Under UV radiation, the number of Langerhans cells
decreases. This phenomenon induces immunosuppression, which is
augmented by modulation of some cytokine secretions, particularly
interleukin 10 and TGF-β.
- – Natural retinoids play an important role in epidermal
ageing. UVA decreases their nuclear receptors leading to a decrease
in their activities.
Other environmental factors that play a part in extrinsic skin
ageing are:
- – Smoking. For many years now, it has been shown that
smoking is an independent factor in the early formation of
wrinkles. It acts by increasing the deterioration of elastin fibres
[7].
- – The Earth’s gravity. A recent study has shown that
wrinkles and ptosis are aggravated during the day, emphasising the
role of gravity and the standing position. The muscular movements
of facial expressions probably also have an aggravating role
[8].
- – Sleep. Sarafakioglu et al. [9] showed that sleeping
position should be considered as an aetiological factor in the
formation of wrinkles.
Table 1 Fitzpatrick skin classification
|
Skin type
|
Colour
|
Reaction to UVA
|
Reaction to sun
|
|
Type I
|
Caucasian; blond or red hair; freckles; fair skin; blue eyes
|
Very sensitive
|
Always burns easily, never tans; very fair skin tone
|
|
Type II
|
Caucasian; blond or red hair; freckles; fair skin; blue or green
eyes
|
Very sensitive
|
Usually burns easily, tans with difficulty; fair skin tone
|
|
Type III
|
Darker Caucasian; light Asian
|
Sensitive
|
Burns moderately, tans gradually; fair to medium skin tone
|
|
Type IV
|
Mediterranean; Asian; Hispanic
|
Moderately sensitive
|
Rarely burns, always tans well; medium skin tone
|
|
Type V
|
Middle Eastern; Latin; light-skinned black; Indian
|
Minimally sensitive
|
Very rarely burns, tans very easily; olive or dark skin tone
|
|
Type VI
|
Dark-skinned black
|
Least sensitive
|
Never burns, deeply pigmented; very dark skin tone
|
Clinical signs of skin ageing
The clinical signs of skin ageing and photoageing [3, 5, 10]
combine to varying degrees:
- – Elastosis.
- – Ptosis. Mainly due to gravity, ptosis is a highly
progressive problem. It first causes modification of the oval shape
of the face, which becomes less regular and firm, and heavy
eyelids. In the final stages there are bags under the eyes and the
face completely loses its oval shape.
- – A change in the texture of the skin due to dehydration
and the loss of the surface lipid film, leading to a loss of the
radiance of the skin with a greyish or yellowish complexion,
roughness, dilated pores, and skin thinning.
- – Wrinkles, which are fine at first, but which
progressively deepen. Wrinkles are caused by two independent or
related actions: muscle movements and a decrease in dermal and
fatty tissues.
- – Marked dyschromia with areas of hyperpigmentation
(lentigines), sometimes hyperplasia (seborrhoeic keratosis) and
hypochromia.
- – Telangiectasia.
- – Hyperkeratoses: pre-cancerous lesions, which some
people consider as an early cancer, that may progress to
basocellular, or, more rarely, epidermal, carcinomas.
Clinical signs result from intrinsic and extrinsic skin ageing
(table 2). Most authors refer to the
four stages of skin ageing as classified by Glogau [11] (table 3).
Table 2 Symptoms of intrinsic and extrinsic skin
ageing
|
Intrinsic ageing
|
Extrinsic ageing
|
|
Sensitive, atrophic skin
|
Irregular skin thickness with an increased number of epidermal
cells
|
|
Degeneration of collagen and elastic fibres
|
Increased speed of collagen and elastic fibre degeneration
|
|
Possible development of cutaneous tumours
|
Possible development of typical photo-induced, age-related
cutaneous tumours
|
|
Clearer skin due to reduced melanin production
|
Dyschromia; solar lentigines
|
|
Dry skin
|
Telangiectasia
|
|
Enlarged sebaceous glands
|
|
Table 3 Classification of skin ageing according to
Glogau
|
Type
|
Age
|
Clinical signs
|
- Type I:
- Early ageing
- “No wrinkling”
|
Before 35 years
|
- Some slight pigment problems
- No keratosis
- Few superficial wrinkles
- Little or no make-up needed
|
- Type II:
- Light to moderate ageing
- “Laughter lines”
|
Around the forties
|
- Mild lentigines visible
- Seborrhoeic keratoses palpable, not visible
- Mild expression lines when laughing
- Using a little make-up
|
- Type III
- Marked ageing
- “Resting wrinkles”
|
The fifties or over
|
- Marked dyschromia
- Telangiectasia
- Visible seborrhoeic keratoses
- Permanent “resting” wrinkles
|
- Type IV
- Heavy ageing
- “Totally wrinkled”
|
60-70 years and over
|
- Grey-yellow skin colour
- Malignant tumours
- General wrinkling with no area left unaffected
- No point in using make-up – it cracks
|
Methods of treatment – Using technical procedures
Cryotherapy
This consists of applying liquid nitrogen-soaked cotton wool to the
lesion being treated. Cryotherapy is effective for lentigines [12];
it is also effective against seborrhoeic and actinic keratoses.
Complications are rare: transitory erythema; very rarely,
hypochromias.
Chemical peels
The word ‘peels’ [3, 5, 13, 14] covers several kinds of treatment
that remove layers of the skin to varying depths. These are
classified as superficial, medium-depth or deep peels. All types of
peels may produce mild irritation or predispose to herpes
infection.
Superficial peels
The agents most often used for superficial peels are glycolic acid
(the first peel on the market), trichloroacetic acid (at a
concentration of less than 15%), salicylic acid or its derivatives,
pyruvic acid and mandelic acid. Recently, a lipophilic derivative
of salicylic acid (LHA) has been tested as a superficial peel at
concentrations of 5% to 10% LHA [15]. In one study it was compared
with glycolic acid peels at concentrations of 20% to 50%. Good,
comparable tolerance was observed with both treatments. A total of
41% of patients saw an improvement in wrinkles with LHA compared
with 30% treated with glycolic acid; in addition, 46% of women
demonstrated an improvement in pigmentation with LHA compared with
34% with glycolic acid.
Generally, superficial peels are very well tolerated, only
producing some redness for a few hours following each session and
not necessitating any social isolation. Several applications (about
6) are usually required at fortnightly intervals, and they can be
performed on any phototype. The results vary very little depending
on the person performing the procedure. Superficial peels are
useful for improving skin texture and complexion and reducing fine
wrinkles and dyschromic lesions [5]; glycolic acid stimulates
collagen synthesis [16]. Complications are very rare and not
severe, including transient mild hyperpigmentation; redness during
the first night post procedure and a flare-up of pimples have been
reported.
Medium-depth peels
This is an ambulatory treatment effective after one session using
trichloroacetic acid at a concentration of 30% to 50%. It may be
applied to local areas or the full face. Aesthetic cosmetic unit
limits must be respected – four units for the full face, comprising
one for the upper lips, two for the cheeks and one for the forehead
[17, 18]. Medium-depth peels cause marked redness for several days,
followed by desquamation that can be quite significant. Down-time
is therefore necessary for about a week. They are used to improve
the texture and complexion of the skin and reduce fine wrinkles and
dyschromic lesions [3, 13, 14]; results may vary depending on the
skill of the person applying the treatment.
There is a high risk of hyperpigmentation and solar lentigines
following treatment, demanding sunscreen protection for several
weeks; medium-depth peels are not suitable for patients with
phototypes V or VI. Due to an increased risk of herpes infection,
prophylactic herpes treatment is often given to patients suffering
from frequent infections.
Deep peels
Full-face deep peels are performed under general anaesthetic or
sedation, so hospitalisation is necessary. Phenol is most often
used or sometimes trichloroacetic acid at concentrations greater
than 70%. Deep peels are effective for moderate to deep wrinkles,
for improving the complexion and for dyschromic lesions [3, 13,
14], although results depend on who applies the treatment. Ten days
post-operative care is needed and social isolation is obligatory
during this time.
The risk of complications is significant, particularly
post-operative infections and, more importantly, pigmentation
problems such as frequent early transient hyperpigmentation
followed by hypopigmentation, or even total and permanent achromia.
Deep peels are therefore performed only in patients with light
phototypes. Results are comparable with other resurfacing methods,
but deep peels are currently less used because of the greater risk
of complications; heart failure has been reported with phenol.
Dermal fillers [5, 19]
Dermal fillers fill light, moderate and deep wrinkles and remodel
facial contours [19]. They are classified according to the origin
of the material (autologous, e.g. fat tissue – homologous, e.g.
hyaluronic acid – heterologous, e.g. animal collagen – alloplastic,
e.g. polylactic acid), the consistency (liquid vs. solid), the mode
of action (volume donors, tissue stimulators and combined
compounds) and the duration of action (permanent, non-biodegradable
> 2 yrs – semi-permanent, biodegradable 1-2 yrs –
non-permanent, biodegradable < 1 yr). The use of
non-biodegradable products has been discontinued because they may
cause severe granuloma formation, even after several years, and
they cannot be removed when complications occur.
Non-permanent biodegradable products such as collagen and
hyaluronic acid [19] are easy to use, give predictable results and
are relatively risk-free. With hyaluronic acid and human or porcine
collagens, allergies are very rare and no prior tests are needed.
With bovine collagen, however, allergic reactions are more frequent
and an intradermal test must be performed before it is used. Side
effects are in general mild including bruising and transient
oedema. They stay in place for 6-12 months, after which wrinkles
may be refilled as necessary without risk of a hypersensitivity
reaction developing.
Semi-permanent fillers usually involve alloplastic materials
such as polylactic acid or calcium-hydroxylapatite (CaHA)
micro-spheres. They stimulate collagen synthesis as a result of
foreign body reactions.
Autologous fat is removed by liposuction and re-injected into
the treatment areas. The time it remains in place is still subject
to debate.
Botulinum toxin [5, 20]
Botulinum toxin A is by far the most widely used agent in aesthetic
dermatology. It works by temporarily blocking the neuromuscular
junction, since, for a long period, expression lines arise only
from muscle movements. Full effects are seen a few days after
injection and it works for wrinkles of three main areas: the
glabella, the forehead and the peri-orbital crows-feet. With an
epidermal component, toxin treatment, followed by the introduction
of a dermal filler, completes the result. Toxin use is
contra-indicated in myasthenia gravis and pregnancy. Allergies are
extremely rare. Headaches may be suffered after injection although
they are rare and normally transient. Unilateral ptosis is possible
but it is rare and normally due to mistakes in the choice of
injection points.
Devices
Numerous devices are used in managing skin ageing. Some have been
used for many years and their use in therapy is well studied and
their risks well known. Other more recent introductions have
benefit: risk ratios that are more difficult to estimate. In a
recent review of different devices used to treat skin ageing and
their different indications, Weiss et al. [21] insisted in their
therapeutic algorithm that patients have to choose between devices
with a short downtime but many sessions, and devices with a longer
downtime but less sessions.
Pigmentary lasers [12]
These are indicated for lentigines, although they are not effective
against thick seborrhoeic keratoses. Several types of laser give
good results, e.g. Q-switched, Nd-Yag, ruby and alexandrite. They
provide an alternative to cryotherapy, allowing for a more precise
and quicker application and do not cause treatment-induced wounding
or scarring. Complications, such as transient hyperchromia, are
very rare. These are ambulatory treatments.
Vascular lasers [22]
Indicated for telangiectasia and rosacea, KTP and pulsed dye lasers
are equally effective. Following KTP laser treatment there is
always marked reddening and sometimes oedema; a risk of transient
hyperpigmentation demands prudent use in a dark phototype.
Pulsed dye lasers may cause post-operative bruising that may
appear unsightly.
Long-pulsed Nd-Yag lasers may also be used for large lesions,
e.g. livid naevi.
Flashlamps or IPL – Intense Pulse Light [23]
These lamps deliver a wide range of intense light pulses. IPL has a
non-specific action on skin and is also effective on vascular or
pigmentary disorders. Flashlamps are of interest in the treatment
of dyschromias, hyperpigmentation, rosacea, photo-rejuvenation and
telangiectasias. They also benefit the complexion; hence they are
important for patients with several different types of lesions.
Several sessions (4 to 6) are required, about a month apart.
Side effects of IPL are similar to those of laser therapy,
except purpura, which is only associated with laser treatment.
There is some risk of burning, which is greater the darker the
phototype, and often redness lasting from several hours to several
days post procedure. Some transient hyperpigmentation has been
described; intense light pulses are therefore not performed in
patients with darker phototypes.
This ambulatory treatment does not require social isolation.
Ablative or resurfacing and fractional lasers [3, 5]
These are CO2 or erbium lasers. They produce burning right down to
the superficial dermis. Healing occurs in about a week, during
which time the patient must spend a considerable amount of time
treating the burns; isolation is necessary for at least as long.
These painful techniques are applied under local or general
anaesthetic and are effective for superficial and moderate wrinkles
and for dyschromic lesions.
They produce redness lasting several weeks, even several months,
and are associated with a high immediate risk of infection,
particularly herpetic, that demands preventive treatment in
patients who have frequent eruptions.
A high risk of transient hyperpigmentation necessitates very
high factor sun protection for several weeks; cases of hypochromia,
or even of permanent achromia, may occur.
Recently, modifications to erbium or Nd-Yag lasers causing
fractional dermal effects termed sub-resurfacing have been
introduced. Their major advantage is that side effects and
consequently social downtimes are largely reduced.
Photodynamic Therapy (PDT)
This technique was first described in 1913, but was only developed
for clinical application in the 1980s. It takes advantage of the
fact that altered cells accumulate photosensitizing substances
(e.g. δ-aminolevulinic acid [ALA8]), which can be activated to
destroy such cells by light of specific wavelengths. It is a very
efficient treatment for sun damage pathologies and can be easily
combined with other treatment options.
Other devices [3, 5]
Other devices employed include infra-red, split laser, radio
frequency and LEDs [21], although they have been developed too
recently for their benefits and risks to have been adequately
assessed. The aim of these new devices is to allow ambulatory
treatment that is similar in efficacy to resurfacing lasers. In
achieving this, they also try to limit treatment-induced burning
that requires several days to heal, and to maintain dermal activity
that brings about neocollagenesis. Certain devices may be effective
in tissue tightening, but only preliminary, and rather fragmented,
studies have been performed so far – further studies are required.
Some devices combine several techniques (pulsed light; radio
frequency; infra-red) in order to provide additive benefit.
These non-ablative devices are indicated in mild and moderate
skin ageing, e.g. wrinkles, dyschromia and scars. Side effects
include erythema, mild swelling, and sometimes scarring.
Surgery [3]
Surgical procedures include localised treatments of wrinkles or
general removal of wrinkles by rhytidectomy, more commonly known as
a face lift.
Local resolution of wrinkles or scars may be performed using
needles or by looping a wire subcutaneously around adhering
connective tissue (“wire scalpel”). A local lifting effect can also
be achieved by permanent or non-permanent barbed threads that have
become popular under the name Aptos® (for anti-ptosis).
This mainly involves face lifts and the removal of bags under the
eyes.
Classical rhytidectomy or face lifts are effective over the
whole face and are performed under general anaesthesia. Treatment
is associated with all the risks of surgery and leaves scars on the
edge of the scalp. While effective for deep wrinkles, surgery has
no effect on complexion, telangiectasia or dyschromic lesions and
is very expensive. Surgery on the eyelids is often performed under
local anaesthetic and gives good results.
Although the different procedures have been well-described,
there has been no standardized evaluation of them until the recent
description of a quality rating scale for aesthetic procedures by
Alam et al. [24]. Use of this scale should permit a better
evaluation and comparison of the different procedures.
Methods of treatment – Cosmetic care and local treatments
Daily care has three objectives: to prevent or slow skin ageing; to
treat skin ageing; and to help maintain results after a procedure.
Numerous cosmetic or medical treatments for daily use are available
commercially and are summarised here.
Medications
Topical retinoids
Drugs: Tretinoin [25] has been used for several decades in the
treatment of skin ageing and numerous studies have shown its
benefits on the complexion and in dyschromic lesions and fine
wrinkles [5, 26-28]. The factor limiting its use is the irritation
it can cause that sometimes necessitates reducing the frequency of
applications or even stopping them altogether. Above all, its
effect only lasts for a limited time.
Non-drugs: The use of other cosmetic retinoids has been
proposed, particularly retinaldehyde and retinol, but they have
been less well studied.
Cosmetics
Low concentrations of alpha hydroxy acids (AHA)
These are a recent introduction in many topical anti-ageing
treatments. Glycolic and lactic acids are the most used in varying
concentrations not normally exceeding 15%.
Indications are seborrhoeic skins (dilated pores) and aging
skins.
They have exfoliatory actions on the epidermis and modulatory
effects on fibroblasts in the dermis.
They produce desquamation of the stratum corneum in the first
weeks of use and improve the global appearance of the skin and to a
lesser extent the complexion, dyschromic lesions and fine wrinkles
[25]. They are better tolerated than retinoids, although they may
cause dryness, a burning sensation, erythema and/or
photosensitization in some patients.
Beta hydroxy acids (BHA)
The leading BHA, salicylic acid, has been used for a long time [22,
25] and produces superficial exfoliation (++ dilated pores,
seborrhoeic skin).
A lipophilic derivative of salicylic acid (LHA) has recently
been tested over three months in two skin-ageing trials and was
shown to improve the complexion and skin softness and reduce fine
wrinkles [29].
Antioxidants and anti-radicals
The principle of antioxidant therapy is to reduce the harmful
effects of free radicals [5]. Vitamin C is a powerful antioxidant
although not very stable. Skin concentration of vitamin C decreases
with age [30]. Its use has an immediate beneficial effect because
it prevents rashes and the build-up of cells killed by the sun
(sunburn cells) as a result of UV exposure [5]. It also has a
long-term effect: a placebo-controlled double-blind study [31]
showed a reduction in wrinkles after 6 months’ use.
Dietary supplements/internal cosmetics
Their indications depend on properties demonstrated in vitro and in
vivo in animal studies; very few in vivo human studies have been
conducted to date.
In skin ageing, a combination of constituents is often used:
vitamins (A, E, C, flavonoid derivatives and carotene); trace
elements (zinc, selenium, copper, manganese, etc.); and plants
(lycopene, soya derivatives, green tea, etc.). Their activity is
predominantly due to antioxidant properties. Four randomised
clinical trials have demonstrated only weak clinical efficacy
[32-35]. In these studies the products tested always included
several active ingredients.
Hormonal therapies
Drugs: Hormonal treatment of the menopause is very effective on
skin ageing, especially in preventing the effects of hormonal
privation. However, there is currently much debate surrounding the
potential risk of cancer with hormonal treatments.
Non-drugs: Phytoestrogens, especially those found in soya
extracts, are currently proposed as topical or oral therapy to
replace hormonal treatment, although their effectiveness has not
been well proven.
Table 4 summarises the different
treatments according to the clinical signs present.
Table 4 Therapeutic indications of different treatments
according to clinical symptoms
|
Daily skin care
|
Peels
|
Dermal filler
|
Botulinum toxin
|
Cryotherapy
|
Vascular lasers
|
IPL
|
Resurfacing lasers
|
Surgery
|
|
Complexion
|
+
|
+++
|
|
|
|
|
+++
|
+++
|
|
|
Dehydration
|
+
|
+++
|
|
|
|
|
|
|
|
|
Skin thinning
|
+
|
++
|
+
|
|
|
|
+
|
++
|
|
|
Lentigines
|
+
|
++
|
|
|
+++
|
|
|
+++
|
|
|
Telangiectasia
|
|
|
|
|
|
+++
|
++
|
|
|
|
Wrinkles
|
+
|
++
|
+++
|
+++
|
|
|
+
|
+++
|
+++
|
|
Ptosis
|
|
|
|
|
|
|
|
|
+++
|
Therapeutic strategy
The management of skin ageing may be simplified into two treatment
phases:
- – Initial or therapeutic phase that treats one or more
signs of skin ageing;
- – Maintenance phase that aims to uphold the results
achieved in the initial therapeutic phase and to prevent further
ageing, since skin ageing is a continuous phenomenon.
The proposed therapeutic strategy (table
5) provides a general view of the role of therapy across
the initial and maintenance phases for four stages of skin ageing.
For each stage, the therapeutic strategy proposed is estimated to
be appropriate for more than 50% of cases.
From stage II through IV, each recommendation is in addition to
the treatments proposed for the previous stage. The apparent rank
of treatments has no importance.
Initial treatment or therapeutic phase
The proposed therapeutic strategy uses the Glogau classification of
skin ageing [11], as referred to by many authors. Although
primarily based on data from the literature, it also takes into
account the personal experiences of European experts.
Stage I: Superficial peels are preferred in order to improve the
complexion and rehydrate the skin. These may be combined with daily
maintenance therapy with skin care products (e.g. topical
retinoids, AHA, BHA and/or antioxidants) and the use of
sunscreens.
Stage II: Superficial peels will successfully treat early-stage
lentigines, and give a radiant complexion. In more pronounced cases
of lentigines, they may be combined with cryotherapy or laser
therapy, and with dermal fillers and/or botulinum toxin for
wrinkles. IPL treatment may also be helpful in early dyschromia due
to mild rosacea. Maintenance treatment is the same as stage I.
Stage III: The approach is more complicated – in all cases
combination treatments are required. Exactly what treatments are
chosen will largely depend on the wishes of patients and their
acceptance of certain demanding treatments. If a patient is
prepared to undergo skin resurfacing (CO2 laser or
medium to deep peels), this method is preferable. It may be used in
conjunction with dermal fillers and botulinum toxin. If declined,
pigmentary laser, vascular laser or IPL may be suitable
alternatives. In cases of ptosis, surgery may be offered. After
therapeutic treatment, adherence to maintenance treatment is
essential to maintain results. This consists of superficial peels,
daily skin care products and preventative treatment.
Stage IV: Surgery and skin resurfacing are the only viable
options. They may be combined with botulinum toxin, dermal fillers
and sometimes vascular laser treatment. When vascular laser
treatment is declined, IPL or pigmentary laser may be used.
At all stages, if actinic keratoses are present their management
must be addressed. This will involve either physical treatments
(laser, cryotherapy, liquid nitrogen, peels, or photodynamic
therapy) or topical medication (fluorouracil, imiquimod, or
diclofenac). Superficial peels may be useful before physical
treatments or in combination with topical treatments to improve
their effects.
As a matter of course, the presence of a carcinoma most likely
demands surgical intervention.
Table 5 Therapeutic strategy in four stages for the
treatment of skin ageing based on the four types of the Glogau
classification
|
Type I
|
Type II
|
Type III
|
Type IV
|
|
Initial treatment
|
- Superficial peels
- Or
- Micro dermabrasion
|
- Type I
- +
- Medium peels
- Dermal fillers
- Botulinum toxin
- IPL and other non-ablative devices
- Cryotherapy/Ablative lasers*
|
|
- Type III
- +
- Surgery
- Deep peels
|
|
Maintenance treatment
|
- Tretinoin – Superficial peels
- Sunscreen
- Cosmetics (cleansers, moisturizing creams, antioxidants
etc.)
|
*Can be used on actinic keratoses and seborrhoeic
keratoses.
Maintenance treatment
This consists of:
- – Regular use of a broad-spectrum UVA and UVB
sunscreen.
Exposure to UV radiation is the main cause of extrinsic ageing.
It has been shown that daily use of a moisturising cream containing
sun filters that absorb most of the UVB and UVA spectra will
prevent most UV-induced skin damage [36].
Photoprotective cream must have a minimum SPF of 15 and contain
efficient UVA as well as UVB filters. UVA is able to penetrate
glass, e.g. windows or windscreens, so large doses may even be
received by those inside at work or at home. Daily sun protection
must be increased during outdoor activities by use of a higher
factor cream [5].
- – Topical retinoids and different cosmetic creams (alpha
and beta hydroxy acids; vitamin C) may be used alongside physical
treatment as well as dietary supplements.
- – Superficial peels are generally well tolerated and may
be repeated at regular intervals in order to maintain the results
of initial treatment and also to eliminate any actinic keratoses or
lentigines before they become clinically apparent.
Conclusion
Skin ageing is a frequent cause of medical consultation that
requires an initial diagnosis to determine therapy management. This
must be tailored to the degree of skin ageing, the existence of
skin lesions caused by over-exposure to the sun, and the skin
sensitivity of each patient. It is imperative to assess the
expectations of patients and to explain how they may benefit from
treatment and its risks. More often than not the therapeutic
approach will involve a combination of treatments. The proposed
therapeutic strategy is designed to help dermatologists in their
decision making and in the justification of any decision to the
patient as necessary.
Acknowledgments
The European aesthetic dermatology board – supported by La Roche
Posay. Dr I. Moulonguet – SCP Cavelier-Moulonguet – Cabinet
d’anatomie pathologique dermatologique – Paris.
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