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Photoaging Reversed

Q:What Skin Resurfacing Can You Do?

The explosion of interest in facial skin resurfacing on the part of physicians has paralleled the desire of members of the general public to acquire a youthful appearance by rehabilitating photoaged skin. Many over-the-counter home, do-it-yourself products are tried by patients before they consult a dermatologist or cosmetic surgeon. By that time, they are ready for more definitive procedures. Facial resurfacing physically removes the cells of the stratum corneum (the rough or scaly outermost layer of the epidermis, the top layer of the skin), by such means as chemical peeling, dermabrasion, and the laser. New, healthy, younger-looking skin replaces the photodamaged skin, reducing wrinkles (rhytides), fading discolored patches (lentigenes), eliminating actinic keratoses (precancerous lesions), and improving other age-related changes.

“New, healthy, younger-looking skin replaces damaged skin.”

Patients have many questions before undergoing a resurfacing technique. Here are the ones I am most frequently asked.

Q:How Do You Evaluate Patients Before Selecting the Treatment Method?

The patient’s skin color, skin type, and degree of photoaging must be taken into account. Three classification systems are available that can help to find the right therapeutic procedure for the individual.

Q:How Are Skin Types Classified in the Fitzpatrick System?

The Fitzpatrick skin type system classifies degree of pigmentation and ability to tan. Types I and 11 are pale and have a high potential for sun burning; types III and IV can burn but usually tan, and V and VI are dark brown and black, tan easily and rarely or never burn. This system not only predicts sun sensitivity, tanning ability, and susceptibility to photodamage, but also classifies each skin type according to its risk factors for complications during chemical peeling. Individuals with Type I and 11 skin are at low risk for reactive hyperpigmentation (darkening of skin color) after a chemical peel. Those with types III through VI have a greater risk for either hyperpigmentation or hypopigmentation (fading of skin color) after a chemical peel. In order to prevent these complications, pre and post-treatment with both sunscreen and bleaching agents may be necessary.

Q:What Are the Four Categories of the Glogau System?

The Glogau system classifies severity of photodamage into Categories I through IV. Patients in Category I with a minimal degree of photodamage can be treated with light chemical peeling and medical treatment with topical agents. Those in Categories II would receive medium-depth chemical peeling, erbium: YAG laser resurfacing, or dermabrasion, while category IV would require deep chemical peeling or laser resurfacing and may need the addition of filler substances to correct gravitational changes, i.e., sagging.

Q:How Do Dark-Skinned Patients Respond to Treatment?

Dark-skinned patients have a greater incidence of post-inflammatory hypo and hyperpigmentation. The physician needs to be very careful in using either deep chemical peeling or laser resurfacing on dark skin. If these modalities are chosen, the patient must be prepared for the procedure with pre and postoperative bleaching agents, retinoic acid, and sunscreen. Medium-depth peeling requires the same preparation, but the risk is less.

Q:Can Resurfacing Halt the Development of Skin Cancer?

The answer to this is yes. Actinic keratoses are sun-induced surface lesions that can develop into squamous cell carcinoma. When removed by resurfacing, they do not proceed to the next stage of development. Both active lesions and incipient growths as yet undetected will be sloughed off with the epidermis.

Actinic keratoses can be treated by many different modalities including cryosurgery, topical 5-fluorouracil, tretinoin (Retin AO), and the erbium:Yag laser. Medium-depth chemical peeling is well suited for these epidermal lesions, as the entire face or a particular sub-unit of the face, such as the forehead, temples, and cheeks can be treated fully within a week to ten days. Deep chemical peels will produce a wound deeper than needed for the removal of epidermal lesions.

Q:Why Are Medium Peels Used for Actinic Keratoses?

Advantages include a limited recovery time of 7 to 10 days, with little postoperative erythema (reddening) after healing. Risk of pigmentary change with either hypo or hyperpigmentation is small. Thus, the patient can return to work rather quickly after healing. There is a long remission period when the patient can expect few or no actinic keratoses to recur.

Q:When Is Dermabrasion Your Treatment of Choice?

Dermabrasion is my primary treatment of choice for scars. For actinic keratoses and photodamaged skin, I would make chemical peels my first selection, laser resurfacing second, and dermabrasion third. For wrinkles and photodamage reaching the dermal (second) skin layer, either dermabrasion or laser resurfacing is needed.

While dermabrasion improves wrinkles, the change is not as long-lasting as deep chemical peeling or laser resurfacing. This may be because heat produced by the laser has a greater thermal effect on collagen contraction and, therefore, on deep wrinkles. The degree of complexity for this procedure is greater than that for chemical peeling and is equal to that of laser resurfacing.

Q:What Are the Drawbacks of Dermabrasion?

General anesthesia or circumferential local anesthesia to block the face is needed. Also, the healing time lasts 10 days to 2 weeks, with redness continuing for 4 to 6 weeks. There is also a risk of Herpes simplex infection, milia formation, and potential scarring. Repeat treatments are seldom needed, except in the case of deep scars where dermabrasion may be used again after a year.

Q:When Do You Favor Superficial Chemical Peeling?

Very superficial chemical peeling removes only the cell of the stratum corneum, a process known as exfoliation, while superficial chemical peeling removes the damaged epidermis as well. The new layer of cells that grows has less photodamage and so presents a more youthful appearance.

Q:What is the Lunchtime Peel?

The very superficial chemical peel has been called the “lunchtime peel” because it can be fitted into a busy schedule with no downtime. The simplicity of the procedure, the quick healing time, few complications, and avoidance of anesthesia are advantages.

Q:When Do You Favor Medium-Depth Peeling?

Medium-depth peeling is defined as controlled damage from a chemical agent to the papillary dermis, the upper portion of the second skin layer. It is effectively used for the following conditions:

  • Removal of diffuse actinic keratoses as an alternative to exfoliation with topical 5-fluorouracil chemotherapy.
  • Mild to moderate photoaging including pigmentary changes, lentigines, epidermal growths, and rhytides.
  • Melasma (a patchy discoloration of the skin) and dyschromia (abnormal skin color).
  • Used in combination with other modalities, i.e., dermabrasion and laser resurfacing, it can blend or unify areas of the face with mild to moderate photoaging changes.

Agents currently used include combination products-Jessner’s solution, 7O% glycolic acid, and solid carbon dioxide combined with 35% trichloracetic acid.

Q:What are the Drawbacks of the Medium Peel?

This procedure requires mild preoperative sedation and non-steroidal anti-inflammatory agents. The patient is told that the peeling agent will sting and burn temporarily; aspirin is given before the peel and continued through the first 24 hours. I usually require sedation for my patients but when the peel is concluded, the discomfort has ended. The patient remains comfortable during healing.

This is not a “lunchtime peel” and requires a week to 10 days for healing. Postoperative erythema, desquamation (the shedding of skin ceus)cellsainage, and edema (swelling) may last 7 to 10 days.

Q:One Often Hears That the Laser is the Treatment of Today. Is This Accurate in Your Opinion?

The laser is the latest tool in our armamentarium of procedures for resurfacing, but it does not replace medium and superficial chemical peeling as well as dermabrasion. These other tried-and-true techniques should not be abandoned. There are, though, conditions that lasers alone can improve.

C02 laser resurfacing is the primary treatment modality for advanced photoaging, especially of the eyelids and around the mouth. It eliminates many of the risk factors found with phenol peeling, and performed conservatively, it will give reliable results in eradicating dermal changes such as wrinkles.

Q:Which Lasers are Currently Being Used?

The C02 laser with a computer-generated scanner (CPG) to distribute the laser light over a broader area can efficiently accomplish deep resurfacing of three layers of the facial skin surface in an hour. Full face resurfacing though, requires either general anesthesia or local anesthesia by means of injections into cosmetic (aesthetic) units of the face. Postoperative side effects can be similar to those of deep chemical peeling, including erythema and even hypopigmentation with textural changes.

The Erbium: YAG laser has been used for facial resurfacing, but I feel it will never replace C02 laser resurfacing as a primary agent for advanced photoaging problems. While successful for medium-depth resurfacing, it is not reliable as a primary agent for deep resurfacing. Recently, it has been combined with C02 resurfacing to promote faster healing with less prolonged erythema. This is thought to be due to less thermal damage.

Q:What are the Advantages of Laser Therapy?

It is safer than deep chemical peeling in treating advanced photoaged skin.

Q:What are the Drawbacks?

Long-term side effects can be similar to those of deep chemical peeling, and the physician must carefully gauge what level of laser penetration each skin type can tolerate.

Q:When Would You Use Combination Therapies?

The typical patient requiring a combination procedure would have advanced photodamage around the eyes and mouth with only moderate photodamage on the rest of the face. The laser could improve the coloration and texture of the eyelids and lips, and then a medium-depth chemical peel would be used for other areas of skin, i.e., forehead, cheeks, and chin. The combination blends the entire face so that there is a uniform texture and color.

I even use a superficial chemical peel on the neck so that further blending will allow a gradual transition from the face down to the chest. The distinctive lines found when a face is resurfaced at the jawline are unattractive and resented by patients.

Q:What Sun Protective Practices Do You Recommend Following Resurfacing?

Patients need to understand that the approach to photoaging skin is not a one-stage procedure but includes post-treatment therapy including long-term photoprotection. I implore my patients to use a sunscreen with an SPF of 15 or higher regularly from this point on, to wear a broad-brimmed hat and sunglasses, and to minimize exposure when the sun is at its peak.

Q:Primary Criteria for Selection of Treatment Method:
  • Micro Dermabrasion
  • Dermabrasion: acne scars and contour defects
  • Chemical Peeling: superficial and medium depth: Glogau I through III, discoloration and actinic keratoses
  • CO2 Laser Resurfacing: Glogau III and IV, with distinctive dermal changes
Q:To Sum Up, Which Treatment Method Do You Prefer?

I favor all three modalities, depending on the individual patient and the specific problem involved. I use them all: micro dermabrasion, chemical peeling, dermabrasion, and laser resurfacing. Having these tools available allows me to pick the appropriate technique as needed. This is far superior to relying on one modality for all patients. In that case, some are under-treated, some are over-treated, and some are not treated correctly.