As time goes by - Skin and Age

Some Informations in english about skin changings in elderly persons:

Cherry angiomas - These are harmless, small, bright red domes created by dilated blood vessels. They occur in more than 85 percent of middle-aged and elderly people, usually on the trunk. Electrocautery or laser therapy removes these spots.

"Broken capillaries" or Telangiectosia - These dilated facial blood vessels are usually related to sun damage. They respond to the same treatments as angiomes.

Skin Diseases
Some skin diseases more common in older people are shingles (herpes zoster), varicose veins, leg ulcers and seborrheic dermatitis.

Shingles/Herpes Zoster - Shingles is an inflammation of a nerve caused by the same virus as chicken pox. Early symptoms are localized pain, headache or fatigue. Shingles can affect people of all ages, but is more common (and painful) in older adults.

The virus attacks a nerve root and follows the course of that nerve. It results in lines of blisters on the scalp, face, trunk or extremities. The disease usually only affects one side of the body.

Shingles can become serious and cause complications. A dermatologist should be contacted immediately if shingles is suspected, especially if the condition appears near the eyes, as treatments are most effective if started within 3 days of onset.

Seborrheic Dermatitis - The signs of seborrheic dermatitis are redness and greasy-looking "scales" on the skin. It usually affects areas of the skin with a high concentration of oil glands, such as the scalp, sides of the nose, eyebrows, eyelids, behind the ears, and the middle of the chest. It occasionally affects other areas such as the navel, breasts, buttocks and skin folds under the arms.

Seborrheic dermatitis can be successfully treated and may even go away on its own, but it tends to recur. Frequent shampooing and washing are very helpful and your dermatologist may prescribe topical medications, including low-strength cortisone preparations and special shampoos.

Varicose Veins - These are enlarged leg veins that appear blue and bulging. They are common in older individuals. The veins become twisted and swollen when blood returning to the heart against gravity flows back into the veins through a faulty valve. This condition is rarely dangerous.

The aching associated with varicose veins can be eased by avoiding standing for long periods, by keeping feet elevated when sitting or lying down and by wearing support hose or elastic bandages. More severe cases can be treated with surgery. Injections or laser therapy may remove smaller varicosities.The symptoms of varicose veins can be eased by avoiding standing for long periods, by keeping feet elevated when sitting or lying down and by wearing support hose or elastic bandages. More severe cases can be treated with surgery or injections.

Varicose Ulcers - The same sluggish blood flow that results in varicose veins can cause varicose ulcers, also known as venous or stasis ulcers. When a crack or cut occurs in the skin of the leg, it may fail to heal because of poor blood flow. The injury can develop into an ulcer or a shallow wound that may contain pus or infection. The ulcers may last for months or even years, healing poorly.

Varicose ulcers often develop at the ankles. They may be accompanied by swelling and red, itchy, scaly skin around the ulcer. Another cause of ulcers on the legs is poor blood flow in the arteries. This condition is associated with medical disorders such as arteriosclerosis, hypertension and diabetes.

Bruising (Purpura) - Many seniors complain of black and blue marks or bruises, particularly on the arms and legs. These are usually a result of the skin becoming thinner with age and sun damage. Loss of fat and connective tissue weakens the support around blood vessels, making them more susceptible to injury. Bruising in areas always covered by clothing should be evaluated. Bruising sometimes is caused by medications that interfere with blood clotting or internal disease.

Itching - A very common problem with aging skin is itching. Although often associated with dry skin, itching also has other causes. Elderly skin appears to be more sensitive to fabric preservatives, wool, plastics, detergents, bleaches, soaps and other irritants. Identifying and limiting exposure to the cause is important. Prolonged itching may lead to lack of sleep and fatigue. Your dermatologist can often offer some medical remedies for itching if moisturizing alone is ineffective.

Although most of the changes we experience in our skin as we age are harmless, there are certain signs of more serious problems that shouldn't be ignored. See your dermatologist if you notice any of the following symptoms:

Symptom	May Indicate
A scaly red spot	Skin Cancer
A change in color, shape or size of a mole
Any new skin growth
Bleeding in a mole or other growth
Excessive dryness and itching that doesn't respond to moisturizers	Dermatitis, Psoriasis, Internal problems
Vague or sharp local pain or headache followed by the formation of groups of blisters	Shingles
Bulging or tender veins in leg	Varicose veins
A sore that fails to heal	Skin cancer, Circulatory problem, Diabetes

 

Topical treatments for photoaged skin - Separating the reality from the hype
Article by Albert M. Kligman, MD, PhD
VOL 102 / NO 2 / AUGUST 1997 / POSTGRADUATE MEDICINE


Preview: Baby boomers have grown up, and when they look in the mirror, they don't like what they see happening. Those early years under the sun have left their mark--photoaging. Within two decades, more than half of the US population will be over 50, so calls for products that halt the process and repair the damage will not stop anytime soon. In this article, Dr Kligman provides an overview of what manufacturers of drugs, cosmetics, and "cosmeceuticals" offer, along with commentary on the accuracy of their claims.

Mention of the changes wrought by aging immediately conjures up the image of a face marked by creases, wrinkles, sagging folds, an uneven texture with blotchy hyperpigmentations interspersed with bleached spots, keratoses, and other unsightly manifestations. In the public's mind, this portrait constitutes the ruin brought on by aging, but the fact is that virtually none of these changes are due to the passage of time. They are not inevitable; indeed, they are largely preventable. The dreaded emergence of prematurely aged facial skin is a direct consequence of cumulative insult from ultraviolet radiation, a process now termed photoaging (1).

People are living longer than ever before. For sun-worshipping cultures, this means that the multiple manifestations of photoaging will become progressively accentuated. In addition, photoaging effects are appearing at a younger age, owing to such factors as more leisure time among children, higher attendance at summer camps, and admiration of a tanned appearance.
Cosmetic surgeons have a cornucopia of interventions that can restore a remarkably youthful appearance. However, most people seek topical products to help improve their skin, ideally by reversing some of the structural degradation caused by the sun. The marketplace is bustling with advertisers purporting that their products have marvelous "anti-aging" effects. It can be very difficult to separate puffery from fakery. In many cases, product claims are grossly exaggerated and engender false hope, but in other cases, some products do yield benefits.

Retinoids

Retinoids are the "gold standard" against which all other pharmaceutical remedies for photoaging can be compared. No other known chemicals or drugs can duplicate the diversity of anatomic and physiologic effects brought about by retinoids. Structurally, these substances resemble the parent compound vitamin A (retinol), and they have similar pharmacologic effects.

The best-known topical retinoid is trans-retinoic acid, or tretinoin (Retin-A), which was introduced more than 30 years ago. Other topical retinoids for photoaging are already on the market, and more may be coming that probably will have effects similar to those of tretinoin. For example, a 0.05% emollient cream formulation (Renova) was introduced recently that is less irritating than 0.05% Retin-A cream but equally effective. Another new form is Retin-A Micro, which entraps tretinoin in "microsponges," allowing slow metered release to reduce irritation.

Numerous publications worldwide have documented topical tretinoin's ability to improve the appearance of photoaged skin (figure 1) by reducing wrinkles, decreasing laxity, bleaching hyperpigmented spots, and bringing about a smoother surface, a more uniform texture, and a rosy glow (2-4). Structural changes underlying these cosmetic benefits include correction of epidermal atrophy, deposition of new collagen, generation of new vessels (angiogenesis), and enhancement of mitogenesis (increasing cell turnover). Enhanced mitogenesis promotes shedding of melanin-laden keratinocytes, resulting in bleaching (depigmentation) (5).

Another capability of retinoids is evacuation of materials retained in dilated follicles, which the laity recognizes as large pores. Retained materials include bundles of vellus hairs and microcomedones consisting of horny impactions of corneocytes. Bacteria and yeasts heavily colonize these impactions, distending the orifices and giving the appearance of blackheads. Additionally, pretreatment with tretinoin for 2 to 3 weeks enhances healing and cosmesis after a chemical or laser peel.

In view of the diverse beneficial effects of topical tretinoin, it is a pity that the drug is so vastly underused. Sales of "antiaging" cosmetics far exceed those of tretinoin. One reason may be the widespread misconceptions regarding the frequency and nature of adverse events, which have kept many physicians from ever prescribing the drug. Many primary care physicians and an embarrassing number of dermatologists do not know how to use tretinoin effectively.

Misconceptions about safety and sensitization
Safety is not a big issue with tretinoin. After decades of use, not a single instance of irreversible side effects, such as scarring, congenital malformations, or systemic abnormalities, has been recorded.

A common misconception is that tretinoin is a photosensitizer. Although initially the face does become somewhat more susceptible to sunburn, this effect normalizes after the drug has been applied for a couple of months. In the meantime, all that is required are simple protective measures, such as avoiding the midday sun, applying a broad-spectrum titanium dioxide-based sunscreen (sun protection factor >15), and wearing a wide-brimmed hat.

A recent review summarizes problems encountered in using tretinoin and offers sensible
guidelines for primary care physicians (6).

Patient instructions on application and expectations
With proper instructions, which should take at least 15 minutes to convey and review, topical tretinoin can be prescribed any time of year in any geographic region. Providing written directions to assure proper use and compliance is also helpful. Physicians who cannot allot adequate instruction time to a new patient should not prescribe tretinoin.

Patients should be warned about early, subjective discomfort, such as stinging or burning and sometimes mild erythema and scaling. In fact, patients can use these symptoms as an indication that the drug is working and can monitor the amount of drug to apply by deliberately inducing them. After some weeks, accommodation generally takes place and discomfort ceases.

Tretinoin should be applied at night. A pea-sized amount of cream is placed on each temple and then spread with the fingers over the entire face, including directly around the eyelids where fine wrinkles are common. (Except for transient stinging, no harm comes from getting tretinoin in the eyes, despite excessive cautions included in the package insert.) After application, no other substance or cosmetic should be used that may dilute or chemically inactivate the drug.

Owing to the exfoliating effect of tretinoin, fine scaling and dryness may occur, especially in winter. Applying a moisturizer generously in the morning is helpful. The best moisturizing agent is petroleum jelly, but it is too greasy for most people. It now comes in a creamy version that is almost as moisturizing as the original. Other effective warhorses are Nivea Ultra Moisturizing Creme and Eucerin creams (not the lotions).

A conservative regimen consists of starting with 0.025% tretinoin cream and increasing to 0.05% cream as tolerance develops. Beneficial effects can be obtained more quickly with the highest concentration (0.1%); however, side effects occur more frequently and are intolerable for some patients. In hot weather, some patients prefer gel (0.01% and 0.025%) over oily formulations. The most potent formulation is 0.05% solution, which requires closer monitoring.

Daily applications should continue for about 1 year, after which Monday, Wednesday, and Friday applications are sufficient for most patients; for others, weekend use is adequate. Since the clock never stops turning, treatment continues indefinitely.

Treatment initiation according to sun-exposure history
When to begin treatment depends on the extent of photoaging. Most sun damage to the skin occurs in childhood. Histologic studies in Celts with apparently normal skin type I (ie, skin burns easily and tans poorly) have found that a surprising amount of damage has already been done to the dermal matrix by age 10. Thus, in blond, blue-eyed, light-skinned, freckled, Scotch-Irish persons, tretinoin therapy may be started before puberty if there is a history of sunburns in childhood, even if signs of photo-aging are not clinically evident. Examination of the skin under Wood's light is a simple way to estimate the degree of photodamage, since subclinical freckles and lentigines appear as conspicuous dark patches.

For persons living in sunny areas, treatment begun in the 20s and 30s is advantageous, even in those with skin type IV (ie, dark skin that burns minimally and tans very easily), unless they have a history of minimal sun exposure in childhood.

Chemopreventive effects
Early retinoid therapy is particularly worthwhile for cancer-prone persons, since these agents are known to prevent tumor progression, a process known as chemoprevention. In older patients with photodamage that includes many actinic keratoses and perhaps past basal cell cancers, the combination of nightly tretinoin and twice-daily use of the chemotherapeutic agent 5-fluorouracil (Efudex, Efudix, Fluoroplex) is an effective anticancer regimen (7).

Antioxidants and other "active" agents

Abundant laboratory evidence shows vitamins C and E to be free-radical quenchers. They have been shown in a multitude of in vitro systems to function as antioxidants, which protect cells against ultraviolet radiation. (For a complete review, see Fuchs and Packer (8).) Formulations containing vitamin C, E, or both are available on the market, but for the most part, claims of antiaging effects have not been supported by scientific proof.

Manufacturers profess that recent vitamin C formulations have been modified to increase fat solubility, resulting in enhanced transcutaneous penetration. Vitamin C concentrations of 10% or more result in far higher levels within the skin than can be achieved by any conceivable oral dosage. In addition, vitamins C and E are natural collaborators and participate in reciprocal self-regulating cycles of regeneration. Thus, the scientific rationale for prevention and reversal of photodamage with vitamins C and E is logical. But so far, there is little compelling evidence that such combinations are effective in vivo.

Marketplace momentum is well ahead of scientific fact. Manufacturers claim that vitamin C and E formulations have antiaging effects comparable to those of retinoids. Although this claim has not been validated by double-blind controlled studies, these intensively advertised products are extremely successful, judging by their high sales numbers, even though they probably do nothing more toward improving photodamaged skin than their vehicle alone would accomplish. The marketplace push is toward use of more and more free-radical scavengers, such as superoxide dismutase, which is often combined with a melange of herbs, minerals, enzymes, hormones, and unpronounceable substances of marine origin.

Cost-conscious buyers should be encouraged to resist these seductive fantasias, which resemble the snake-oil exotica of a bygone era. A working rule is that a formulation will probably not live up to its claims if it contains more than three "active" ingredients. Another dictum is that efficacy does not necessarily correlate with cost; cheaper preparations are often just as effective as expensive ones.

Alpha hydroxy acids

These natural fruit acids, used since antiquity, have recently been "rediscovered" as a topical application to improve the appearance of photoaged skin. They include a bevy of acids that have in common a hydroxy radical in the alpha position next to the terminal acid group. Common examples are glycolic, lactic, and citric acids. (See Van Scott and Yu (9) for a scholarly review of the actions of alpha hydroxy acid.)

Only a few years ago, a simple product from Avon (Anew) containing 4% glycolic acid hit the market with a big bang. Its commercial success was so great that there are now hundreds of manufacturers of alpha hydroxy formulations. Products come in a dazzling and bewildering array of compositions--often two to five fruit acids along with ever more numerous ancillary ingredients, such as vitamins and antioxidants. Claims for cosmetic formulations have increasingly expanded to include myriad benefits under the rubric of antiaging. Scientific evidence to support such claims is incomplete and controversial. Suffice it to say that unrestrained hype has overtaken the entire field of fruit acids. Formulations vary greatly in efficacy, so it is probably wise to stick with well-known manufacturers.

What sober and sensible comment can be made about the alpha hydroxy phenomenon? Clearly, these substances must provide some perceivable benefit to have reached $1 billion in sales worldwide. A proper perspective of the biologic effects of hydroxy acids may be better attained by realizing that they are distributed in three tiers:

Low-concentration (usually not exceeding 10%) mass-marketed cosmetic formulations. Activity is pH-dependent. Products with lower pH (<3.5) show greater efficacy; many formulations have a pH higher than this. Complete neutralization destroys efficacy. Moderate-concentration (usually 20% to 30%) solutions for light peeling. These are used in salons by aestheticians.
High-concentration (eg, usually unbuffered 70% for glycolic acid) peeling solutions for resurfacing of photoaged facial skin. These are intended for office use by physicians.

One incontestable biologic property of all alpha hydroxy acids is that they enhance shedding of surface corneocytes (10). When corneocytes are retained as loose aggregates in photoaged skin, the surface becomes rough and scaly and feels dry. Exfoliation of old, hard, dried-out corneocytes results immediately in a smoother, more uniform surface, which is readily perceived by touch. Although rapid smoothing of rough skin is the main reason for the phenomenal success of alpha hydroxy acids, prolonged use also leads to moderate bleaching of the mottled pigmentary appearance of photoaged skin, further enhancing surface texture.

Although the improvements fruit acids produce are unmistakable, the mechanism by which they cause corneocytes to detach from each other is not understood. Other vexing questions also remain. For example, is the alpha position of the hydroxy group a prerequisite for efficacy? This structural position has not been proved to be mandatory and, in fact, it is probably irrelevant. There is evidence that any weak acid can induce exfoliation. A case in point is acetic acid, the parent compound of glycolic acid. It contains no hydroxy radical but is as effective as glycolic acid in achieving textural benefits. Of course, its odor is objectionable, but we have it from no less an authority than Cleopatra that vinegar increased her attractiveness.

All alpha hydroxy acids are effective in reducing the excessive scaling of ichthyotic disorders and are capable of removing retained scales. Strictly speaking, they are not moisturizers, but since they are helpful in relieving the signs and symptoms of dry, xerotic skin, they fulfill the requirement for product labeling as a moisturizer. A little-known but worthwhile benefit is that foundation lotions and camouflage cosmetics can be applied more easily and uniformly on facial skin that has been treated for 2 to 3 weeks with cosmetic formulations of alpha hydroxy acids.

Alpha hydroxy acids are moderately beneficial in improving the signs of photoaging (11). Some dermatologists are persuaded that concomitant use of topical tretinoin has synergistic effects. Apart from somewhat increased stinging and burning, the two agents are not basically incompatible. Nonetheless, it would be difficult to show convincingly that alpha hydroxy acids substantially increase the antiaging benefits of tretinoin.

As regards glycolic acid peels administered by cosmetic surgeons, moderate benefits in appearance are obtainable. However, peels are required every 2 to 4 weeks to maintain enhanced textural improvements. The safety of repeated procedures over long periods has recently come under question and is presently unresolved. Although the Food and Drug Administration has expressed concern about possible adverse effects of long-term use of cosmetic formulations, accumulated evidence does not suggest that there is an appreciable hazard. Resurfacing facial skin with an ultra-pulsed CO2 laser is undoubtedly more effective than peel procedures.

Other exfoliant formulations

It should surprise no one that in the highly competitive marketplace of "cosmeceuticals," other exfoliants are being explored and sold. The most venerable one, salicylic acid, a beta hydroxy phenolic acid, has been used for treating such dermatologic disorders as dandruff and psoriasis for more than a century. Salicylic acid, unlike fruit acids, is insoluble in water and has different biologic effects, which may bring added benefits. A newly introduced product line (Oil of Olay Daily Renewal Cream) contains 1.5% salicylic acid in a moisturizing base. It is less irritating than alpha hydroxy acid formulations and is at least as effective. Already, formulations combining salicylic acid and various alpha hydroxy acids are becoming available.

Summary

Most patients have committed the usual folly of recreational sunbathing in childhood, and in adulthood they notice the manifestations in the mirror. Increasingly, they are seeking professional advice regarding the growing stream of products that promise to improve their photoaged skin. Physicians need to be informed about the great range and complexity of products available, if for no other reason than to steer patients clear of traveling-medicine-show products. A better reason is to be able to provide guidance on proper use of formulations that have proven benefit.