Treatment of Photodamaged Skin Focus on Combination Therapy
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama
Needs Assessment
Chronic exposure to ultraviolet radiation results in histological damage to the skin that can produce undesirable visible alterations, such as rhytides, telangiectasias and dyschromia, as well as precancerous lesions. A wide variety of non-invasive treatments, including cosmoceutical topicals such as retinoids, hydroxy acids and bleaching agents, nonablative light therapies, and ablative procedures such as chemical peels, laser resurfacing, and dermabrasion, are available. Topicals are often a starting point for the treatment of milder cases of photodamage, and can also be used before, during, and after office-based procedures to augment outcomes for patients with more extensive damage. A review of current treatment options, including the application of combination therapy regimens, can assist clinicians in the development of individualized treatment plans for patients with photodamaged skin.Learning Objectives
Upon completion of this continuing education activity, participants should be better able to:
• Describe the categories of change that occur in photodamaged skin.
• Discuss the available treatments for the signs of photoaging.
• Discuss the role of topical agents in the treatment of photodamaged skin.
• Discuss the advantages of using both topical and procedure-based treatments as part of a combination therapy regimen.Introduction
Chronic exposure to solar ultraviolet (UV) radiation results in premature skin aging. The clinical manifestations of photoaged skin include wrinkling, mottled pigmentation, roughness, sallow color, and loss of elasticity. Underlying these visible signs of photoaging are various histological and cytological changes induced by chronic UV exposure. The loss of collagen fibers, which normally provide structural stability, and the degradation of elastin fibers, which gives skin its natural elasticity, result in a general breakdown of the skin’s fibrous matrix. This creates an inelastic, thin, dull-appearing skin. In addition to the structural damage to the dermal extracellular matrix, chronic exposure to the sun’s UV rays causes a generalized dysplasia of a variety of epidermal cell types, including keratinocytes and melanocytes. This type of cellular damage contributes to the mottled and/or hyperpigmented appearance of photoaged skin.
Photoaging (extrinsic aging) differs histologically from intrinsic aging, the changes that occur normally over time. The histological signs of intrinsic aging include epidermal atrophy, resulting in thin, translucent skin with hypocellular changes of the dermis, and increased crosslinking of the collagen matrix. Extrinsic aging, on the other hand, produces changes such as thickening rigidity and scaling of the epidermis with a concomitant destruction of collagen and elastin and the deposition of colloid material with hypercellularity of the dermis. Susceptibility to photodamage is largely determined by an individual’s Fitzpatrick skin type. Lighter skin tones—Fitzpatrick types I through III—are more susceptible to extrinsic photoaging than darker skin tones—Fitzpatrick types IV through VI. The intrinsic photoprotection present in darker skin makes it less prone to damage from actinic exposure.
[FACULTY—PLEASE PROVIDE chart/pictures outlining extrinsic vs intrinsic aging
to be inserted here]
Photodamage can be classified into three categories of change. Color changes include the redness of inflammation, irritation, and telangeictases, and areas of brown coloration in the form of lentigines and postinflammatory hyperpigmentation. Dermal changes, in the form of the irregular destruction of collagen and elastin, are the cause of wrinkling, surface irregularities, and skin sagginess/loss of elasticity. Finally, epidermal dysplasia, hyperkeratosis with actinic keratoses fall into the category of pre-pre or precancerous changes; these are atypical proliferations on the skin that stem from deeper cellular damage and that may evolve into cancerous lesions.
[FACULTY—PLEASE PROVIDE histology images representing these categories of change
to be inserted here]Recognizing the specific types of changes that have occurred in a patient’s skin and quantifying the extent of the damage are crucial first steps in designing an effective treatment plan. In 1996, Glogau published a system for classifying patient photoaging types (the “Glogau wrinkle scale”; Table 1), with the aim of facilitating discussion and rational comparison of therapies and their outcomes. The Glogau wrinkle scale may be a valuable tool for determining which treatment modalities may be of the most benefit for patients.
• Patient age: 20s or 30s
• Early photoaging
o Mild pigmentary changes
o No keratoses
o Minimal wrinkles
• Education
• Tropical tretinoin
• Creams: 15-30%
• Glycolic acid peels: 40-70%
• Botulinum toxinType 2: “wrinkles in motion”
• Patient age: late 30s or 40s
• Early to moderate photoaging
o Early senile lentigines visible
o Keratoses palpable but not visible
o Parallel smile lines appearing
• Education
• Tropical tretinoin
• Creams: 15-30%
• Glycolic acid peels: 40-70%
• Botulinum toxin
• Patient age: 50s and up
• Advanced photoaging
o Obvious dyschromia, telangiectasia
o Visible keratoses
o Wrinkles, even at rest
• TCA chemical peel: 30-50%
• Combination TCA peels
• Laser resurfacing (periorbital, perioral)
• Combination laser resurfacing
• Soft tissue augmentation
• Botulinum toxin
• Combination procedures
• Patient age: 60s or 70s
• Severe photoaging
o Yellow-gray skin color
o Prior skin malignancies
o Wrinkled skin throughout
• Combination CO2 laser and TCA peel
• Deep peel
• Facelift
• Brow lift
• Blepharoplasty
• Botulinum toxinTable 2. Glogau Wrinkle Scale
Many treatment options, including both topical agents and office-based procedures, are available for treating photodamage, and different treatment modalities can target different features of photoaged skin. For this reason, combination therapy plans that incorporate more than one treatment modality may help patients achieve the greatest benefit.
In a recent roundtable discussion, experts in the treatment of photoaging skin discussed the available treatments, and the benefits of a combination therapy approach to the treatment of sun damage and related conditions.Available Options for the Treatment of Photodamage
Dr. Alster: In addition to all the options that will be discussed, it is very important to emphasize to our patients that every single aspect of photoaging starts and ends with photoprotection. We have to make it very clear to our patients when we’re attempting to treat them that we want to prevent further photoaging as much as possible, and photoprotection is a big part of that.Dr Nestor: Peels have been used for the longest time for photodamage. Peels help treat some of color changes that occur with photodamage—specifically the brown type of coloration. In my experience, peels are only minimally effective for the telangiectatic changes. They are certainly beneficial for the sun damage aspect of hyperkeratotic, precancerous changes, and, depending on the depth of the peel, they can help improve rhytides and related dermal changes.
Recently, a lot of peels have been supplanted by ablative laser treatments. The CO2 and erbium laser are still being used, and they have the same general type of effect as peels. In some hands they can be specifically targeted to be deeper or more superficial, depending upon the laser and how it’s used.
For nonablative treatments, the classic treatment for me is photorejuvenation, with intense pulsed light (IPL). IPL can treat two aspects of photoaging: coloration, both red (telangiectases) and brown (lentigines), and dermal remodeling, though perhaps not as dramatically as with the ablative lasers.
The newest treatment on the block is photodynamic therapy, the topical application of aminolevulinic acid, followed by exposure to blue light. Photodynamic therapy, when combined with IPL or other devices, can improve all three aspects of photoaging: color changes, dermal remodeling, and precancerous changes.
There are a variety of laser devices that can affect change in one or more of the processes of photoaging. From the standpoint of the telangiectatic red changes, certainly lasers such as the pulsed dye 532 nm laser, as well as other lasers in that general category, can affect change in the blood vessels, in addition to having an impact on dermal remodeling. The Q-switched ruby, Q-switched YAG, and Alexandrite lasers can affect changes in pigmentary states. Lasers in the 1320 nm to 1450 nm range can be used to target changes related to dermal remodeling.
I look at the topical treatments as either a step-up process or an augmentation process to the procedural treatments. Certainly retinoids, such as Renova and Retin-A, to me are a very, very good adjunctive treatment, and a starting point for people who are not ready for more significant laser or other physical treatments. A variety of different topical agents, such as cosmeceutical agents containing glycolic acid, other over-the-counter topical agents, and a variety of other categories, from amino acid filagrin-based antioxidants (AFAs) to azelaic acid, can be used adjunctively as part of a combination treatment plan to target several different histological aspects of photodamage. DR. NESTOR—PLEASE ELABORATE ON HOW YOU CHOOSE A TOPICAL AGENT
Dr. Alster: We next turn to Gary Monheit for background on fillers, dermabrasions, Botox, and peels.
Dr. Monheit: My first approach is always to ask “where is the problem, what are we looking at, and what is the best way that we can solve the problem?” I developed an index of photoaging skin that I use with my patients. It categorizes the problems of photoaging skin into textural changes and lesional changes, quantifies the level of damage, and gives it a score. It is a good tool for identifying where the problem is, and it allows the clinician to individualize the treatment plann.
[DR. MONHEIT—PLEASE PROVIDE YOUR INDEX to be inserted here]
The aging face must be considered in addition to aging skin, when we target our treatments. In order to target problems of volume loss, both in the skin and below the skin, fillers can be used. Muscle spasms are responsible for the development of dynamic wrinkles and furrows, and for this we use botulinum toxin, a relaxing agent to ease muscle spasms that have caused crow’s feet, forehead wrinkles, and glabellar lines.
Before resurfacing techniques are used, we have to determine where the damage lies in the skin: is it superficial, medium depth, or is it deep? Superficial damage, involving just the epidermis, can be targeted by a superficial agent that exfoliates the stratum corneum in the uppermost epidermis. Light chemical peels, including glycolic acid, Jessner’s solution, salicylic acid, or some of the other combination peels, can be used. The very superficial peels are designed to to remove the stratum corneum,stimulate epidermal proliferation and encourage the growth of a plumper, fresher epidermis. Microdermabrasion, a mechanical abrasive method, can also be used to remove the stratus corneum and stimulate epidermal growth. Lasers aren’t used for superficial exfoliation at all.
Medium depth techniques destroy the epidermis, and either inflame or destroy a portion of the papillary dermis. For medium depth chemical peeling, my favorite is the combination Jessner’s solution and 35% trichloracetic acid, a very safe, effective, peeling formula. It completely destroys the epidermis, and also inflames the papillary dermis, causing enough destruction to get regeneration of a new epidermis that does not have the pigmentation, hyperkeratosis, or atrophy that the patient had before. The creation of a newly rejuvenated epidermis also addresses the fine line changes we find in the papillary dermis. A medium depth peel will not have an effect on blood vessels, so there will not be a change in telangiectases or reddening. For medium depth dermabrasion, I mainly use manual dermasanding. This technique uses silicon carbide sandpaper on water to sand off epidermis until we get to petechial bleeding. I like to use this in combination with superficial or medium depth peeling as a background, and we can sand into lesions all the way into the mid-papillary dermis. Erbium lasers can also be used for medium depth resurfacing. [DR. MONHEIT: PLEASE DISCUSS HOW YOU CHOOSE A MODALITY FOR AN INDIVIDUAL PATIENT- See below]
For deep levels of resurfacing, we can use a deep chemical peel. Deep chemical peels destroy the epidermis, the papillary dermis, and portions of the reticular dermis or the mid-reticular dermal area. The Baker’s (phenol) peel is the major peel used. It has major side effects and is a major surgical procedure that is not used as much as it used to be, but it still has a place. [FACULTY PLEASE PROVIDE ADDITIONAL INPUT] A mechanical dermabrasion procedure can bring the destruction and removal down to the mid-reticular dermis. Finally, CO2 laser resurfacing can be used, which can reach the reticular dermis in order to achieve regeneration of new collagen and a completely new epidermis.
For example, this patient has significant rhytids in the periorbital and perioral areas. They require deep resurfacing. The remaining face has medium depth damage of epidermal growths, dyschromias and fine rhytids. I have chosen a combination procedure utilizing C02 laser resurfacing – perioral and periorbital medium depth chemical peel (Jessner’s + 35% TCA) – remaining face with light chemical peeling on the neck. This will blend the cosmetic units giving a natural appearing skin rejuvenation.See Figures 1, 2, 3, 4 and 5
Dr. Alster: Dr. Lask, how are lasers used in your practice, versus other types of surgeries you perform? I think it’s important to note that some people still do some mainstay surgical procedures in addition to some of these other cosmetic enhancement procedures.
Dr. Lask: Like phenol peels, I think deeper laser resurfacing has gone out of fashion. I think that now, more nonablative techniques are used for photoaging, primarily vascular and pigmented lasers for removing erythema, telangiectases, and dyschromia. The ones we like best are intense pulsed light, pulsed dye lasers, and Q-switched lasers, which all seem to work very well. Because downtime with most of these devices is quite minimal, and the improvement is fairly significant, these are very popular in our practice.
Topical Agents and Combination Therapy
Dr?-can someone identify the speaker?Dr. Monheit: Combination therapy has two major benefits: number one, enhancing the ultimate effect of the treatment, and number two, prolonging the effect for the longest period of time and preventing problems from occurring. With any type of treatment, we want to get the best effect with the least amount of problems or side effects and the least amount of treatment for the patient. The ultimate treatment would give superior results without any side effects or downtime. Combination therapy using retinoids and other topicals, along with the other treatments we’ve been talking about, gets us much closer towards this best-case scenario.
Dr-identify speaker Dr. Monheit: Topicals add a pharmacologic aspect to the destructive procedures we are using. Everything mentioned—whether it is nonablative, selective thermolysis, peeling, or dermabrasion—is destructive in the sense that we are destroying one cell or one structure or generally destroying a layer of epidermis or dermis. We are stimulating a regeneration of skin. Topicals can allow us to tailor the regeneration process to fit the result we’re seeking.
Hydroquinone blocks the enzyme tyrosine, thus preventing the production of new melanin and stopping pigment production. This pharmacologic effect is combined with light chemical peels to lighten dyschromic skin.
Dr. Alster: Another reason we use topicals is really as a primer for some of the other procedures we do. There Is a certain amount of improvement we can get by using a combination of topicals alone, and they “prepare the canvas” for the other destructive methods that we use in our office, and enable us to use either fewer, or less intense, treatments.
Dr. ?identify speaker:Dr. Monheit: I think an important point is that we are all talking about long-term care of people with an ongoing problem: photoaging skin. What we suggest at the beginning of treatment may be different from what the patient will have a year from now, or two years, or five years, but what we are doing is incorporating these patients into a program where we are going to be the primary physicians for their skin. Many times the topical treatment is the glue that holds the treatment plan together temporally—we start with some of the less aggressive treatments, such as IPL, and then as the patient gets older and the photodamage increases, we can move on to other things like fillers, or some of the more aggressive ablative treatments. But, that’s down the road, and they will continue to look to us for continued improvement, and to protect the skin from further photodamage.
Dr. Alster: That’s a very good point, not only in terms of moving patients up to other, more aggressive forms of treatment, but also in terms of using some of these topicals as maintenance. The topicals are like steps to the bridge. We use them as primers, throughout the treatments, and then as maintenance down the line.
There’s been a trend towards using a combination of lighter therapies, as opposed to the more invasive treatments like ablative lasers or even dermabrasion, because when you can do this with topicals, and with some of these other nonablative treatments that we have been talking about, you can get very much the same results without as much downtime or as many side effects.
[FACULTY—PLEASE PROVIDE A SIMPLE LIST/TABLE BRIEFLY COMPARING THE TOPICAL AGENTS FOR PHOTODAMAGE YOU USE MOST FREQUENTLY IN YOUR PRACTICES (EG SUNSCREEN, TAZAROTENE, AHAs, HYDROQUINONE, AZELAIC ACID, ETC ). FOR EACH, PLEASE PROVIDE GENERIC NAME, PURPOSE, AND TYPICAL PROTOCOL FOR USE - Below]
Topical Agents Most Commonly Used to Correct Photoaging Skin
1. Sunscreens
2. Retinoids: Retinoic acid
3. Tazarotene
4. Glycolic Acid
5. Hydroquinone
6. Ascorbic Acid
[separate box]
Tretinoin in the Treatment of PhotodamageTretinoin (all-trans-retinoic acid), a compound derived from retinol (Vitamin A), is the only topical pharmaceutical agent proven to repair photodamaged skin. While the exact mechanisms of action are not fully understood, treatment of photodamaged skin with topical tretinoin is known to result in the regeneration of the dermal collagen matrix, epidermal thickening, compaction of the stratum corneum, and promotion of epidermal hyperplasia and angiogenesis. Studies have demonstrated that retinoids are able to induce collagen synthesis in cultured human dermal fibroblasts, and that retinoic acid applied topically to the skin prevents UV induction of the matrix metalloproteinases (MMPs) that play a role in the destruction of the extracellular matrix. The histological alterations induced by tretinoin treatment have been correlated with clinical improvements, including smoothening of the skin, lightening of hyperpigmented lesions, disappearance or significant improvement of fine wrinkles, and, to a lesser extent, of coarse wrinkles. Tretinoin has also been shown to protect skin against photodamage induced by repeated UV exposure, making it an ideal agent for maintenance therapy.
Tretinoin is available in several formulations and concentrations, the choice of which is usually determined by the patient’s tolerance. Tolerance of topical retinoids by patients may vary with age, race, skin type, extent of photodamage, and local climate. Treatment should be combined with photoprotection in order to prevent further photodamage. Clinical effects may be noted as early as the first month of treatment.
Summary of the cytological, histological and vascular effects of topical tretinoin on photodamaged human skin:
? Epidermal thickness
Compaction of the stratum corneum
? Stratum granulosum thickness
? Melanin content and ? melanocytotic hypertrophy/hyperplasia
Reduced epidermal atrophy and promotion of epidermal hyperplasia
? Epidermal atypia and dysplasia
? Synthesis of collagen
? Number of collagen-containing anchoring fibrils in the cutaneous basement membrane zone
? Skin elasticity at high test loads
Exfoliation of retained keratinous horn in follicles
New blood vessel formation and ? blood flow
Symbols: ? indicates significantly increased; ? indicates significantly decreased.
Table adapted from Noble & Wagstaff, 1995.
The first step in treating a patient with photodamaged skin is the assessment of the type and extent of damage. Our faculty experts discussed possible combination therapies for several hypothetical patients.Case Study #1: A patient with dyschromia (redness or brown mottling of the skin, with very little loss of elasticity).
Dr. Lask: If a person comes in with dyschromia, I almost always start them on some bleaching agents first. The biggest problem with bleaching agents we have is local irritation. In people that irritate, obviously we have to stop, but we still find improvement without irritation, even using it once every second or third day. For dyschromia, we almost always also put patients on retinoids. They diminish pigmentation, which has been proven in many different clinical studies, and improve skin texture and quality. [DR. LASK, PLEASE EXPAND ON PROTOCOL FOR USE (DOSE, TIMING, ETC)]
For the next step with dyschromia, we primarily use the Q-switched lasers. We also use intense pulsed light (IPL) for dyschromia, but I think the Q-switched lasers like the YAG or the Alexandrite give you a quicker response. There is a little bit of downtime, five or seven days, but the response is much quicker.
And for the erythema or vascular component of photoaging, we primarily use the V Beam or pulsed dye laser, as well as IPL. I do think the V Beam is a little better for erythema, and it is certainly safer to use and a little more user friendly than IPL, but both work fine. They both require multiple treatments.
Dr. Monheit: I think you have to separate the younger patient with dyschromia, who really doesn’t have a lot of atrophy, poikiloderma of the skin, or telangiectasia, but who mainly has more of a melasmic discoloration and sun dyschromia as the major problem. Like Dr. Lask, I would begin with topical therapy. I would include a bleaching agent such as a hydroquinone: depending on the severity of the dyschromia, I would either go from 2% or even up to 8%. As you increase the concentration of hydroquinone you get more irritation, so you must be careful with it.
I like to combine that with a topical retinoid, because I think that with our bleaching agent, we essentially stop or inhibit the transformation of dopa to tyrosine through tyrosinase by blocking it, so we’re mechanically stopping the production of new pigment. At the same time we want to speed up epidermal proliferation to push out old pigment, and that’s what we’re doing with the topical retinoid. In addition, the use of sunscreen is essential to protect the skin from further sun damage.
So, those three topicals (a bleaching agent, a retinoid, and sunscreen) are the real baseline we want to have the patient using readily before we add on office procedures. For this particular kind of patient I would start with a light chemical peel. I like salicylic acid peels better than the others because they are less inflammatory with less of a chance of postinflammatory hyperpigmentation occurring. They remove the stratum corneum, stimulate more epidermal proliferation, and pull out more pigmentation. I would do this as a repetitive peel every three to four weeks, along with topical treatment, and follow them along on this regimen first.
If the response is not significant, I would then go on to a medium depth chemical peel, which would obliterate the entire epidermis but then have to be followed carefully with both bleaching agents and anti-inflammatories, such as topical steroids, to prevent postinflammatory hyperpigmentation. After that, I would use some selective lasers such as the Q-switched YAG, or if more extensive damage is present, even intense pulsed light (we use the Quantum laser). That is my basic regimen for treating pigmentation as a major sign of photoaging.
Dr. Nestor: I like to look at it more from the aspect of what patients can and will tolerate. In my patient population, more and more of them really want as much benefit as possible without the downtime. I rarely see a lot of dyschromia in and of itself without other changes. Certainly, it occurs, but I would really categorize this as spot dyschromia versus generalized photoaging. I look at photoaging much less as spot dyschromia, which would be lentigines here or there, or something that would occur separately from the photodamage type of dyschromia, which is more generalized. Certainly lentigines are a part of it, but it is much more of an overwhelming presentation than individual lentigines or brown areas. I would agree with Dr. Monheit that the melasma picture is something different, and I think that’s really not necessarily associated as much with photoaging as it is with a genetic predisposition and hormonal changes. I look at photoaging in a different category.For the majority of my patients I tend to use and start with photorejuventation or IPL because of the benefit of having no downtime for many of them, and because this is not just pure hyperpigmentation. We generally see some degree of redness and telangiectases, as well as some degree of dermal change. I believe IPL does a nice job of helping all of these at the same time.
I generally use a Q-switched laser as a secondary treatment for this category, but for the category I mentioned earlier—the individual lentigines or areas—I tend to use it much sooner, because those patients tend to have a lesser degree of photoaging, and the individual lesions are very easy to remove with the Q-switched laser.
For patients that can tolerate downtime, in the past I’ve started with an erbium laser or in some cases a CO2 laser, but recently I have been using more photodynamic therapy, because it really augments the photorejuvenation process significantly. It does have at least two or three days of downtime, possibly more depending upon how you use it.
When it comes to topicals along with these treatments, I look at them as adjuncts in this case. For the hyperpigmentation aspects I use a combination agent containing fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05%, which can, I believe, significantly augment the problem of repigmentation, and can also help with the overall improvement. I also use retinoids in this category. [DR. NESTOR, PLEASE EXPAND ON THIS—HOW AND WHY ARE THEY USED]
Again, I want to stress the issue of photoprotection. For a lot of these patients, I use a broad spectrum physical block with titanium dioxide or zinc oxcide. I think that we tend to make many of our patients significantly better, and they tend to go down the tubes pretty quickly by just creating more sun damage so I think that’s a big factor.
[FACULTY—PLEASE PROVIDE before & after pictures of patient(s) treated for dyschromia]
Dr. Alster: To summarize the various treatment regimens for dyschromia, everyone uses some sort of adjunctive topical. Most people use it preliminarily to prime the skin, and keep their patients on this therapy while they pursue other treatments, most notably in the case of Dr. Lask—pulsed dye laser and intense pulsed light for the erythema, and then Q-switched pigment-specific lasers with IPL for the pigment. In the case of Dr. Monheit, he starts with topicals, goes through light peels and medium peels, depending on the amount of dyschromia, and then finishes up with laser or light sources for any residual erythema. Dr. Nestor uses the adjunctive topicals and quite a bit of photodynamic therapy for the more generalized dyschromia, versus Q-switched pigment-specific lasers for spot dyschromia. Photoprotection is also very important.
Case Study #2: A patient with periorbital and perioral rhytides.
Dr. Alster: How do you mix and match treatments for a patient with rhytides around the eyes and mouth?
Dr. Lask: Well, now if anybody comes in with periorbital rhytides, usually the first thing I will suggest is botulinum toxin, because most people do get significant improvement. Again, I put almost everybody on a topical retinoid as well in order to enhance the outcome and improve skin texture.
I do not use peeling much anymore. I used to use some laser peeling for the eye area, but I’ve found it not to be dramatically rewarding for eyelid wrinkles. The skin is very thin, so if you peeled to a certain depth you either got pigment loss or some texture change on the lower eyelids. I do think it helps texture, but not really wrinkling. The only thing I believe helps with significant wrinkling of the lower eyelids is phenol peeling, but I do think it often results in some long-term or permanent pigment loss.
As far as the upper lip rhytides, I think they’re the hardest, I find, to treat in my office. The simplest approach may be a topical retinoid; I’ve seen some studies showing that retinoids actually enhance even upper lip wrinkling to some degree, though in very small amounts, so I think using retinoids on the upper lip is a worthwhile endeavor. Some people will try botulinum toxin injections for the upper lip, and I do think it helps. The problem is that botulinum toxin does alter the upper lip a little bit, making it a little bit flatter, and it can also cause the patient to have a strange sensation in their mouth. A lot of people don’t like that, so I don’t do it a lot. It does help wrinkling for some patients.
The fillers such as Hylaform, Restylane, and the human and bovine collagens can be useful as well. Patients who are relatively young and whose lip lines are small may benefit from CosmoDerm, CosmoPlast, Zyderm or Zyplast, but these only provide short-term improvement, so the patient has to be willing to come back quite often. Hylaform, which I’ve only been using for a short time now, seems to last at least a few months, so it seems to have a longer duration than Zyderm, Zyplast, CosmoDerm, and CosmoPlast. These products may have a bigger role in upper lip treatments than the collagen products.
The ablative processes (laser abrasion, chemical peeling, dermabrasion) all can improve upper lip rhytides, but in a fair amount of patients they do result in some long-term pigment loss. Some patients, especially younger patients, do not want to deal with that. So I think that unless you’re willing to face that potential complication, it is a hard road to go down.
Dr. Monheit: The first thing I do is quantify the problem: how much damage is there, and how much do we have to correct? Most of the “lunchtime procedures” work very well for people who have either Glogau I or II levels of rhytides and damage. The other factor we have to consider, as Dr. Nestor mentioned earlier, is how much downtime a patient is willing to put up with. My initial approach is to be conservative and to explain and make suggestions about what we can offer to the patient as far as the lunchtime procedures. All of my patients get a topical program to begin with, and that includes a retinoid, some form of exfoliating agent, such as glycolic acid or mechanical exfoliation, and sunscreen protection. [DR. MONHEIT, PLEASE EXPAND ON HOW THESE AGENTS ARE USED—DURATION? DOSE?]
The patients are treated for two to six weeks prior to other resurfacing procedures. Topical home therapy is the cornerstone of all other procedural therapy to be performed in the dermatologist’s office.First I address wrinkles around the eyes and the periorbital area. Using botulinum toxin, we can relax frown lines and glabellar lines, and a unit or two of botulinum toxin directly below the tarsal plate may relax a hypertrophic orbicularis muscle and actually smooth some of the larger wrinkles under the eye. The next step is resurfacing, and for nonablative procedures we use the Cool Touch laser for periorbital areas; we also use IPL around parts of the forehead. Again, these are conservative—minimal to moderate—changes we will see. As I get into the ablative procedures, I still use CO2 laser resurfacing around the eyes but I do not use phenol peeling. When I use CO2 laser resurfacing, I like to do at least a medium depth chemical peel on the rest of the face to blend it so that if there is a pigmentary change, it won’t be apparent.
As we move down to the lower aspects of the face, volume changes are very important, especially in the perioral area. I find that rhytides need a combination of both volume filling and some nonablative or ablative resurfacing to get results. I like to combine filling agents together for these patients, for example using a hyaluronic acid like Hylaform or Restylane and then combining it with CosmoDerm, first to take care of the deeper filling in the dermis, and then the very superficial fine lines with a lighter filling agent. I also believe when combining hyaluronic acid along with a collagen, we are in essence adding back the substances that are being lost in the skin: the collagen fibers, the elastic fibers, and the hyaluronic acid. When we put them back together again, we’re adding back the bricks and mortar of the dermis, filling it back up. After we accomplish the filling, then we look at what we can do with nonablative resurfacing.
For the population of people with more severe photodamage, I use blepharoplasty. I will do transconjunctival blepharoplasty for removal of fat and relocation of fat to resurface the area. We will do fat filling for sad pockets underneath the eye and to augment the tear trough, and we’ll take skin out from the upper lid. For around the mouth, I’m now using the Feather Lift to bring up some of the skin on the perioral area to raise the nasolabial fold, as well as filling. For more permanent filling, we’re using fat injections and fat autograft muscle injections (FAMI) as filling material, and we combine that with resurfacing techniques for patients with more severe forms of aging (Glogau III and IV).
So we really have a step-wise program we go through, based on the patient’s needs and desires. While many patients prefer lunchtime procedures with no downtime, I often say “go for the gold”: give up some downtime, have more permanent procedures and address more severe problems with the more aggressive procedures we use.
Dr. Nestor: Around the eyes, I also use a step-wise process and approach it from the patient’s needs. One thing we have not covered is the issue of either dyschromia or dark circles under the eyes, which can accompany superficial or deep rhytides. I tend to use a fair amount of erbium laser resurfacing for these patients to combine the improvement in both the pigmentation and the fine lines. [DR. NESTOR—HOW MANY TREATMENTS?]
In patients who are not significantly affected around the eyes, I do see some benefit with nonablative laser, either the Cool Touch, Smooth Beam, or even pulsed dye laser. The nonablative laser seems to be less effective around the mouth. Certainly I have found that, for more superficial damage, combining the deeper tightening agents such as Thermage or ThermaCool with photodynamic therapy can result in some degree of significant improvement. Certainly this can be augmented with the use of fillers.
Since the advent of Restylane, we’ve seen wonderful improvement in treating perioral rhytides in those patients that really don’t want to have the downtime of the deeper laser procedures. For the lips, I often use a combination of CosmoPlast and Restylane, and I’ve found that this works well for improving the perioral area, as well as the areas of the mesiolabial fold. We can inject Botox into some areas, including the musculature that pulls down the angle of the mouth, to improve any sagging.
I do use topicals as adjunctive treatments, including Renova and Retin-A. With my population of patients here in this warm climate, I tend to use a lot more .025% Retin-A; studies have compared the lower to the higher concentrations of Retin-A, and found little difference except for the degree of side effects and irritation. I do think that the combination therapy gives us a dramatic degree of improvement.
[FACULTY—PLEASE PROVIDE before & after pictures of patient(s) treated for perioral/periorbital rhytides See figures 6 and 7]
Dr. Alster: So, for dyschromia, and perioral and periorbital rhytides, we all incorporate some sort of topical, typically a retinoid product, to get the process started. Very rarely will we see enough change in our patients to not go at least an extra step, particularly around the mouth. Sometimes people can improve enough with the topical retinoid around the eyes, but if there is any movement association there, which I think the majority of our patients have, Botox comes into play. Fillers are useful around the mouth, and of course, as was pointed out, ablative or nonablative lasers and peels also play a role in treating some of the deeper rhytides. If downtime is not an issue, they can go through some of these more intensive procedures. In terms of the dark circles under the eyes, in addition to the erbium laser, you can still use a CO2 laser at a lower energy in order to get the same peeling effect; peels also work very nicely in that area.
Case Study #3: Patients with photoaging and acne and/or rosacea.
Dr. Alster: In our aging population, we see a lot of people who have acne and rosacea; many of the procedures we’ve been talking about also apply to these conditions. [FACULTY—IS IT ACCURATE TO SAY YOU SEE A LOT OF PATIENTS WITH PHOTODAMAGE AND ACNE OR ROSACEA?]
Dr. Nestor: Acne and rosacea are physiologically different conditions, although there certainly is some crossover. In the photoaging population, we’re probably dealing more with rosacea than with acne in general. My regimen for acne has changed dramatically over the past year or so because of the advent of both the blue light therapy (420 nm) and photodynamic therapy. For rosacea, I tend to use a lot of intense pulsed light; I think this works great. Certainly pulsed dye laser also works in this case, and I’ve combined that more and more with photodynamic therapy, mainly because of the effects it has on sebaceous glands and the augmentation that occurs in the other aspects of rosacea. For acne, this has also proven to be a tremendous advancement because of the effect on the sebaceous unit, and we tend to get very, very significant effects, especially in the older populations. In my hands, we get more of a long-term clearing in the older patients than the younger patients, for whatever reasons. The blue light has also helped us as an augmentation. Again, I tend to see even better results in the older population of patients than I do with the younger patients, and for all of these patients, I almost always augment with a retinoid. I tend to use a lot of adapalene, just because for many of my patients there’s less of an issue of irritation, but I certainly use a lot of Retin-A Micro in these patients. I tend not to use Renova because the emollient formulation tends to aggravate the acne. For my patients with rosacea, I will add a metronidazole cream or another topical to help augment the treatment.
[FACULTY: HOW DO YOU COMBINE TREATMENTS FOR PHOTODAMAGE WITH TREATMENTS FOR ACNE/ROSACEA? IS ONE TREATED FIRST, THEN THE OTHER, OR IS TREATMENT CONCURRENT? PLEASE REVISE THIS SECTION ACCORDINGLY]
It is best to control the active rosacea first with topical and systemic antibiotic therapy before the vessels and dyschromia are treated with specific lasers. Rosacea exhibits vasomotor flushing which can be triggered by facial trauma; i.e. chemical peels, Microdermabrasion or lasers. Thus, the inflammatory condition must be controlled first.Dr. Monheit: I think it’s important to separate the adult acne population and the photodamaged patient who has true acne from the rosacea population, mainly because of the vasomotor phenomena that occurs in rosacea, which some of our acne therapies can actually make worse. I usually start with a topical regimen, then I suggest to them physical modalities that will augment it. I want them on a topical treatment program that they can adapt to for long periods of time, and to know that the lasers, or the peels I’m going to use, are not going to cure the situation, and they’re not going to maintain it. They will augment what the patient’s basic home care is going to do for this condition, which is a long-term condition.
Starting with patients with adult acne, if I need to I put them on antibiotics, and on topical therapy a retinoid is very important. I like Retin-A Microgel. If the patient has sensitive skin we use the 0.04%; we use the stronger one (0.1%) if the patient has an oily complexion and can tolerate it. This is a daily regimen. Along with that, I add an azelaic acid and/or a benzoyl peroxide to be used at night, depending on their skin tolerance.
We use a blue light laser, and I think that a series of four to six treatments can really put a lot of lesions to rest and cut down on the frequency of topical therapy. One other treatment that I think is invaluable is salicyclic acid peels for acne. They are lipid soluble; the crystals will penetrate into the comedones and break up the blockage, and this can really be a nice adjunct to help make the retinoid work much better, and more quickly.
In contrast, when we treat rosacea, I really do not use a lot of inflammatory peels, or even microdermabrasion, because of the flushing response these patients get. Metronidazole and sulfacetamide are important for basic maintenance therapy. In addition, I use IPL and pulsed dye lasers. I tend to use IPL more for the flushing and the telangeictases. I tell my patients that we need to control the acne component of the rosacea first, and once we see that this has resolved with either antibiotics or topicals, I’ll then put them on an IPL program to deal with the flushing and the telangiectases.
Dr. Lask: Two different lasers have been used a lot more recently for acne, the Smooth Beam and the Cool Touch, both of which have FDA clearance for acne treatments. As mentioned earlier, a lot of these devices are used for three to six treatments. I don’t think there’s any set numbers of how many times you treat these patients, but I do see quite a variety of responses. Some do very well, and some don’t respond at all, but there are nice new innovations for acne besides the topical medications.
For the rosacea, besides the effect on the erythema, flushing, and heat response that the B Beam and the intense pulsed light can give, I think there’s some correlation diminishing the breakouts in these patients as well, so these make very nice adjunctive therapies.
[FACULTY—PLEASE PROVIDE before & after pictures of patient(s) treated for photodamage and acne and/or rosacea See figures 8 and 9]
Case Study #4: Treatment of darker-skinned patients.
Dr. Alster: In general, do you modify your treatments for different ethnicities? I know in my practice I will tend to use less aggressive forms of treatment in my patients with darker skin types, and incorporate more of the topical and lighter peels, compared to somebody with lighter skin tones.Dr. Lask: People with darker skin types tend to come to me because of dyschromias, not generally the classic photoaging problems, and in this population I use primarily the bleaching agents, and the retinoids. I do sometimes use less aggressive treatments, i.e. lower concentration of hydroquinone or fewer applications, or how often they apply it, because if they irritate, as we all know, they will discolor more than a fair-skinned patient, so I have to be more careful.
Dr. Alster: Dr. Nestor, how do you treat these individuals, especially in terms of the intense pulsed light and PDT combination? Do you scale back what you use, in terms of energies, or do you tend to use other forms of treatment?
Dr. Nestor: I think these patients of different Fitzpatrick skin types come in with different aspects of photoaging. I think that the classical triad of hyperpigmentation, redness, and actinic-type changes, with actinic keratoses, are much more geared toward type I, II, and maybe some type III. We see more rhytides, though certainly not to the same extent as in types I, II, or III, and dyschromia with types IV or V, and the type VI patients tend to have more acneform eruption, much less rosacea, and certainly much less of the other classical signs of sun damage, though there could be some dyschromia.
I tend to individualize my treatment plan based on the presentations of the patients. In darker-skinned individuals, we tend to use more nonablative procedures if we’re targeting rhytides and those types of changes, as we’ll certainly use botulinum toxin and fillers, because those are not necessarily sensitive to Fitzpatrick skin types. In this population there is much less of a need for the more aggressive, more ablative, procedures.
I find that the other nonablative procedures that we’ve talked about (Cool Touch, Smooth Beam, and others), are equally tolerated by darker-skinned and lighter-skinned individuals, although with the pulsed dye laser and IPL, you have to be much more careful with the darker skin types—using less energy, and possibly using different filters for the IPL. With regard to topicals, the only thing I would stress is that with the darker skin types, when there is a lot of irritation associated with topical treatments, you may see some hyperpigmentation, so you have to be a lot more careful with a postinflammatory change. This is just something to keep in the back of the mind. [DR. NESTOR—CAN YOU PROVIDE AN GENERAL TREATMENT PROTOCOL?]
[FACULTY—PLEASE PROVIDE before & after pictures demonstrating treatments for darker-skinned patients]
Conclusion
Chronic sun exposure results in deleterious effects on the skin, a process known as photoaging. Characteristics of photoaged skin include fine and coarse wrinkles, roughness, laxity, mottled pigmentation, actinic lentigines and keratoses, coarseness, sallowness, and telangiectasia. Depending on the extent of photodamage and the desires of the individual patient, there are many available options for treatment, including both topical agents and office procedures such as lasers, dermabrasion, peels, and fillers. The use of multiple treatment modalities as part of a combination therapy plan may provide the most benefit to patients, as this approach allows for concurrent treatment of multiple symptoms. Topical retinoids are recommended for priming the skin prior to office procedures, and as maintenance therapy to maintain treatment results and to prevent further sun damage. Photoprotection should be an essential part of any photoaging treatment regimen.
Copyright © 2008 Total Skin & Beauty Dermatology Center. All Rights Reserved. Legal Notice
2100 16th Avenue South, Ash Place, Suite 202, Birmingham, Alabama 35205