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ADVANCES IN SKIN CARE, Part I
Timothy J. Mickel, M.D., F.A.C.S.
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Remember when Noxema, Oil of Olay and good genes were the only weapons a woman had to defend her skin from the ravages of time, gravity and the elements? Well this is not true anymore. Skin care has become a billion-dollar industry. Almost every major cosmetic label features a line of skin rejuvenation products that purport to turn back the hands of time. While many contain active ingredients with medically proven benefits, some contain a variety of herbs and spices designed, I suppose, to make you taste as good as you feel.
The occasional "fringe" product notwithstanding, the past several years have seen explosive growth in the number and quality of skin care products available to both women and men. Some are available through physicians only, while others can be bought over the counter. In general, over the counter products have a lower concentration of active ingredients than comparable products obtained by prescription or from a doctor's office. Unfortunately, they don't always cost less. We often pay extra for fragrance, moisturizers, brand name and packaging.
The major topical ingredients with proven beneficial effects on the skin include alpha hydroxy acids, retinoids, bleaching agents, antioxidants and sunscreens. Some of these products, such as the alpha-hydroxy acids, have been around for centuries. Others, such as the antioxidants and retinoids, are vitamin derivatives that have only recently been used topically for skin rejuvenation. This is the first in a series of articles that will examine these topical ingredients, and take a closer look at their medically proven beneficial effects on the skin. We will begin with an agent that I believe should be the cornerstone of every woman's skin health regimen: Retin-A.
Retin-A (tretinoin) belongs to a group of compounds called retinoids. These are Vitamin A derivatives that have been used to treat a variety of skin conditions since the early 1960's. Initially, retinoids were used to treat acne, psoriasis and other benign skin problems. In recent years, researchers have shown that the best known retinoid, Retin-A, is beneficial in reversing some of the skin changes associated with the aging process.
As we age, our skin becomes thinner. The dermis, or deep layer of the skin, contains less collagen than it did in our younger days. Skin also becomes less elastic with age, so while our skin may seem more stretchy as we get older, in actuality, it is much like a worn out elastic waist band that has lost its recoil. Aged skin contains less water, making moisturizers more important. The end result of these microscopic changes is skin redundancy and wrinkling.
Sun exposure accelerates aging changes, and in addition causes significant alteration of the elastic fibers in the dermis. The single best thing you can do to preserve a youthful complexion is to avoid excessive sun exposure. We will discuss sun damage, or photoaging, in a subsequent article.
Fortunately, Retin-A helps to reverse some of the skin changes associated with both normal chronological aging and photoaging. Kligman, a dermatologist, applied medium dose Retin-A (0.05%) to the forearms and faces of thirty sun-damaged volunteers for one year then biopsied their skin and examined it under the microscope. He found that abnormal cells and pre-malignant skin lesions were obliterated. New collagen was formed and there was an increase in the blood supply to the dermis. Other researchers have shown that higher collagen levels in the dermis leads to increased skin elasticity, i.e., tighter skin. More recently, researchers from the University of Michigan noted sustained improvement in skin wrinkling and texture after a 22 month trial of Retin-A. Many other studies from around the world substantiate the beneficial effects of Retin-A on aging skin.
Before you go out and dive into a vat of Retin-A, let me point out a few of its drawbacks. First of all, don't expect immediate results. In fact, your skin will look worse before it looks better. The stronger the concentration of Retin-A the greater the effect and the sooner it will become evident. Maximum effects from Retin-A are generally not seen for 4 to 12 months.
The most common side effect of Retin-A is the so called "retinoid skin reaction", characterized by redness, peeling, itching and a sensation similar to sunburn. This can be quite miserable for the first few weeks of treatment and will make you question why you volunteered to do this to yourself. Your skin will be much more sensitive to the sun while you are on Retin-A, so sunscreen is mandatory. After several weeks the reaction subsides and you begin to enjoy the benefits of younger looking skin.
Most authorities now believe that the benefits of Retin-A are dose dependent and recommend using the highest concentration the patient will tolerate. Night application is recommended to avoid degradation of tretinoin by light and possible inactivation by concomitant use of sunscreens and cosmetics. Application more frequently than once a day is generally not recommended, and after the reaction phase is over (4 - 12 months) the frequency of application can be decreased to two to three times per week.
Retin-A comes in three strengths: 0.025%(weakest), 0.05%, and 0.1%. Renova is 0.05% Retin-A in a heavy oil base. Treatment approaches range from conservative to aggressive depending on the concentration of Retin-A and the frequency of application. The higher the concentration and the more frequent the application, the more intense the reaction phase but the sooner the irritation will subside. Rarely, patients find the reaction phase intolerable and have to decrease the dose of Retin-A, temporarily add a steroid cream, or stop treatment altogether.
Over the years, many plastic surgeons and dermatologists have found that there are several adjunctive products that enhance the effects of Retin-A and can make the reaction phase more tolerable. These include mild alpha-hydroxy acids, steroid creams, bleaching agents to even out pigmentation, gentle skin cleansers, astringents, pH balanced moisturizers and skin toners. At Dermatique, rather than worry about compatibility problems between products from different sources, we use the Obagi Nu-Derm program. This incorporates Retin-A and practically all of the adjunctive products mentioned above into a single skin health and maintenance regimen that can be followed indefinitely. All of the products are built around the same neutral base so they can be used together in any combination without one cream decreasing the effectiveness of another.
The Nu-Derm program allows for individual variability with regard to the dose of Retin-A and the number and concentration of adjunctive products utilized, depending upon patient needs, skin tolerance, etc. Patients must be willing to learn about the products and take an active role in the day to day "fine tuning" of their skin care routine. Of course, the entire staff at Dermatique uses the Obagi program, and they are always available for questions, one-on-one consultation or hand holding during the initial reaction phase.
In conclusion, while Retin-A is not quite the fountain of youth in a bottle, it's probably the next best thing. If you are willing to put up with a few weeks of irritation, the reward will be smoother, younger looking skin that holds up better over time. To learn more about Retin-A and the Obagi skin care program, drop by Dermatique for a free consultation.
