Consultation for Photoaging Skin
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Synopsis
Chemical peeling remains a valuable tool for the cosmetic surgeon to treat photoaging skin. Choices available include superficial, medium and deep chemical peeling agents along with preparatory cosmoceutical agents to prep the skin and maintain rejuvenation. This chapter will prepare the cosmetic surgeon to include the latest agents in his practice and choose correctly which treatment is best for patients with individual problems of photoaging of the face and body, acne scars and pigmentary problems. These modalities will be compared with other treatment modalities such as laser and dermabrasion.

The explosion of interest in chemical peeling and laser resurfacing on the part of cosmetic surgeons has paralleled the general public’s interest in acquiring a youthful appearance by rehabilitating the photoaged skin. The public’s interest has been further heightened by advertising for cosmetic agents, over the counter chemicals and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Most of these over the counter home do-it-yourself programs have been tried by patients and by the time they consult their plastic surgeon, cosmetic surgeon, or dermatologist, they are ready for a more definitive procedure performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient’s skin type, degree of photoaging skin, and thus prescribe the correct facial rejuvenation procedure that will give the greatest benefit for the least risk factors and morbidity. The cosmetic surgeon should have available for his consumer the options of medical or cosmoceutical topical therapy, dermabrasion, chemical peeling, and lasers available for selective skin destruction and resurfacing. Each of these techniques maintains a place in the armamenteria of the cosmetic surgeon to provide the appropriate treatment for each individual patient and his specific problem.

With an aging baby boomer population expressing an interest in rehabilitating weathered and photoaging skin, the male patient has become a major consumer for the cosmetic surgeon. The approach to photoaging skin has expanded beyond a one-stage procedure to now include preparatory medical therapy and post-treatment cosmoceutical topical therapy to maintain results and prevent further photodamage. Thus, the cosmetic surgeon’s office has become not only a surgical treatment session, but also an educational setting for skin protection and care and a marketplace for the patient to obtain the necessary topicals for skin protection. It is up to the dermatologist, cosmetic surgeon, plastic surgeon to fully understand the nature of skin and sun damage, protective techniques available, and active agents that work as cosmoceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right procedure to restore and rehabilitate their skin.

Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Various classification systems have been available and I would like to present a combination of three systems that would simplify and help the physician define the right program or therapeutic procedure for his patient. The Fitzpatrick skin type system classifies degrees of pigmentation and ability to tan. Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage, and ability for facultative melanogenesis (one’s intrinsic ability to tan). In addition, this system classifies skin as to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin type I and II are pale white and freckled with a high degree of potential to burn with sun exposure. Three and four can burn but usually is an olive to brown coloration. Five and six are dark brown to black skin that rarely ever burns and usually does not need sunscreen protection (see Table I). The patient with type I or II skin with significant photodamage needs regular sunscreen protection prior to and after the procedure. He, though, has little risk for hypopigmentation or reactive hyperpigmentation after a chemical peeling procedure. The patient, though, with type III through VI skin has a greater risk for pigmentary dyschromia – hyper or hypopigmentation, after a chemical peel and may need pre and post-treatment with both sunscreen and bleaching to prevent these complications. Pigmentary risks are generally not a great problem with very superficial and superficial pigment chemical peeling, but may become a significant problem with medium and deep chemical peeling. It can also be a significant risk when regional areas such as lips and eyelids are peeled with a pulsed laser, creating a significant color change in these cosmetic units from the rest of the face. This has been classified as the “alabaster look” seen with taped deep chemical peels in regional areas. The physician must inform the patient of this potential problem, especially if he is of skin type III through VI, justify the benefits of the procedure, outweigh these risks and, in addition, plan for the appropriate techniques to prevent these unwanted changes in color.

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects. The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised for therapeutic intervention in that category I or minimal degree photodamage can be treated with light chemical peeling and medial treatment. Category II and III would entail medium depth chemical peeling while category IV would need those modalities listed plus cosmetic surgical intervention for gravitational changes (see Table II).

Monheit and Fulton have devised a system of quantitating photodamage developing numerical scores that would fit into corresponding rejuvenation programs.3 In analyzing photodamage, the major categories include dermal with textural changes and epidermal with skin lesions. Dermal changes include wrinkles, cross-hatched lines, sallow color, leathery appearance, crinkly thin parchment skin, and the pebblish white nodules of milia. Each of these is classified, giving the patient a point score, 1 through 4. In addition, the number and extent of lesions are categorized from freckles, lentigenes, telangiectasias, actinic and seborrheic keratoses, skin cancers, and senile comedones. These also are added in a classification system 1 through 4 and the final score results are tabulated. A total score of 1 through 4 would indicate very mild damage and the patient would adequately respond to a five-step skin care program including sunscreen protection, retinoic acid, glycolic acid peels and selective lesional removal. A score of 5 through 9 would include all of the above plus repetitive superficial peeling agents program such as glycolic acid, Jessner’s solution, or lactic acid peels. A score of 10-14 would include medium depth chemical peeling, and a score of 15 or above would include deep chemical peeling or laser resurfacing. The patient thus could understand during the consultation his degree of photodamage and the necessity for an individual peeling program.