Prevention and Treatment of Actinic Damage

In keeping with the theory of preservation, the most obvious and simplest steps to be undertaken are those of prevention. Topical blocking agents with an SPF of 25 or greater are essential in minimizing UV damage. Short of total abstinence from sun exposure, diligent use of these agents can essentially eliminate solar elastosis. Frequent use of topical cleansers and approved restorative creams containing both high water content and free radical blockers reduce skin damage from ultraviolet radiation. When the damage has shown its first manifestations, early intervention is critical if a youthful skin appearance is to be preserved.

Retinoids

The use of Vit A related compounds (retinol) has been well documented in the dermatologic literature. The most commonly used preparation for correction of actinic damage is Trentinoin RA or "Retin A." Studies have found an increase in collage synthesis of 245 % over baseline in irradiated mice treated with retinoids, with the benefits sustained long after topical application was discontinued. Skin lesions called "actinic keratoses" were obliterated with normal epidermis created in their place. The usual dosage of Retin A is 0.025% to 0.05% cream applied nightly for 8 to 12 months, followed by a maintenance schedule of twice weekly. Applications of up to 0.1% are of even greater benefit if tolerated by the patient. While Retin A in and of itself has shown to be of significant benefit in young, minimally damaged skin, its use is of dramatic benefit in the preparation of more severely damaged skin for deeper resurfacing protocols.

Chemical peels

The precursor of all chemical peeling agents was the phenol-derived peel popularized in this country some years ago. While highly effective in removing wrinkles, phenol peels are also difficult to control, often penetrating up to 1000 microns in depth. This can lead to permanent removal of pigment. The combination of these problems with the potentially toxic cardiac effects of phenol have limited the usefulness of phenol peels for early prevention and preservation.

The two acid based agents which have been shown to allow greater control and lesser depth of penetration are the "alpha-hydroxy" acids ( a.k.a. "fruit" acids), and "trichloroacetic" acid (TCA). Of the two, the fruit acids are available in lesser concentrations, and therefore penetrate to a lesser depth than TCA. Alphahydroxy acids at low concentrations apparently diminish keratinocyte adhesion, while at higher concentrations they cause frank removal of epidermis. Glycolic acid, with its small molecular size, may actually penetrate the dermis and stimulate collagen production. The more concentrated TCA peels have been shown to occasionally produce hypertrophic scarring like the deeper phenol peels. Consequently, they must be used under the careful supervision of the plastic surgeon. Because alphahydroxy acid preparations are available in low concentrations, they are useful for home administration by younger patients. In such a program, they may be useful adjuvants in a maintenance and prevention program.

Skin resurfacing with the laser

The theory of laser light generation is beyond the scope of this discussion, but it is important to note that the resurfacing laser uses a wavelength of light outside the visible spectrum. This wavelength leads to selective photothermolysis of tissues with high water content. Also, its relatively long wavelength makes it an extremely forgiving method, as its depth of penetration is minimal. The skin's high water content makes it an ideal target for this instrument.

Most lasers are relatively high powered instruments which have been employed over the past 25 years as cutting instruments only. The development of the ultra short duration "pulsed" lasers now allows the laser energy to be delivered in a time period less than that needed for the skin to recover. Thus the thermal vaporization of the surface could be accomplished with minimal heat damage to the deeper tissue. The great control of the "pulsed" laser, allows for its use in delicate areas such as lower eyelid skin, where more aggressive treatments such as dermabrasion and deep peeling are contraindicated.

Dermal and subdermal filling agents

The use of bovine "collagen" (animal protein) in the filling out of wrinkles has been widespread. Unfortunately,the effects have proven short-lived for most individuals. The high cost for each treatment and the need for repeated injections, make patient dissatisfaction frequent with this regimen. However, for those who desire a short term "fix", with minimal inconvenience, collagen remains a viable choice.

Autologous fat ( i.e. the patient's own fat) seems to work best when limited to the deep subdermal tissues for treatment of depressions or scars. Its use for superficial correction seems negligible, however, because it, too tends to disappear from the skin. While the early results from subdermal augmentation seem promising in some practitioners hands, there is little statistically significant data to support definitive conclusions. Multiple fat injections can also become costly and are not without risk.