treatment of ageing skin

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TREATMENT OF AGEING SKIN DR MIKHIN GEORGE THOMAS

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Page 1: Treatment of ageing skin

TREATMENT OF AGEING SKIN

DR MIKHIN GEORGE THOMAS

Page 2: Treatment of ageing skin

• Continuous ongoing dynamic chronological process

• Irreversible process

• Visible and its social impact

• Life expectancy on the rise

Page 3: Treatment of ageing skin
Page 4: Treatment of ageing skin
Page 5: Treatment of ageing skin

Types of ageing

• Intrinsic ageing

Genetics

Cellular metabolism

Hormone

Metabolic processes

Page 6: Treatment of ageing skin

Intrinsic ageing

. Fine wrinkles.

. Thin and transparent skin.

. Loss of underlying fat leading to hollowed cheeks and eye sockets with noticeable loss of firmness on the hands and neck.

. Bones shrink away from the skin as a result of bone loss, which causes sagging skin.

. Dry skin with pruritus.

. Inability to sweat sufficiently to cool the skin.

. Greying hair eventually turning white.

Page 7: Treatment of ageing skin

FACTORS CAUSING AGEING IN FACE

FACTORS AREAS OF THE FACE AFFECTED

Gravitational force Upper and lower eyelid, cheeks,neck

Depletion of subcutaneous fat Forhead, periorbital, buccal, inner line of nasolabial folds, temporal and perioral areas

Subcutaneous fat accumulation Submental, around jaws, outer lines of nasolabial folds, lateral malar area

Resorption of bone and cartilage Maxilla, mandible and frontal bone

Page 8: Treatment of ageing skin

EXTRINSIC AGEING

CHRONIC LIGHT EXPOSURE

POLLUTION

IONIZING RADIATION

CHEMICALS

TOXINS

Page 9: Treatment of ageing skin

GLOGAU’S

Page 10: Treatment of ageing skin
Page 11: Treatment of ageing skin
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Page 13: Treatment of ageing skin

THE THEORIES OF AGING

• Cross-linking theory of aging

• Wear and tear theory of aging

• Free radical theory of aging

• Somatic mutation theory of aging

• The pacemaker theory of aging

• Genetic theory of aging

Page 14: Treatment of ageing skin

• Cumulative endogenous damage- free radical theory

• Genetic determinants- telomeres

• Changes in sex hormone levels

• Altered cytokine levels- TGF beta 1

Page 15: Treatment of ageing skin

KEY FEATURES

• Epidermal hyperplasia and dysplasia

• Dermal thickening

• Solar elastosis

• Actinic vasculopathy

• Dry, coarse and lax skin

• Actinic keratoses

• Malignant tumors

Page 16: Treatment of ageing skin
Page 17: Treatment of ageing skin
Page 18: Treatment of ageing skin

Ageing in the Indian skin

• Complex and variable in color

• Better equipped for protection

than western skin

• Less chance of skin changes and

malignancy due to photodamage

Page 19: Treatment of ageing skin

Approach

• Evaluation of patient

• Preventive management

• Medical management

• Combination treatment

• Surgical management

• Cosmeceuticals

Page 20: Treatment of ageing skin

EVALUATION

• Individualized

• Attitude, racial, cultural, ethnic backgrounds

• Psychological outlook

• Limitations of procedures to be explained

• Clinical signs of ageing to be documented

• Appropriate consent and photographs to be taken

Page 21: Treatment of ageing skin

Preventive strategies

• Eating fresh fruits and green leafy vegetables

• Regular exercise

• Adequate sleep

• Avoid strong sun and wind

• Avoid smoking and excess of alcohol

• Avoid stress

Page 22: Treatment of ageing skin

SKIN CARE

• Healthy and functioning skin barrier

• Daily skin care may increase skin regeneration, elasticity,

smoothness, and thus temporarily change the skin condition

Page 23: Treatment of ageing skin

PHOTOPROTECTION

• DNA photodamage and UV-generated

reactive oxygen species (ROS) are the

initial molecular events.

• Wrinkles and pigmentary changes.

• Sunscreens- SPF of 15 or higher.

• Sun-protective clothing- ultraviolet

protection factor (UPF) of 50+ and reportedly

blocks 98% of ultraviolet A and B.

Page 24: Treatment of ageing skin

• Sun avoidance

• Patient education- avoid midday sun exposure

• Participate in outdoor activities early or late in the day

• Seek shady, covered areas rather than direct sunlight

Page 25: Treatment of ageing skin

Moisturizer

• Maintains hydration of skin

• Decreases fine wrinkles

• Decreases roughness of skin

• Usually combined with sunscreen

Page 26: Treatment of ageing skin

MEDICAL MANAGEMENT

Topical retinoids

• Cordero (1983)

• Kligman, Grove, Hirose, and Leyden- (1986).

• Surface roughness, dyspigmentation, and fine wrinkles- most

improved

• Due to effects on the dermis- increased collagen type I in photoaged

skin

• 0.05% or 0.1% cream

Page 27: Treatment of ageing skin

• Increases epidermal thickness

• Promotes dermal collagen production

• Reduces its degradation

• Inhibits UV-induced matrix metalloproteinases

Page 28: Treatment of ageing skin

Side effects

• Erythema

• Peeling

• Burning sensation

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ANTIOXIDANTS

(1) directly neutralize FRs

(2) reduce the peroxide concentrations and repair oxidized membranes.

(3) quench iron to decrease ROS production.

(4) via lipid metabolism, short-chain free fatty acids and cholesteryl

esters neutralize ROS.

systemic antioxidants- vitamin C, vitamin E, carotenoids, trace

elements copper and selenium.

Page 30: Treatment of ageing skin

• Topical vitamin C 5% cream- improvement in the appearance of

photoaged skin with regard to firmness, smoothness, and dryness

and stimulates the collagen-producing activity of the dermis

• N-acetyl cysteine (NAC)- converted to glutathione, an endogenous

antioxidant.

Prevents UV induced extracellular signal-regulated protein kinase

(ERK) activation and subsequent up regulation of matrix

metalloproteinase (MMP)s which prevent collagen breakdown.

Page 31: Treatment of ageing skin

• Idebenone, a synthetic analog of coenzyme Q10 with potent

antioxidant activity- reduces the skin roughness, increases hydration,

reduces fine lines

• Genistein- isoflavone and the major active constituent in soybeans

has well documented potent antioxidant activity

• Green tea polyphenols- increase the minimal erythema dose,

decreases the number of Langerhans cells and reduces DNA damage

in the skin.

Page 32: Treatment of ageing skin

Hormonal replacement therapy

• LACK OF HORMONES

• Skin dryness

• Decrease in skin firmness and elasticity.

• Oestrogens - synthesis, maturation and turnover of collagen,

increase the synthesis of hyaluronic acid, and promote water

retention

Page 33: Treatment of ageing skin

HRT

• Increased skin surface lipids

• Increase in epidermal hydration and elasticity

• HRT beneficial in both UV-exposed and non-exposed sites

• Increases in both skin collagen and thickness during HRT

Page 34: Treatment of ageing skin

5-Flourouracil

• 5- flourouracil (5-FU) when applied topically- increase the levels of

type1 procollagen mRNA and protein, thus increasing the collagen

synthesis.

• For patients unwilling to undergo costly laser resurfacing procedures

• For those with actinic keratoses

Page 35: Treatment of ageing skin

IMIQUIMOD

• Immune modulator

• Wrinkle reduction

• Improvement in dyspigmentation.

• The epidermal changes characteristic of aging skin like atrophy and

atypia were diminished after therapy

• Dermal changes were not noticed.

Page 36: Treatment of ageing skin

Surgical management

Non invasive

• Low energy ablative lasers

• Nd: YAG laser

• Infrared laser therapy

• Radiofrequency

• Intensed pulsed light

• Endermologie

Page 37: Treatment of ageing skin

NONABLATIVE SKIN REJUVENATION

• “SUBSURFACING”

• Low risk

• Selective, heat induced denaturalization of dermal collagen that leads

to subsequent reactive synthesis.

• Type I- ectatic vessels and erythema, irregular pigmentation, and

pilosebaceous changes

• Type II- improvement of the dermal and subcutaneous senescence

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• Lasers- 532-, 585-, 595-, 755, 800-, and 1064-nm wavelengths

• IPL systems- filtered light

• Pulsed dye lasers (PDL)- oxyhemoglobin as the primary chromophore are now

employed for Type II photo rejuvenation only

Page 39: Treatment of ageing skin

• Release of inflammatory mediators and GF into the interstitium

followed by stimulated fibroblast activity

• Initiation of tissue repair

• Enhanced collagen and elastin neoformation replacing the originally

damaged elastic tissue

Page 40: Treatment of ageing skin

ENDERMOLOGIE

• Noninvasive mechanical body-contouring used in the treatment of

cellulite.

• Cellulite-affected skin is sucked between the rollers and kneaded for

approximately 34-45 min.

• This temporarily reduces the appearance of the cellulite

• Short lived

Page 41: Treatment of ageing skin
Page 42: Treatment of ageing skin

Monopolar RF

• Electric current

• Generates heat through resistance in the dermis and as deep as the

subcutaneous fat, with proprietary cooling of the epidermis.

• Skin tightening and immediate collagen contraction with a single

treatment.

• Patient selection- early laxity of forehead, neck skin.

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Page 44: Treatment of ageing skin
Page 45: Treatment of ageing skin

MINIMALLY INVASIVE

• Chemical peels

• Platelet rich plasma

• Microdermabrasion

• Botulinum toxin

• Fillers

• Fractional photothermolysis

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CHEMICAL PEELS

• Chemical ablation of defined skin layers

• Induce an even and tight skin as a result of the regeneration and

repair mechanisms after the inflammation of the epidermis and dermis

Page 47: Treatment of ageing skin
Page 48: Treatment of ageing skin

Superficial peel

• Target the corneosomes

• Cause desquamation

• Increase epidermal activity of

enzymes

• Lead to epidermolysis and exfoliation

Medium-depth peels

• coagulation of membrane proteins

• destroy living cells of the epidermis

• depending on the concentration, the

dermis.

Deep peels

• coagulate proteins and produce

complete epidermolysis

• restructure of the basal layer and

restoration of the dermal architecture

Page 49: Treatment of ageing skin

MECHANISM OF CHEMICAL PEEL

• Increase in collagen content, water and GAG in the dermis.

• Improvements in skin elasticity and wrinkles after chemical peeling

can be attributed to increase of col-1 with or without col-3

• Dense rearrangement of collagen fibers

Page 50: Treatment of ageing skin

MICRODERMABRASION

• Skin surface is abraded with rough aluminum oxide or sodium

chloride crystals

• Principle- superficial trauma which damages the skin barrier which

repairs within 24 h and also stimulates the fibroblasts to produce

collagen

• bleeding, infection and hyperpigmentation

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The depth of peeling depends not on the substance used only, but on its

concentration, pH of the solution and time of application

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Page 53: Treatment of ageing skin

AUTOLOGOUS PLATELET-RICH PLASMA

• Platelet-derived growth factor (PDGF)

• Transforming growth factor (TGF)

• Vascular endothelial growth factor (VEGF)

• Insulin-like growth factor (IGF)

• α-granules of concentrated platelets activated by aggregation inducers

• Induce the synthesis of collagen and other matrix components by

stimulating the activation of fibroblasts

Page 54: Treatment of ageing skin
Page 55: Treatment of ageing skin

BOTULINUM TOXIN

• Dr Alan Scott

• Neurotoxin used to paralyze various muscle groups of the face for cosmetic

improvement of wrinkles.

• Glabella, forehead, and periocular regions

• Neuromuscular inhibition of acetylcholine

• 3 to 6 months

• Pain, bruising, and paralysis of the nerves that control eyelid function

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Two main serotypes

• Botulinum toxin type A (BTX-A)

• Botulinum Toxin Type B (BTX-B)

• Type B botulinum toxin (BTX-B)- shorter duration of effect than BTX-A

• Used if therapeutic resistance is observed to BTX-A.

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Indications for Botox• Forehead lines

• Glabellar lines

• Crow’s feet

• Bunny lines

• Perioral wrinkles

• Platysmal bands

• Dynamic wrinkles respond better than fixed wrinkles.

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Page 59: Treatment of ageing skin

Contraindications

• Injections in patients with peripheral motor neuropathic diseases or

neuromuscular functional disorders.

• Coadministration with aminoglycoside antibiotics or other agents that

interfere with neuromuscular transmission.

• Treatment of patients with inflammatory skin disorders at the

injection site.

• Pregnancy and lactation

Page 60: Treatment of ageing skin

COMPLICATIONS

• Pain

• Edema

• Erythema

• Ecchymosis

• Headache and short-term hypesthesia

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SOFT TISSUE FILLERS

• Products injected within or beneath the skin to improve its physical

features by soft tissue augmentation

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Categories of dermal fillers

• Autogeneic- fat, autologous plasma, autologous collagen

• Allogeneic- human cadaver tissue, human fibroblast cell culture

• Xenogeneic- collagen, usually derived from bovine or porcine sources;

hyaluronic acid products derived from animal sources or the results of

bacterial fermentation

• Synthetic products, e.g. silicone, polymethyl methacrylate,

hydroxyapatite, carboxy cellulose, poly-l-lactic acid, polyacrylamide

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HYALURONIC ACID

• Natural hyaluronic acid has a half-life in tissue of only 1 to 2 days

• Undergo aqueous dilution and enzyme degradation in the liver to

carbon dioxide and water.

• The duration of effect for hyaluronic acid fillers ranges from 3 to 12

months

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• Staphylococcus equine fermentation

• Space filling

• Lubrication

• Shock absorption

• Protein exclusion

• Regulator of cell proliferation

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• Temporary

• Semi permanent- lasting between 1–2 y

• Permanent materials- lasting longer than 2 y.

Page 66: Treatment of ageing skin
Page 67: Treatment of ageing skin

MECHANISM OF ACTION

• Stimulate fibroblasts to express collagen-1, MMP-1 and tissue

inhibitor of matrix metalloproteinase-1 (TIMP-1)

• Participate in wound healing

• Modulation of inflammatory cells

• Interaction with proteoglycans of the extracellular matrix

• Scavenging of free radicals

Page 68: Treatment of ageing skin

INDICATIONS OF DERMAL FILLERS

• Depressed scars: Post-surgical, traumatic, post-acne or other diseases

• Wrinkles and folds

• Lip sculpting

• Enhancement of facial contour

• Periocular melanoses and sunken eyes

• Dermatological diseases: angular cheilitis, dermal atrophy, AIDS

lipodystrophy

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Page 70: Treatment of ageing skin

CONTRAINDICATIONS

• Keloidal tendency

• Hypersensitivity to products as demonstrated by positive skin testing

• Unrealistic expectations

• Patients with autoimmune disease

Page 71: Treatment of ageing skin

COMBINATION APPROACH

• Sandwich procedure: Here a layering technique, where one product is

injected above the other in different planes for a better esthetic effect

• Botulinum toxin: Injecting botulinum toxin 1 week prior to soft tissue

augmentation in the areas to be treated results in a synergistic effect

• It reduces the amount of product required for correction .

• Helps to increase the longevity of the filler in the treated area.

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LASER PROCEDURES

• Ablative laser resurfacing is considered to be the gold standard to improve clinical features of the aging face and generally refers to treatment with a carbon dioxide laser (10,600nm)

• It improves fine and some coarse wrinkles and overall dyspigmentation

• Lightens dark under-eye circles

• Generally improves the texture of skin

• This procedure works by vaporizing the epidermis and portions of the

papillary dermis so that neocollagenesis can occur

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ABLATIVE

• Epidermal ablation

• Collagen shrinkage

• Stimulation of neocollagenesis

• Extensive dermal remodeling

• Regeneration of cellular organelles and intercellular attachments

• Persistent erythema, hypo- or hyperpigmentation, infection or scarring

Page 74: Treatment of ageing skin
Page 75: Treatment of ageing skin

Fractional laser skin rejuvenation

• Creates microscopic zones or columns of thermal damage surrounded

by healthy tissue

• Facial rhytides, photodamaged skin and scarring

• Triggered by motion across the skin- described as a ‘rolling’ laser

system.

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Page 77: Treatment of ageing skin

Non-laser skin surface rejuvenation

• Recent development

• High surface energy generated with nitrogen gas released at high

velocity

• In research

Page 78: Treatment of ageing skin

Skin surface cooling

• To reduce undesirable thermal injury to epidermis

• There are three main types of tissue cooling:

1 Cold air convection -directed on to the area prior to and during treatment

2 Contact cooling - laser or light tip itself is cooled and thereby cools the

skin surface

3 Cryogen spray cooling - frozen gas is sprayed on to the skin just prior to,

and with some lasers during, the delivery of the laser light

Page 79: Treatment of ageing skin
Page 80: Treatment of ageing skin

Adipose-derived stem cells- new therapeutic modality

• Stem cells are undifferentiated cells, which have the important properties of self-

renewal and differentiation

• Adult stem cells have variable reproductive properties and potentials

characteristic of embryonic stem cells

• Adipose-derived stem cells (ADSC) that are easily obtained from subcutaneous fat

tissue have the relative advantages of accessibility and abundance

• wrinkles are reduced by increasing dermal thickness and collagen density after

ADSC injection into photodamaged aged skin.

Page 81: Treatment of ageing skin

Mechanism for anti-ageing effect ofADSC

• Paracrine effect -secretes variable cytokines that modulate extracellular

matrix remodelling, angiogenesis and antioxidant effect

• The other is a possibility of variable differentiation, which means that

injected ADSCs were differentiated to another type of cells such as

fibroblasts and endothelial cells

Page 82: Treatment of ageing skin

COSMECEUTICALS

• Cosmetic products

• Biologically active ingredients

• Available without a prescription

Page 83: Treatment of ageing skin
Page 84: Treatment of ageing skin
Page 85: Treatment of ageing skin