Skin wrinkles and blemishes
As you age, your skin undergoes gradual changes:
Sunlight, Ultraviolet Radiation, and Photoaging
Sunlight exposure is the most important cause of early aging of skin (a process called photoaging). Sunlight exposure is also the main cause of skin cancers. The two types of sun rays that can injure the skin are ultraviolet A (UVA) and ultraviolet B (UVB). Exposure to ultraviolet radiation accounts for most of the symptoms of early skin aging. Much of the damage is underway by age 20:
Processes Leading to Wrinkles. Wrinkles form in the following way:
Other Factors Responsible for Wrinkles
In addition to sunlight, other factors can speed the formation of wrinkles.
Cigarette Smoke. Smoking produces free radicals in the body. These cause wrinkles and age-related skin problems to develop sooner. Free radicals also increase the risk of non-melanoma skin cancers. Studies suggest that smoking and resulting oxidation produce higher levels of metalloproteinases.
Air Pollution. Ozone is a common air pollutant. It may reduce the body's vitamin E level. Vitamin E is an important antioxidant that protects cells against the effects of free radicals.
Three common types of blemishes are liver spots, purpura, and seborrheic keratoses.
Liver spots are also known as lentigos or sun-induced pigmented lesions. They are flat brown spots on the skin. Despite the name, these blemishes have nothing to do with the liver. Instead, they are common signs of aging. Liver spots are most noticeable on the hands and face. They often get larger and darker over time. Their number, sizes, and brownness are determined by skin type, sun exposure, and age. Liver spots are harmless, but they should be distinguished from lentigo maligna, which is an early sign of melanoma.
Liver spots or age spots are a type of skin change associated with aging. The increased pigmentation may be brought on by exposure to sun or other forms of ultraviolet light, or other unknown causes.
Treatment. Liver spots do not require treatment, although some people are bothered by their appearance. Treatments may include the following:
Purpura occurs when tiny blood vessels called capillaries break and leak blood into the skin. In older people, the condition is called senile or actinic purpura and is usually caused by blood vessels that break easily. The capillaries appear as flat purplish patches. These patches are called petechiae when they are smaller than 3 mm (about a tenth of an inch). When they are larger than 3 mm, they are called ecchymoses. Purpura looks like a rash that may appear red at first and gradually turns brown or purple.
Treatment. There is no specific treatment for purpura. Persons with purpura should avoid trauma, including vigorous rubbing of the skin, which may damage the capillaries. Lotions that soften the skin may be helpful. Some doctors also recommend vitamin C, but its effectiveness is unproven.
Seborrheic keratoses are common skin disorders in older adults. Their cause is unknown. These skin growths usually appear on the head, neck, or trunk. They range in size from 0.2 - 3 cm (a little over an inch). They have clear borders and look like they are pasted on the skin. Their appearance can vary widely. They can be:
Seborrheic keratoses are non-cancerous (benign) though they can look like melanoma because of their sometimes irregular border. A dermatologist (skin doctor) can tell the difference. Because melanomas can hide among seborrheic keratoses, they may go unnoticed without close inspection. Seborrheic keratoses have an even appearance, whereas melanomas often have a smooth surface that varies in height, color density, and shading. In some cases, keratoses cause itching or irritation.
Treatment. Seborrheic keratoses can be removed with surgery, laser, freezing, or scraping. Vitamin D3 ointment is also being tested as a treatment.
Exposure to Sun in Childhood. Medical researchers estimate that most skin damage begins in childhood and adolescence as a result of intermittent, intense sun exposure that causes severe sunburns.
Aging. Most people over age 70 have at least one skin disorder, and many have three or four skin disorders. Skin changes are normal as a person ages. But a long life is not the only factor that determines whether a person develops skin problems. Family history, genetics, and lifestyle choices all have an impact on the onset of aging-skin symptoms.
Activities Leading to Overexposure to Sunlight and Ultraviolet Radiation
Exposure to UV radiation from sunlight is the most serious risk factor for skin conditions related to aging. Persons most at risk include:
Doctors classify skin types, also called skin phototypes (SPTs), based on the sensitivity to sunlight. SPT ranges from SPT I (lightest skin plus) to SPT IV (darkest skin). Skin types I and II are at highest risk of photoaging skin diseases, including cancer. Early aging of skin from sunlight exposure can affect people of all skin shades.
The common belief is that women are at greater risk of wrinkles than men. Evidence suggests, however, that given the same risk factors, men and women in the same age groups have the same risks of skin photoaging. Some studies report that men are more likely than women to develop non-melanoma skin cancers.
The skin of smokers in areas of their bodies not exposed to sunlight also seems to age more rapidly compared to nonsmokers in the same age group. Heavy smokers in their 40s often have facial wrinkles more like those of nonsmokers in their 60s.
Smokers tend to have thinner skin, more and deeper wrinkles than nonsmokers. Cigarette smokers are also more prone to skin cancers, including squamous cell carcinoma and giant basal cell carcinoma. Research has found that women who smoke have much lower levels of vitamin E secretions in their skin. Vitamin E is an antioxidant that may help protect the skin from sun damage.
The best long-term prevention for wrinkles and blemishes is a healthy lifestyle and protecting the skin against sun damage.
Eat Healthy Foods. A diet with plenty of fresh fruits and vegetables and whole grains along with healthy oils (such as olive oil) may protect the skin from damage by free radicals. This is because these foods have high levels of antioxidants.
Exercise. Daily exercise keeps blood flowing, which brings oxygen to the skin. Oxygen is important for healthy skin.
Avoid Tobacco Smoke. Smoking increases wrinkles. Quitting smoking prevents many health problems not just unhealthy skin. Exposure to secondhand smoke is also dangerous to overall health and is damaging to skin.
Wearing Sunscreen. Use a sunscreen daily that protects against UVA and UVB rays.
Daily Preventive Skin Care
Daily measures for skin protection include:
Protecting Against Sunlight and UV Rays
An important way to prevent skin damage is to avoid too much exposure to sun and ultraviolet light. Here are some guidelines:
Products and Methods for Improving Skin Appearance
Many products and methods are available to improve the appearance of skin. Some are for home use while others must be administered by a doctor.
Moisturizers help prevent dryness, bruising, and tearing, but used alone they have no effect on wrinkles. Moisturizers are applied when the skin is still damp after washing. These products retain skin moisture in various ways:
Most moisturizers contain combinations of these compounds. They usually have other ingredients, such as alpha hydroxy acid, sunscreen, collagen, and keratin. Collagen and keratin leave a protein film and temporarily stretch the skin, which may reduce wrinkles.
The skin under the eyes is very thin. It does not produce much of the protective oils that keep skin soft and supple. Under-eye products are advertised as being able to reduce puffiness and dark circles. They work in one of two ways:
Follow the instructions on the package about how to use the product. Under-eye products are applied with light dabbing to stimulate absorption of the cream into the skin. Do not rub the cream onto the skin. Rubbing causes wrinkles to form, which over time can become permanent.
Cosmetics can be effective in masking the signs of aging skin, including wrinkles and age spots. Cosmetic can also slow water loss from the skin. Many cosmetics contain sunscreen.
Moisturizer. Apply moisturizers before foundation. If reddish discoloration is extensive or the skin is sallow, tinted moisturizers may be helpful and can be worn alone or under foundation.
Foundation. Caking on make-up causes cracks at the wrinkle lines and increases the appearance of aging. Cover large areas of the face with a moderate-coverage foundation that has a matte or semi-matte finish. Facial powder reflects light and thus minimizes wrinkles. Persons with dry skin should not use facial powder, though.
Correcting Color. When blemishes are especially visible, applying color correctors under foundation can be effective:
Blush. Blushes and color washes can help conceal the spidery network of dilated capillaries on the nose and cheeks. Powder blushes are preferred because they blend easily on top of foundation.
Eyes. Powder eye shadows applied on top of a moisturizer are better than cream-based shadows. Light-colored shadow, applied along the upper eyelid crease and above the iris (the colored part of the eye) is best for offsetting the appearance of deep-set eyes. Slightly deeper shade of the same color can be applied to the lower part of the eyelid and drawn out to the corner.
Lips. Lip-setting cream or facial foundation should be applied before lipstick to help prevent it from bleeding into surrounding wrinkles. A stiff bristle brush works better than a lip pencil. The brush helps keep the lipstick on and prevent it from bleeding. (Some women use the pencil itself for the full lip, which gives color but appears natural.) Make-up artists recommend cream lipsticks instead of matte.
Antioxidant Creams, Lotions, and Ointments
Antioxidants are substances that counter the effects of free radicals. Exposure to sunlight reduces antioxidants in the skin. But these antioxidants can be replaced.
Antioxidant ointments, creams, and lotions may help reduce the risk of wrinkles and protect against sun damage. Unlike sunscreens, they build up in the skin and are not washed away, so the protection may last longer. Selenium, coenzyme Q10 (CoQ10), and alpha-lipoic acid are antioxidants that can be applied to the skin. Evidence of their benefit is limited and more studies in humans are needed. More commonly used antioxidants are described below. Your dermatologist (skin doctor) can tell you which product is right for you.
Vitamin A. Vitamin A is important for skin health. UV radiation leads to vitamin A deficiency in the skin. Topical (applied to the skin) vitamin A products have been researched and approved for treating skin problems due to aging. Products include natural forms of vitamin A (retinol, retinaldehyde) and chemicals related to vitamin A called retinoids (tretinoin, tazarotene). These products help repair skin damage due to sunburn and natural aging, such as fine wrinkles, liver spots, and rough skin. It may take months before the skin shows improvement. Side effects include redness, scaling, burning, and itching, which can be treated with corticosteroid cream. Sunscreen needs to be applied during the day because vitamin A products can cause the skin to be sensitive to sunlight. Warning: Women who are pregnant or think they are pregnant should not use any product related to vitamin A. Oral tretinoin is known to cause birth defects. Topical tretinoin may also cause birth defects.
Vitamin C. Vitamin C, or ascorbic acid, is a strong antioxidant that may also help rebuild collagen. Though there are many vitamin C products, none has been approved as a treatment for age-related skin conditions. Most research on the effects of antioxidants on the skin has used this vitamin. In laboratory studies, vitamin C seems to reduce or even protect against damage to skin cells caused by UV radiation. Vitamin C also seems to help skin cells survive after exposure to UV rays.
Antioxidants Under Investigation for Skin Care. Other antioxidants are being researched for their value in skin protection. Like vitamin C products, none of these antioxidants has been approved as a treatment for age-related skin conditions. Most of these products contain very low concentrations of antioxidants. In addition, the antioxidants are not well absorbed by the skin and have only a short-term effect. New ways of getting the ingredients into the skin may offset some of these problems.
Home Exfoliation: Abrasive Scrubs and Alpha Hydroxy Acid
Exfoliation (resurfacing) is one of the basic methods for improving skin and eliminating small wrinkles. It involves removing the top layer of skin to allow growth of new skin. Home exfoliation methods include simple scrubs and special creams. Strong exfoliation methods may not be suitable for people with dark skin because scarring or discoloration may result. If you are not sure of a product, talk to your dermatologist.
Abrasive Scrubs. These involve using an abrasive material to remove old top layer skin so that new skin can grow. Types of abrasives include sugar or salt grains, ground fruit pits, aluminum oxide particles, and tiny plastic beads (also called polyethylene beads or microbeads). Microbeads are the mildest scrub because the particles are smooth and round. Ground fruit pits and aluminum oxide are the strongest scrubs because their particles have rough edges that may injure the skin. The abrasive material is mixed with a base, often a cream or cleansing fluid. Scrubs can worsen certain skin conditions such as acne or broken blood vessels. Scrubs are also not suitable for sensitive skin.
Topical Alpha Hydroxy Acid and Similar Substances. Alpha hydroxy acids (AHAs) ease the shedding of dead skin cells and may even stimulate growth of collagen and elastin. Natural alpha hydroxy acids include:
Most alpha hydroxy acid products contain glycolic acid. Skin care products are also made from polyhydroxy acids (PHAs) and beta hydroxy acids (BHAs). Research suggests that PHA products may cause less skin irritation than AHA or BHA products.
Acid concentrations in over-the-counter AHA preparations are 2 - 10%. Prescription strength creams contain at least 12% glycolic acid. Glycolic acid peels of 30 - 70% concentration may be administered in a doctor's office. Treatment is done weekly or monthly.
Results of AHA treatment vary. Side effects can include skin burn, itching, pain, and scarring. AHA may increase the chance of sun damage to the skin, even at concentrations as low as 4%. Side effects can last up to a week after a person stops using the product. Experts advise that for home use, AHA concentrations of 10% or less are suitable. AHA peels of up to 60% are available without a prescription. These concentrations should be used only under a doctor's supervision. If side effects occur, stop using the product right away. When using these products, avoid sunlight and use sun protection.
Other Skin Treatments
Copper Peptides. Certain copper-containing compounds may protect skin. This is because copper is an antioxidant. Copper peptides may also help repair skin because it helps the skin grow collagen and elastin. Copper is harmful when there is too much in the body. Follow instructions on the package when using these products. Check with your dermatologist if you are not sure which product is right for you.
Topical Fluorouracil. This is a medication prescribed to treat precancerous and cancerous skin problems. It also seems to improve the appearance of skin damaged by the sun. Problems that may be corrected include wrinkles and spots. The effects may be similar to those of laser therapy.
Epidermal growth factor (EGF). This is a type of protein (or polypeptide). It is being looked at for its role in improving the appearance of aging and wrinkled skin. EGF is found in several “cosmeceuticals,” substances that are thought to provide both cosmetic and therapeutic benefits.
Herbs and Supplements
Many herbal products and supplements are advertised as being healthy for the skin. The Food and Drug Administration (FDA) does not regulate herbal remedies and dietary supplements. Manufacturers and distributors do not need FDA approval to sell their products. Any substance that affects the body's chemistry can produce side effects that may be harmful. Check with your doctor before using herbal products and supplements.
Some natural remedies can cause the skin to be extra sensitive to light (photosensitivity). They should not be used before talking with your health care provider:
Skin resurfacing (exfoliation) is usually done in the office of a doctor, such as a dermatologist or plastic surgeon. The aim of skin resurfacing is:
When deciding on skin resurfacing, discuss the following with your dermatologist or plastic surgeon:
Your age also determines which procedure is suitable:
In older persons, combination procedures may be helpful:
Superficial, medium, or deep resurfacing can be considered. The doctor will ask about your medical history and medicines you take. This is because the different resurfacing methods cannot be done if you have certain medical problems or take certain medicines. For example, a chemical peel cannot be done on persons who have severe liver and kidney disease, HIV, or immune system conditions. It should be avoided in those with open wounds or active infection. Candidates should have proper expectations for results, and be willing to endure some burning or stinging sensations on the face.
After any resurfacing procedure, follow instructions about avoiding sun exposure. Apply sunscreen of SPF 30 to protect your new skin from UV damage.
Chemical peel is also known as chemosurgery. It helps restore wrinkled, lightly scarred, or blemished facial skin. A chemical peel removes the top layers of skin so that the new skin that grows back is younger-looking. The procedure is very effective for the upper lip, but it cannot be done around the eyes. A partial peel is often done along with a facelift. A chemical peel can also be combined with topical antioxidants such as tretinoin and vitamin C.
Your doctor will evaluate your skin type before recommending the type of chemical peel for you. This is because there are different types of acids and peeling methods as well as depth of treatment.
Complications. Complications may include any of the following:
Dermabrasion affects deeper layers of skin than chemical peels. It is often used to treat scars due to acne or injury. For aging skin, dermabrasion is effective for wrinkles on the upper lip and chin, but it cannot be used around the eyes. Some doctors use dermabrasion instead of lasers for darker skin.
Your doctor will determine if your skin type and problem area are suitable for dermabrasion. Be aware that dermabrasion may not completely improve skin problems such as wrinkles and sun damage.
Standard Dermabrasion. Standard dermabrasion uses a rotating brush that removes the top layers of a person's skin. As with chemical peels, dermabrasion removes the upper layers of skin, leaving the underlying layers exposed. After the procedure, the treated skin forms a scab. For full-face dermabrasion, a local anesthetic or general anesthesia may be used.
Microdermabrasion. This is a gentler form of dermabrasion. There are two methods. One uses a handheld device that streams tiny crystals to polish the skin. An attached vacuum removes the used crystals and exfoliated skin. Another method uses a handheld device that has a diamond tip and an attached vacuum.
Results of microdermabrasion are similar to those of light chemical peels. Mild redness occurs after treatment. For best results five or six treatments may be needed every 1 - 2 weeks.
Follow your doctor’s instructions about how to take care of your skin after you go home. Doing so helps your skin heal and prevents complications such as infection.
Complications of dermabrasion may include any of the following:
Lasers are an effective tool for eliminating wrinkles. One advantage of lasers over other resurfacing methods is their ability to tighten the skin. A successful procedure can make patients look 10 - 20 years younger, and the results can last for up to 10 years.
The procedure helps most around the eyes, nose, and mouth, and can also be done on the neck. Laser therapy can also be effective for acne scars that are widespread on the face.
When used alone, laser therapy may not completely eliminate crow's feet and other wrinkles, broken blood vessels, or dark circles under the eyes. Therefore, some doctors combine different laser techniques depending on the skin problem. Other treatments, such as dermabrasion, may also be combined with laser treatments. (A laser and dermabrasion combination is called lasabrasion.) Pretreatment with botulinum toxin injections before laser resurfacing, for example, may also improve the treatment of crow's feet.
Standard laser dermabrasion is too harsh for thinner skin layers such as on the neck. Gentler laser techniques, however, stimulate collagen without removing skin layers and may be useful for necklines.
Laser resurfacing is not recommended for persons with very sensitive skin and who cannot tolerate the necessary medicines and skin lubricants.
Choice of Lasers. The laser technology and source of laser beam used depend on the skin type and severity of the condition. These technologies can be combined for different areas of the face and are used to treat a variety of skin conditions:
Ablative Laser Resurfacing Procedure. The procedure works in the following way:
Recovery. The redness and irritation that occur during the healing process can be severe. Laser resurfacing that only removes thin layers of skin does not have the same severe after-effects as other laser treatments. For 8 - 9 days, the face looks skinned and swollen. During this time, continuous moisturizing and gentle washing is needed to prevent infection. Redness and sensitivity can last for 1 - 4 months. Exposure to sun must be avoided as much as possible during this time and in the future to prevent further skin damage. Sunscreen of SPF 30 should be applied daily.
Complications. Risk of complications from ablative laser resurfacing depends in part on the surgeon's experience. Scarring and infections develop in about 1% of procedures. People with a history of herpes simplex may experience flare-ups of fever, facial pain, and flu-like symptoms for 5 - 6 days after the procedure. Persons with darker skin may need to avoid the procedure, because it can cause changes in skin color or uneven skin color.
Other Exfoliation Procedures
Thermal Resurfacing. This method is also called cold ablation, or coblation for short. It is used mainly for early wrinkles on the forehead or around the eyes or mouth. Coblation uses radiofrequency energy. This energy is a much lower temperature than that of laser energy. Coblation heats the deeper layer of skin. This causes the collagen to contract, improving the appearance of wrinkles.
Intense Pulsed Light. Intense pulsed light (IPL) uses filters to deliver different wavelengths of light to the skin. IPL is used to treat a number of photoaging skin problems, and it appears to have long-term effects. Typically, four to six treatments are performed over a 4-month period. Each treatment takes 15 - 20 minutes. Unlike laser light, which uses one color wavelength (such as green or red), intense pulsed light starts with a full spectrum of light. The doctor can then block off specific wavelengths depending on how shallow or deep the treatment.
Injectable Skin Fillers
Injectable skin fillers are a common means of reducing wrinkles and folds. Fillers can also be used for depressions under the eyes as well as acne and other scars. The procedure usually involves using a tiny needle and syringe to inject the filler material under the skin of the area to be treated. The aim of fillers is to replace tissue volume that has been lost due to aging or illness. For example, fillers are used to enhance the lips to make them fuller. The process is also referred to as soft tissue augmentation.
Skin fillers are made of different materials. Some materials come from natural or human sources, such as fat taken from another part of your own body. Other materials are manmade (synthetic) such as silicone. Hyaluronic acid, derived from rooster or bacterial sources, has become one of the most widely used temporary fillers, lasting 6-9 months. It is compatible with all tissue types and does not require a skin test.
Filler types can differ by placement, or how far into the layers of the skin it is injected. Depending on how long the effects last, fillers are also divided into temporary (<6 months), long-lasting (6 months - 2 years), semi-permanent (2-5 years), and permanent (>5 years) types. There are over 20 fillers approved for use in the U.S., and the list of options continues to grow.
Complications. Skin filler injections are generally safe and effective. If there are complications, they usually go away. Your doctor can tell you the risks and complications of the specific filler that is recommended for you. In addition, a skin test can be done before the procedure to make sure you do not have an allergy to the product. In general, complications of any skin filler may include:
Botulinum Toxin Injections
Botulinum toxin (Botox, Myobloc) is used to smooth wrinkles that are formed over the years by muscles that are active when you make facial expressions. Forehead furrows, frown lines, and crow’s feet are the kinds of wrinkles that botulinum treats successfully.
Botulinum toxin is a substance made by a bacterium. Botulinum toxin is purified before it is used for cosmetic purposes. Botulinum causes muscles to relax. To smooth wrinkles, tiny amounts of the substance are injected where the muscles contract. This blocks the muscles from contracting thus reducing wrinkles or even causing them to disappear. Botulinum will not keep you from making normal facial expressions. It only relaxes the muscles that link to the wrinkles that are being treated.
Botulinum is recommended for persons 30 - 50 years old, whose wrinkles are just starting to form. Botulinum does not work for deep wrinkles, which are common in older persons.
Improvement is noticed about 1 week after the injections. Injections need to be repeated every few months because the effects wear off. Repeated use is safe and effective.
Before treatment, tell your doctor if you are allergic to eggs because botulinum is prepared with an egg base. Warning: Pregnant women should not receive botulinum toxin injections.
Complications. Botulinum toxin injection is generally safe and effective. Your doctor can tell you the risks and complications of botulinum injections. If there are complications, they may include any of the following:
Cosmetic surgery is surgery done to improve a person’s appearance. Aging causes the skin and tissues of the face to lose firmness. As a result, the skin and tissues sag, causing wrinkles. Cosmetic surgery can correct such wrinkles. Main types of cosmetic surgery for wrinkles of the face and neck are facelift, forehead lift, and neck lift.
Facelift surgery is also called rhytidectomy (rhytids means wrinkle). Degree of improvement after surgery depends on many factors, including age, bone structure, skin type, and lifestyle habits such as smoking and sun exposure. You and your doctor will discuss the areas you would like improved. Be sure you understand the amount of improvement to expect after surgery.
The Procedure. Simple facelift surgeries are done in a doctor's office under local anesthesia. More involved surgeries are done in a hospital under general anesthesia. The facelift procedure may be one of the following:
Your doctor can tell you which procedure is appropriate for you.
Recovery. Recovery lasts several weeks to several months. With endoscopic facelift, scarring is minimal and recovery is usually faster than with the SMAS procedure. With either procedure, swelling and discoloration are common. There may be tingling or numbness, which go away as damaged nerves regenerate. To speed healing, your doctor will likely instruct you to avoid activity for a few days. You may also be told to keep your head elevated on pillows while lying down. This helps reduce swelling. Follow any other instructions on how to care for yourself at home. Keep all follow-up appointments.
Complications. Complications are rare, especially with a skilled surgeon. But the more complex the facelift, the greater the risk of complications. Complications may include any of the following:
Forehead lift is also called brow lift. This is surgery that improves wrinkles on the forehead, including the horizontal wrinkles and vertical wrinkles between the eyebrows. It can also improve crow’s feet wrinkles at the outer corners of the eyes.
Surgery can be done using long incisions (open procedure). Or it can be done using smaller incisions (endoscopic procedure). These procedures are described above under facelift. Forehead lift can be performed alone or along with other cosmetic procedures such as blepharoplasty (eyelid surgery).
Recovery and complications are the same as for facelift surgery.
Wrinkles that appear on the neck during aging are due to sagging skin and muscles and excess fat. Surgery can reduce neck wrinkles and improve the overall appearance of the neck.
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