Is there a Wrinkle Cure?

When I do a skin care consult, the most common concern people want to improve upon is wrinkles, wrinkles, and wrinkles. Wrinkles are associated with aging. No one wants to look older and wrinkles are definitely not attractive. The problem is that just about every product and brand claims to have something to prevent wrinkles and most of the time, only minimal changes are seen and maintained. Is there a wrinkle cure?

Well to understand wrinkles, let's talk in brief about why and how they occur. One reason why we wrinkle is that as we age, certain genes become turned off spontaneously, thereby causing us to form wrinkles. The genes that are turned off are the ones that produce collagen. The second phenomena is the constant exposure to free radicals. As described in a previous blog, free radicals are cells that are unstable and cause a vicious cycle of destruction when they try to become stable. We are exposed to free radicals every where. It comes from the air, solar radiation, ozone, and pollutants. Normal cell metabolism also cause free radicals to form. It is the accumulation of these free radicals that causes us to age. And lastly, there are natural decreased levels of anti-oxidants in the skin that decrease our ability to fight off the free radicals and accelerate the aging process.

There are two types of skin aging: Intrinsic Aging and Photoaging. In Intrinsic Aging, the natural collagen production will decrease by 1% per year throughout the adult life span. What we see is reduced collagen formation at the nuclear and cellular level. This produces the chronological changes we see with age. In Intrinsic aging the skin appears dry, dull, pale with fine wrinkles. There is some laxity to it and it is prone to benign skin growths. With Photogaing, this is aging related to sun exposure. The UV radiation causes direct damage to the DNA of the skin cell damaging its ability to repair itself as well as reproduce normal skin cells. It greatly reduces the body's ability to form collagen and repair collagen, and lastly, there is a very large amount of free radicals accumulating that worsen everything I just mentioned. The more sun damage there is, the reduced ability the body has to repair itself, leading to more damage and more wrinkles. It is a vicious cycle. The skin with photoaging has very coarse, deep wrinkles, a leathery look, dry, and mottled appearance. It also is suspect to precancer and cancer lesions of all types.

Two other things can cause skin to age faster are smoking and reduced hormone levels. Smoking accelerates the formation of free radicals and works synergistically with sun damage to cause wrinkles. Reduced hormone levels occur in both men and women as they age. We begin to lose critical hormones after 30 by 1-3% per year. This loss of hormones causes a decrease in collagen and elastin production which causes us to age even more. For women, the decrease in collagen production after menopause is 2.5% per year, which is more than 1% as seen with intrinsic aging. That is why in our center, we talk about hormone optimization as being part of the skin care program. Patients who don't want to do that, end up spending more money and see less change per treatment. My patients who do the wellness with the advanced skin care, have the best results because we can heal from the inside out and the outside in.

So, to stop wrinkles, you must use sunblock and vitamin C topical. Sunblock which has both UVA and UVB protection should be used everyday to prevent solar radiation exposure. Vitamin C serum is important to use as a topical anti-oxidant to reduce the formation of free radicals.

For patients who have wrinkling, I add Retinols which if used over time (for one year) will correct intrinsic damage done to the skin. OBAGI is a great skin care line to use for those with both deep and fine lines.

The other items I recommend are treatments. Patients with fine lines can see changes with both peels and laser skin rejuvenation. Laser skin rejuvenation involves an Intense Pulse Light (IPL) which penetrates the skin about 20-25 microns deep to improve skin tone, texture, and soften fine lines. This IPL treatment reorganizes damaged collagen and elastin but does not cause new collagen and elastin production. Most patients typically need about 5-6 treatments to obtain maximum improvements. They will need a touch up every three to four months.

Peels can help as well but are not as dramatic mostly because superficial peels penetrate only about 5-12 microns deep in the skin. The skin damage is usually 100's of microns deep in the skin. Peels are a great starting point for young people who want to prevent wrinkles, but for my more mature clients, I think the skin rejuvenation is better. The more deeper peels, are generally losing favor due to the down time of 5-10 days. Most of my clients work and that is not something they want to do or can afford to do. We don't even offer it in our centers because we have other laser treatments that work even better without the down time.

For patients with deeper lines or a lot of fine lines, I use our fractional ablative laser, the PIXEL. This is the newest technology to improve skin with minimum down time. The PIXEL uses the same Erbium laser that was used in the past with ablative lasers (the lasers used to peel off your whole skin and made you look like Freddie Kruger for a few weeks. The new skin would be regenerated over time improving appearance) However the down time associated the old lasers was too much and were falling out of favor. This new fractional ablation is great. We can have about 30-150 microns deep penetration in skin with each treatment and causes the formation of new collagen and elastin. This is what fills in the wrinkles resulting in a more even, health look. There is about two days of looking sun burned and two more days of some mild peeling but nothing to stop you from going to work with each Pixel treatment. Most people need about 3-6 treatments for optimal results and then maintenance every 6-12 months. It works for wrinkles, sun damage, melasma, scars, acne, and just overall appearance in skin tone and texture. It

The Pixel's counterpart is the Fraxel. The fraxel uses the same fractional ablation technology but the physician has to buy a whole new system for it (which means to the consumer, a more expensive procedure), a blue dye is placed over the skin to see where it has gone, and is more painful than the Pixel. I think as a consumer you should check out both but for cost and effectiveness, the Pixel is better.

The other things you can do to help reduce wrinkles is the skin tightening laser. Most people use this for the laxity around the jawline and turkey neck. This laser uses infrared technology to heat up the dermis to pull closer the stretched out collagen and elastin fibers, resulting in a tighter firmer look. Most clients need about 4 treatments once per month for optimal results and then a maintenance treatment once every six months.

For patients, who want to try injectables, there are lots of options. Botox is used for lines in motion whether they are on the forehead (your worry lines), the glabella (the frown lines you get when you get mad; also called the 11's), the crow's feet area (the smile lines around your eyes), the smoker lines around the lips, and for depressed mouths. It is a small injection done over these areas using Botulinum A. This weakens the muscle so it can not move but still allows for normal facial movements. It last about 3-6 months. My patients tell me that when they do the PIXEL and Botox, the Botox last longer.

For lines at rest, we use fillers. The most common fillers are Restylane and Juvaderm. Both are made from Hylauronic acid and both last about 6 months. The difference from the two is more what the individual physician and patient feels, thus far. Juvaderm is newer and less information is out on it in the United States. It came from Europe and has an excellent track record there. It uses slightly more hylauronic acid then Restylane and feels softer when applied. It is also the first filler approved for People Of Color. Restylane has a long track record of working well with minimum side effects. It does last about 6 months in average, and most patients require some block to be used before it can be injected. I use both and I prefer Juvaderm because it is easier for me to apply and less painful. I will have to see anecdotal which one last longer!

For the longer fillers, there is Sculptra and Radiesse. Sculptra was approved for HIV lipodystrophy (the thinning of the face from fat loss that is seen in HIV patients) but is now cosmetically used for aging on our thin, hollowed out faces. It is suppose to last about 1-2 years. Radiesse is the longer filler like Restylane and Juvaderm which is suppose to last 1-2 years. I recommend it only to my patients that love the way they look with the Juvaderm or Restylane since it is so long lasting. Patients do complain that it feels hard but not enough to stop anyone from getting it done.

As you can see there are lots of options for wrinkles. To find out which is the best for you, it is best to speak with a professional. Remember, skin care products and healing from the inside are just as important as healing from the outside!

The Most Important Skin Care Products

I meet and see a lot of different patients and each one is looking for that perfect product that will take care of everything. Well, the truth is, that perfect product does not exist, but rather a lot of great complementary products can be used to achieve good results. New skin care products keep coming on to the market but the most important ones that have been shown to make a difference in the literature over and over again, and these products have remained the same. Sure, you can try whatever is new and upcoming, but if you just want to know what the basics are, read on.

Skin care products work if they can change the skin surface or inside of the skin cell. The skin is in a constant state of renewal. A new skin cell forms deep in the dermis and slowly moves up to the skin surface over 6-8 weeks, to slough off. What happens as we age is that the percentage of skin that is renewing and sloughing off, diminishes. Young children (about 10 or so) have beautiful luminescent skin because everything is renewing and exfoliating at 100% like it should. As we age, the exfoliation process slows down, causing the skin to look duller, more uneven, and older. Skin that has problems with it, can also have a disruption in the renewing or exfoliation process exacerbating the skin condition. So at 30 years of age, the percentage of skin that is renewing and or exfoliating drops to about 70%, at 40 this is about 60% or lower; thus causing the skin to look older.

To help the skin look healthier and younger, the skin needs to be exfoliated. Many of my patients are using over the counter products to do this. The most popular items reported by my patients are the St. Ives Apricot Scrub, facials, and the hardest thing used was a scrubbing brush. Unfortunately these may not be the best products because exfoliation is dependent on depth of penetration. These are rather superficial and will not cause true skin changes. The young patient using a scrubbing brush can be injuring her skin even further and causing more damage. I believe in using skin care products that penetrate a little deeper and can cause the skin to rejuvenate as well. These two products have been on the market for some time and work well. They are alpha hydroxy acids and Retinols.

Alpha hydroxy acids are made from edible fruits and vegetables that when fermented become acidic, causing the skin to exfoliate. They are found in many over the counter products under the label AHA. AHA's help with exfoliation and skin rejuvenation thereby reducing fine lines, brown and red spots, even out skin tones, as well as help reduce acne. Some patients will not be able to tolerate them because they have very sensitive skin and it will irritate when applied. Typically, this resolves after a few weeks, but for those patients, it may be more useful to use the next generation of these products which is poly hydroxy acids. They are slightly bigger molecules and penetrate the skin slower, thus are more gentle for that sensitive skin.

What is the difference between over the counter AHA's, the salon grade, and the physician grade products? The difference is in the concentration of the AHA. The higher the grade of AHA, the more pure it is and thus more effective it is. The physician grade is about the same price as the salon grade so do yourself a favor, and buy something that works! You do have to use AHA's for awhile to see a difference and it is great for all ages and even pregnant women!

The next exfoliant is Retinols. This can be Retin-A, Renova, Tazorac, Tretinoin, etc. This is a much stronger product than the AHA because it is more penetrating. It is a great product to use because if you use it over time, greater than one year, it actually intrinisically repairs the skin cell that was damaged with the sun and age, thereby reducing wrinkles, fine lines, brown/red spots, acne, and scarring. Studies show that long term use of Retin-A at 0.1% will reduce the incidence of skin cancer!

The problem with Retin-A is the side effects of peeling and redness. This can be overcome by using a lower strength of retin-a, using an alternative breakdown product, or mixing it with a blender than will soften the delivery of Retin-A. For people who are very sensitive, I recommend starting with 0.025% cream and slowly building up to 0.05%. The goal is to be able to use 0.1% because this is what helps reduce skin cancer formation. The breakdown products such as retinaldehyde are more gentle on the skin and do not cause as much irritation and redness. The blender product is something that works synergistically with Retin-A to penetrate the skin without the same amount of redness. Retin-A should not be used by pregnant and lactating women.

The third product is Vitamin C. Vitamin C is the only product that prevents wrinkles (that's right, I said prevents wrinkles) and brightens the skin. Vitamin C stabilizes free radicals. Free radicals are cells that have become unstable due to a loss of an electron. (Do you remember in physics class how you learned that electrons and protons need to always be together in an atom, otherwise it becomes unstable? The free radical is an atom that has lost an electron). This unstable cell wants to become stable so it steals an electron from the next cell. The next cell now is unstable, and steals and electron from another cell and so on and so on. What Vitamin C does, is it comes by and donates the missing part to stabilize the cell. Vitamin C does not become unstable because it can intrinsically repair itself. Another question patients ask me is if their oral Vitamin C will be enough for them. No, because there is not enough skin penetration unless you did 25 Vitamin C pills daily.

The fourth type of product that helps the skin is lightening gels. These can be hydroquinone, Kojic acid, soy, licorice, etc. They all suppress the melanocytes (the cells that produce pigment) thus there are less darkened areas. Hydroquinone is the strongest of them all but the one that is the most controversial. THe FDA recently banned hydroquinone 2% that was commonly found in over the counter products like Porcelana, Esoterica, Black Opal.

This came after some controversial research showed an increase in cancer in laboratory rodents. This has not been shown in humans. Furthermore, across the world, it is difficult to find for these reasons but also because it was not regulated, patients were bathing in such high doses of 10-20% hydroquinone. (the strongest dose in the US is 4% found in prescription skin creams). At such high levels, patients experienced something called Ochronosis-graying of the skin and reflex darkening of the skin. Unfortunately this came from using such large concentrations for long periods of time. I typically provide a 4% hydroquinone for about 4-6 months and then use as needed. I still use hydroquinone with all the controversy because nothing else seems to work as well. I use hydroquinone in conjunction with other items such as the vitamin c to brighten the skin and retin-a to exfoliate the skin so you need less of hydroquinone then if you used it on your own.

The last item that is important is a total sun block. There are three types of sun rays: UVA, UVB, and UVC. UVC we are thus far protected because of the ozone layer. Once that is gone, we will need protection from that. UVB is a weaker sun ray and does not penetrate through glass. UVB causes sun damage and skin cancer. We are protected from it by using SPF. Using a SPF 15 is great because it will provide you great coverage without adding more chemicals to the skin. However, SPF does not protect you against UVA. UVA has both long and short rays and need to be blocked by using a physical barrier such as zinc, titanium and parasol. The new one on the market is by L'Oreal that has avobenzene.

I realize that this is a lot of information but be smart about what you are using and know what works and what doesn't. Most of these are very complementary to one another and many of my patients use a little of everything so they get less side effects from each product. So use the right products to help you maintain great skin!

Spots and Scars-What to do?

Most people can relate to spots and scars which can occur anywhere on the body. Spots and scars are due to any injury on the skin. It can be from acne, sun damage, an infection (such as a boil, severe dry skin from eczema, psoriasis), skin conditions that causes ulcerations and patches, bug bites, ingrown hairs, picking at the skin, etc. There are so many reasons I can't list them all but you get the picture. The skin got hurt and it left a mark. This happens because when the skin is injured, cells that provide color in our skin the melanocytes become too active and lay down extra pigment. If you have very fair skin, it will look red to light brown. If you have more olive to light brown complexion, it will look light to dark brown. If you have more brown to black skin, it will look more brown to black but darker than your normal skin color always. The medical terminology for this is post inflammatory hyper pigmentation (PIH).

It is important to understand what caused the spot or scar in the first place to understand what treatment is the best. The most important thing to do is stop the injury from occurring in the first place. If it is from acne, we need to treat the acne. For more information on that refer to the acne blog. If it is dry skin or ulcerations, the cause of this needs to addressed and the skin needs to be intact before any other treatment can be started. The most common cause for spots is usually from sun damage and from acne scarring.

What I do for this is start on good skin care products. We need to use products that will exfoliate the skin and lighten the spots/scars. Two items that will exfoliate the skin are alpha hydroxy acids and retinols. The skin cycle which is the renewal of new skin that matures and comes up to the surface of the skin to be sloughed off is 6 weeks long. As we age, the percentage of skin that turns over or exfoliates every cycle begins to diminish. When we are young, most of our skin exfoliates every 6 weeks leaving healthy, glowy skin. As we begin to age or if we have skin problems, this process slows down leaving more dull, irritated skin.

Alpha hydroxy products expedite the exfoliation process to keep the skin looking healthier and younger. Retinols penetrate deeper to exfoliate and if used for over one year with consistency, can actually correct any damaged DNA to leave the skin looking radiant. It does take one year of use at 0.1% strength to achieve this. The typical prescription is for 0.025% or 0.05% only. In fact, studies on transplant patients show a reduction in skin cancer using retinols at high strengths, so I am a firm believer in using Retinols for not only problem skin, but for wrinkle correction and prevention as well as for the prevention of skin cancer. (No, it will not protect you if you continue to be a sun worshipper!) . Using exfoliation products will cause lightening of the spots/scars over time. This does take about 6-9 months to see the results with products alone. Retin-A is contra-indicated in pregnant and breast feeding women.

I also use lightening creams/gel and Vitamin C. Lightening Gels/Creams are from Hydroquinone 4%, which is prescription strength to use two times daily to the affected area. If it is really bad, wait five minutes and reapply it in 5 minutes to get optimal results. Most people will need 3 months to see optimal results. Hydroquinone is contra-indicated in pregnant and breast feeding women.

I love using Vitamin C serum to brighten the skin and it helps prevent wrinkles! It is the only product out there that will do that. Vitamin C must be at the right pH, right molecular structure, and a clear serum for it to work well. There are many products that claim to do a great job but have no studies behind it. Skinceuticals and Obagi have great Vitamin C serums. I like Obagi better because you can use it on the eyes. The eyes are where everyone starts to age and for many of us, this is where dark circles from chronic sleep deprivation, genetics, etc begin. Vitamin C does not make these circles go away, but can soften and blend the color closer to your natural skin tone. I use Vitamin C daily around the eyes and 3 times per week to the full face. My patients always ask me if their oral Vitamin C will work. If you took 25 pills of 500mg of Vitamin C a day then maybe but the one to two pills that people take will not do it. Vitamin C stops free radicals from causing destruction to the skin. The skin does super saturate with it so you do not need to use it everyday, but many people do because they love the way their skin looks. It does take about 3 months to see good results with this as well.

For the treatments of spots and scars, it will depend on how long they have been there, are they indentations or pick marks deep in the skin, and any other conditions you may have. The longer they have been there, the deeper they are. If you have some superficial spots that have been there less than a few months, high strength chemical peels and aggressive medical dermabrasion may work for the face. For the rest of the body, I usually recommend lasers and microderm treatments because the skin is usually thicker and does not respond as quickly.

To understand how deep things are, let me tell you that for acne scarring and pits, that scar mark is about 800microns deep in the skin. The best laser out there penetrates about 150microns so that is why repeated treatments are necessary. Think about an indentation in the skin as a big pot hole in the skin. This pot hole is usually treated in three ways. It can be filled with something temporarily, the skin around it can come down so it looks less noticeable, or it can be filled with new collagen and elastin to be a more permanent solution.

To fill the scar, we can use a filler such as Restylane, Juvaderm, Radiesse or Sculptra. The first two last about 6 months and the latter two, last 1-2 years. You will need to return back to get this filled regularly just like the pot hole does every year. Option two is a resurfacing laser. This is a procedure that requires sedation and down time for a week to 3 weeks depending on how deep they went. The resurfacing laser removes all of the skin and lets new skin grow back. To go back to the pot hole analogy, the whole road around the pot hole got taken off and then it was slowly filled. It does not always fix the very deep scars because they do not get filled. It is rather the skin around it came down so it looks less obvious. The third option is a fractional resurfacing. This uses similar technology as the latter but there is only a weekend of down time and it actually fills the pot hole with new collagen and elastin. It does take time to get optimal results because the marks are deep.

For patients with spots secondary to sun damage-using an intense pulse light or the fractional resurfacing laser are two great options. Once again, the difference is how long has it been there and how deep is it. The deeper it is, the more treatments it requires and the better you will do with the one that penetrates deeper in the skin-the fractional resurfacing laser is my choice.

For scars that come from trauma-bug bites, boils, dry skin, etc, the resurfacing laser is our best treatment. But once again, using the skin care products is complementary to this and it will take time.

Spots and scars are a long topic and cover a lot of different problems. This I hope will at least provide you with some preliminary background to help you understand the choices out there and also to differentiate what people are just trying to sell to you. I really think a lot of my patients with bad scarring will try anything but not everything will work. The best thing to do is do your homework, go and talk to the specialist, see what they offer, see what results they have gotten, and have them answer all of your questions! Make an informed decision and give it a try. I really do think these treatments help soften and blend down spots and scare but people just have such unrealistic expectations of what will happen. It is important to understand that you will not achieve perfection as much as an improvement. [