Aging Skin (photoaging skin)

Are You Confident of the Diagnosis?

Photoaging is accelerating aging of the skin due to prolonged sun exposure.It is also known as dermatoheliosis, and occurs most often in older, fair-skinned patients who have spent a great deal of time outdoors, especially during youth.

What you should be alert for in the history

The history points to a long pattern of sun exposure due to work, leisure sports (tennis, golf) or other outdoor activities, and/or tanning salon use. Patients often have a history of being sun burnt on multiple occasions, with reddened skin that lasts for days or weeks.

Characteristic findings on physical examination

Several skin lesions resulting from photodamage may be present on examination, such as actinic keratoses, seborrheic keratoses, telangiectasias, solar lentigines, and guttate hypomelanosis. Other findings on examinaton show yellowing or sallowing of the skin complexion. The skin texture is dry and rough with wrinkling, and the skin tone is unevenly pigmented with dilated blood vessels. There is an easy distensibility of the skin as well as bruisability (Figure 1).

Figure 1.

Expected results of diagnostic studies

Photoaging is a distinct clinical and histologic entity. Histopathology will show epidermal thinning, flattening of the rete ridges of the dermoepidermal junction, loss of collagen and elastic fibers, development of the Grenz zone with amorphous degenerated collagen, as well as increases in hyperplastic fibroblasts, melanocytic clumping, and inflammatory infiltrates.

Who is at Risk for Developing this Disease?

Patients who have spent a great deal of time outdoors and/or tanning salon users, especially as a child/teenager are at risk.Males are affected more frequently than females. The presentation is more severe in Caucasians, especially those with Fitzpatrick skin types 1 and 2.

What is the Cause of this Disease?

Exposure to ultraviolet (UV radiation), most prominently with UVB radiation, is the cause of aging skin, but it is also seen with UVA radiation.

Systemic Implications and Complications

A distinct systemic implication or complication has not been seen with photoaging. However, there is an increased risk of melanoma, which can have systemic implications. In addition, nonmelanoma skin cancers, as well as an increased number of preskin cancers, such as actinic keratoses (AK) can occur. Also, seborrheic keratoses, actinic lentigines and elastosis, telangiectasias, and worsening of rosacea have been attributed to photodamage.

However, when these changes are observed in childhood, one must entertain the possibility of rare disorders, such as xeroderma pigmentosum. In addition, patients on chronic immunosuppressant agents, (ie, kidney transplant patients) also have an increased risk for nonmelanoma skin cancers and actinic keratoses.

A complete physical examination should be carried out, with attention to photoexposed areas like the face, neck, ears, chest and upper back, as well as forearms, hands and lower legs. Biopsies of any suspicious lesions should be readily performed in the above population groups.

Treatment Options

MEDICAL TREATMENTS

Photodynamic therapy (PDT)

A topical photosensitizer such as Levulan (aminolevulinic acid) or Metvixia (methyl aminolevulinate) will be used, followed by blue light (415 nm) or red light (635 nm) respectively. This treatment may cause a severe sunburn-like reaction that takes 1-2 weeks to heal.

Chemical peels

Superficial peels may be used along with a pretreatment of either 5-FU cream or Imiquimod (given 1 week prior to the peel); medium-depth chemical peels can be performed without pretreatment, but take longer to heal (up to 2 weeks).

Cryosurgery and EDC

Both treatments can render patients with cosmetically unacceptable sequelae, namely hypopigmentation, possible hyperpigmentation, and mild scarring. These procedures can be employed when the numbers of actinic keratoses are plentiful, or if patients cannot tolerate the topical therapies at home, or are non-compliant with topical therapy.

Of note, cryosurgery, PDT, or chemical peels can be used when there is up to 25 cm² of photodamage with the presence of AKs.

Lasers, in general, are not as effective in treating AKs specifically.

COSMETIC TREATMENTS FOR PHOTOAGING

Other sequelae of photoaging skin may be considered as more cosmetic and treated accordingly. These would include actinic lentigines and elastosis, seborrheic keratoses, telangiectasias, fine and coarse wrinkling, rough texture with uneven complexion, and dyspigmentation.

In treating photoaged skin cosmetically, the following should be considered. First, a topical skin care program should consist of broad-spectrum sunscreens, such as Anthelios (Mexoryl) and titanium dioxide or zinc oxide. Helioblock (Neutrogena) is a newer sunscreen that in addition to UVB protection, offers UVA radiation protection (UVA1 340-400 nm and UVA2 320-340 nm).

Many studies to date have shown the efficacy of using topical retinoids to improve the appearance of photoaged skin. In 1988, the first double-blind placebo-controlled study of photoaged skin using topical Retin A (all trans retinoic acid) 0.1% cream every evening for 6 months was documented.

Both fine and coarse wrinkling were shown to improve over this time period but side effects such as redness, peeling, itching, stinging and burning were noted to some degree in patients. Moisturization has been found to help alleviate these side effects. Also decreasing the frequency of Retin A to 3 times a week or less at the beginning of the skin regimen, and increasing the application of Retin A to nightly as tolerated, helps to manage the above side effects.

Other topical retinoids that are precursors to tretinoin, such as retinols and retinaldehydes have shown some merit in photoaged skin. It is felt that retinol dosing equivocates to retinoic acid at a 10:1 ratio; eg, retinol 1% equivocates to retinoic acid 0.1%. Retinoids have been shown to improve collagen, mucopolysaccharides, glycosaminoglycans (GAGs), and to decrease melanosomes, thereby reducing hyperpigmentation.

Other scientific studies have shown that alpha hydroxy acids (AHAs) also have merit in treating photodamaged skin. AHAs can improve the mucopolysaccharide content of the skin, elastic fibers, and to a smaller degree, collagen.

There are other topical cosmeceutical ingredients too numerous to mention here. However, scientific evidence based research is lacking in some, so they are not reported here.

COSMETIC TREATMENTS FOR ACTINIC LENTIGINES

Topical treatments:

Bleaching agents with hydroquinone (HQ) 4% and increase if needed (up to 10%) with medical monitoring, as ochronosis is of concern. Bleaching agents can be used as a solo agent or in combination with retinoids and AHAs. Bleaching agents that do not contain HQ are kojic acid, arbutin, berberry, Elure (Syneron) and Perle (Neocutis), which contains a melanocomlex to inhibit MSH, and other factors in pigment production. Non-HQ agents should be used in patients with a history of ochronosis.

Retinoids. In retinoid-sensitive individuals start with retinaldehyde or retinols every other evening and increase as tolerated to every evening.

AHAs every morning starting in a stepwise manner from 10% and increase as tolerated to a maximum of 20%.

All patients should be on a sunscreen regimen every morning and repeat every 90 minutes if outdoors or exposed to sunlight.

Surgical treatment:

Intense pulsed light (IPL) can be used if the brown spots are dark enough; may be started immediately or after 1-2 months if a topical treatment regimen is started. Desired results are usually accomplished in 1 to 3 treatment sessions; downtime is roughly 1 week secondary to the possibility of scabbing.

Lasers-Q switch YAG or fractional lasers; anticipated downtime is at least 1 week.

Chemical peels- superficial peels need to be repeated and often it takes 6 peels to see results; however, little to no downtime is needed after treatments.Medium depth peels are usually the “one and done” approach in patients with Fitzpatrick skin types 1-3, however there is a risk of hypo- or hyperpigmentation and scarring.

Microdermabrasion requires 6-8 treatment sessions done monthly.

Cryosurgery may be an option, but the risk of hypo- or hyperpigmentation should be considered.

PDT-least favored approach.

COSMETIC TREATMENT FOR SEBORRHEIC KERATOSES

Topical treatments

Retinoids (in retinoid-sensitive individuals start with retinaldehyde or retinols every other evening and increase as tolerated to every evening).

AHAs every morning starting in a stepwise manner from 10%, and increase as tolerated to a maximum of 20%.

All patients should be on a sunscreen regimen every morning and repeat every 90 minutes if outdoors or exposed to sunlight.

Surgical treatments

Cryosurgery may be an option, but the risk of hypo- or hyperpigmentation should be considered.

Electrodesication and curretage (ED+C) also carries the risk of hypo or hyperpigmentation, but can be easily done.

IPL can be used if the brown spots are dark enough; may be started immediately or after 1-2 months if a topical treatment regimen is started. Desired results are usually accomplished in one to three treatment sessions; downtime is roughly one week secondary to scabbing.

Lasers-Q switch YAG or fractional lasers.

Chemical peels-superficial peels need to be repeated and often takes six peels to see results, however little to no downtime is needed after treatments. Medium depth peels are usually the “one and done” approach and work well for single spots or the entire face in patients with Fitzpatrick skin types 1-3, however there is a risk of hypo or hyperpigmentation and scarring.

Microdermabrasion.

COSMETIC TREATMENT FOR RHYTIDS

Topical treatments

Retinoids (in retinoid sensitive individuals start with retinaldehyde or retinols every other night and increase as tolerated to every evening).

AHAs qam starting in a stepwise manner from 10%, and increase as tolerated to a maximum of 20%.

All patients should be on a sunscreen regimen qam and repeat every 90 minutes if outdoors or exposed to sunlight.

Injectable treatments

Botox/Dysport/Xeomin

Fillers (folds)- Juvederm, Restylane.

Contouring agents (volumization)- Sculptra, Radiesse.

Surgical treatments

Lasers-CO2 or fractional lasers.

Chemical peels- superficial peels need to be repeated and often takes six peels to see results, however little to no downtime is needed after treatments. Medium depth peels are usually the “one and done” approach in patients with Fitzpatrick skin types 1-3, however there is a risk of hypo or hyperpigmentation and scarring.

Microdermabrasion/Dermabrasion- lasers and deeper chemical peels seem to have decreased the number of these procedures.

PDT

Radiofrequency- Thermage (monopolar), Titan/Pelleve (bipolar)- newer procedures, data forthcoming.

Ultrasound (Ultherapy)- newer procedure, data forthcoming.

Optimal Therapeutic Approach for this Disease

The optimal therapeutic approach is patient dependent; namely, how much time the patient can afford for recovery (downtime), how willing they are to come back to the office for follow-up treatments, how compliant they are with medication use, and how they want to look after treatment.

Patient Management

Stress ongoing sun protection and sun avoidance for all patients.

Patients should be followed up quarterly while on topical treatments to adjust the dosage of medications; for AHAs increase in a stepwise fashion, 10%–>15%–>20%; retinoids can also be increased in frequency to everyday and in strength from 0.01%–>0.1%).

Risks/benefits of each treatment should be explained to the patient. The more aggressive the treatment (ie, lasers, medium-depth chemical peels) the higher the risk of scarring, hyperpigmentation, or hypopigmentation, while the less aggressive treatments (ie, topical therapies, microdermabrasion, light chemical peels, IPL) present with lower risks, but require coming back to the office for treatments. In addition, blood splattering may be less controllable with dermabrasion than with lasers, making lasers a more popular treatment option.

For the above treatment options, topical treatments are the least costly to the patient, but often takes 3-10 months to see results and achieve patient satisfaction. Additional treatments may be needed to maintain results. For the surgical treatment methods, superficial peels cost the patient the least amount of money, with surgical laser treatments costing the most, and IPL and medium-depth chemical peels being in the middle.

Unusual Clinical Scenarios to Consider in Patient Management

Be aware of patients with underlying psychiatric conditions (obsessive-compulsive disorder, body dysmorphic disorder) presenting with unrealistic expectations with treatments. Secondly, be alert for patients with a history of neurotic picking, and refer to psychiatry prior to treatment consideration.

What is the Evidence?

Cohen, SR, Henssler, C, Johnston, J. ” Fractional photothermolysis for skin rejuvenation”. Plast Reconstr Surg . vol. 124. 2009 Jul. pp. 281-90. (In-depth review of nine fractional laser models; reviews techniques and side effects for each laser.)

Creidi, P, Vienne, MP, Ochonisky, S. “Profilometric evaluation of photodamage after topical retinaldehyde and retinoic acid treatment”. J Am Acad Dermatol . vol. 39. 1998 Dec. pp. 960-5. (The efficacy and safety of a 0.05% retinaldehyde cream and a 0.05% retinoic acid cream in comparison to placebo was evaluated in photodamaged facial skin. Results showed a significant reduction in wrinkles and roughness of the skin after 18 weeks with both active preparations. However retinaldehyde was well tolerated throughout the study, while retinoic acid did cause local irritation in patients.)

Ditre, CM, Griffin, TD, Murphy, GF. “Effects of alpha-hydroxy acids on photoaged skin: a pilot clinical, histologic, and ultrastructural study”. J Am Acad Dermatol. vol. 34. 1996 Feb. pp. 187-95. (The effects of AHAs on photoaged human skin are discussed, with an emphasis on the clinical and microanalytic factors.)

Kafi, R, Kwak, HSR, Schumacher, WE. “Improvement of naturally aged skin with vitamin A (retinol)”. Arch Dermatol. vol. 143. 2007 May. pp. 606-12. (Elderly patients (mean age of 87) were enrolled in a double-blind, randomized, placebo-controlled study in which topical 0.4% retinol was applied to the patient’s arm up to 3 times a week for 24 weeks. Results showed an improvement in fine wrinkles as seen with natural aging. Interestingly, skin treated with retinols also showed an increased resistance to injury and ulcer formation.)

Manuskiatti, W, Fitzpatrick, RE, Goldman, MP. ” Long-term effectiveness and side effects of carbon dioxide laser resurfacing for photoaged facial skin”. J Am Acad Dermatol . vol. 40. 1999 Mar. pp. 401-11. (Follows 104 patients who received CO2 laser resurfacing for 24 months; results include a high rate of satisfaction in patients,considerable persistence of wrinkle score improvement, along with an increase in thickness of the grenz zone as seen on histologic samples from patients after 3 months. Hypopigmentation was the most common long-term side effect from treatment. Patient improvement photos and histologic slides are shown.)

Matarasso, SL, Salman, SM, Glogau, RG, Rogers, GS. ” The role of chemical peeling in the treatment of photodamaged skin”. J Dermatol Surg Oncol. vol. 16. 1990 Oct. pp. 945-54. (Describes indications, side effects and techniques in the application of superficial, medium- and deep-depth chemical peels.)

Sachs, DL, Kang, S, Hammerberg, C. “Topical flurouracil for actinic keratoses and photoaging”. Arch Dermatol . vol. 145. 2009 Jun. pp. 659-66. (Examines the clinical and molecular changes after the application of topical flurouracil cream 5% in patients with actinic keratoses and photodamage.)

Van Scott, EJ, Ditre, CM, Yu, RJ. “Alpha-hydroxyacids in the treatment of signs of photoaging”. Clin Dermatol. vol. 14. 1996 Mar-Apr. pp. 217-26. (In-depth review on the use of AHAs in photoaging; details the chemistry of AHAs, proper technique in using AHAs, as well as side effects and contraindications.)

Weiss, JS, Ellis, CN, Headington, JT. “Topical tretinoin improves photoaged skin. A double-blind vehicle-controlled study”. JAMA. vol. 259. 1988 Jan 22-29. pp. 527-32. (Results show a statistically significant difference in the appearance of photoaged skin on the forearms and face with the application of tretinoin versus placebo cream.)

Yaghmai, D, Garden, JM, Bakus, AD. “Photodamage therapy using an electro-optic Q-switched Nd:YAG laser”. Lasers Surg Med . vol. 42. 2010 Oct. pp. 699-705. (Reviews the use of the Nd:YAG laser in patients with photodamage; demonstrates effectiveness of treatment in a randomized split-face study with a single pulse and double pulse options.)

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