From: PM (pm2800@hotmail.com) Subject: Anti-Aging Skincare FAQ, ver 4.1 Newsgroups: alt.skincare Date: 2004-10-22 14:55:09 PST Anti-Aging Skincare Frequently Asked Questions, Version 4.1 Revised October 2004 Posted to alt.skincare Author code 91587355
| This FAQ may be reproduced if it is referenced as the Anti-Aging Skincare FAQ, version 4.1, posted to alt.skincare. |
| This FAQ provided in its entirety unedited by Janssen Cosmeceutical Treatments Please visit our website at Janssen-Beauty.US |
Most people start seeing aging effects in the skin by their late 30s. Over the years you may also accumulate scars from cuts, scrapes, and burns. This FAQ answers common questions about how to slow skin aging and improve the appearance of aged or scarred skin. The information applies to both men and women. It does not cover cosmetics, injected fillers or Botox (botulism toxin). It does not cover plastic surgery procedures, except for skin resurfacing and scar revision. Rather, it deals with products and medical procedures that can improve skin structure. It is based on a review of medical research, dermatology textbooks, popular skincare books, Internet consumer reviews and personal experience.
The pharmaceutical information and product brand-names are for customers in the USA. Products with the same active ingredients are obviously available in other countries. Brand-name products from the same company will often have slightly different names in different countries. If a generic version of a prescription product is available from your pharmacist, it is simply identified by the active ingredient name. For example, the active ingredient in the brand name product Retin-A is called tretinoin. Generic versions usually cost much less than brand-name products. Prices for the products mentioned in this FAQ, in USA dollars, were current as of the revision date. The information on importing prescription products into the USA under the FDA regulations should not be considered legal advice and should be used only at the reader's own risk.
This FAQ does not constitute professional medical advice. Most internal
medicine specialists and general practice physicians can provide you with
basic medical skincare information, but for specialized advice and procedures
you should consult a dermatologist or a nurse or physician-assistant who
specializes in dermatology. Plastic surgeons also understand skincare and do
procedures such as resurfacing and scar revision. The information about
medical professionals and cosmetologists in this FAQ applies to the USA.
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The outer layer of the skin is the epidermis, and the next layer is the dermis. The epidermis, which is generally less than a millimeter thick on the face, is constantly being regenerated as surface cells are shed. As epidermal cells are pushed to the skin surface, they become flattened, and a hard protein called keratin is formed in them. The thicker dermis under the epidermis contains collagen and elastin fibers that give skin its elasticity. The pores contain fine hairs and secrete sebum (skin oil) to keep your skin moist. Sweat glands open onto the skin surface to cool the body in high temperatures. Both the pores and sweat glands are sources for new cells that spread out on top of the dermis to form the epidermis. The appearance of your skin is governed by the condition of both the dermis and epidermis.
As we age, changes occur in the structure of the skin that affect its appearance. The dermis becomes less elastic and the epidermis becomes thinner. Because of these changes, wrinkles and fine lines develop, pores appear larger, and the surface texture becomes more coarse. Dynamic wrinkles, which are caused by making various facial expressions over the years, become more prominent. Discolorations also often appear. Some of these changes are cause by intrinsic cellular aging, but most are caused by extrinsic damage from sun exposure (called photoaging or photodamage). Solar ultraviolet light damages all types of cells in the skin and can also cause skin cancer. Dark-skinned people usually have much less photoaging because the melanin pigment in their skin partially blocks sunlight from reaching the lower dermis. The best-looking skin most people have is in areas without much sun exposure - under the arms, on female breasts or on the rear. Note that you probably haven't been using any special cleansers or expensive skincare products on these areas, and the skin there still looks like a baby's.
The dermis can also be damaged by injuries. If a wound penetrates deeply into the dermis, thick, uneven scar collagen can form as the wound heals. This produces a raised scar. If a wound causes significant tissue loss in the dermis, a pit or depressed scar may form. Burn scars can have an irregular appearance with both raised and depressed areas.
While the condition of the dermis is reflected in wrinkles, lines and scars, the condition of the epidermis affects the surface texture of your skin. Generally, the best appearance is produced by a thick epidermis. A thicker epidermis also tends to minimize the appearance of pores and depressed scars. However, if the epidermis grows abnormally or is excessively dry, the skin can appear rough or scaly. At the other extreme, stripping off the upper epidermal layers with excessive scrubbing or over-use of cosmetic acids can temporarily produce an uneven surface texture and increase the size of the pore openings. Scraped or burned areas sometimes have a thinner epidermis, even after complete healing.
You should not expect the texture of the epidermis to be porcelain-smooth. The openings of the pores and sweat glands cause small indentations, and there are small ridges covering the surface. Many people have a false sense of how smooth adult skin should appear because they see models and celebrities who seem to have perfect skin in magazine photos, on TV and in movies. Only children or people who have generally avoided sun exposure have this type of skin. Most close-up magazine photos are touched-up to smooth skin texture, and both men and women wear a lot of makeup on TV and in the movies. (There is a Net site with candid photos showing that many celebrities have the same skin problems as everyone else.) Even politicians and news-people wear a lot of makeup on TV. Special camera lenses, filters, lighting, and digital image processing help to hide wrinkles and rough skin. A recent magazine article and companion network news report had an interview with a famous actress who showed exactly how her skin was "cleaned up" for magazine photos with computer software. Remember too, that after about age 50, many celebrities have facelifts, which stretch the skin and make the surface appear smoother than normal (often unnaturally smooth, with a stretched appearance ).
Based on skin anatomy, we can say that a true anti-aging skincare treatment will produce one or more of the following effects:
Scientific research has identified a variety of factors that affect extrinsic and intrinsic aging of the skin. Many of these factors are controllable by simply modifying your behavior and diet. This section covers ways to prevent skin aging, and the following sections cover ways to treat it.
Avoiding sun damage is the most effective thing you can do to prevent aging of your skin. The sun is a huge nuclear fusion reactor, producing not only visible light and heat, but also intense ultraviolet (UV) light that can damage your skin. Sunlight is the major cause of extrinsic skin aging because it damages collagen and elastin, and produces abnormal changes in other cells. Doctors call aging due to sun exposure photoaging, that is, aging produced by light. While photoaging is usually described as a cosmetic problem, it is also a serious health concern since it can lead to skin cancer. Unfortunately, apart from dermatologists, many healthcare providers don't warn their patients adequately about the risks of sun exposure.
Everyone is susceptible to photoaging, even people with dark skin. Though more skin pigment reduces sun damage, the intensity of sunlight and cumulative exposure will eventually cause photoaging in people of all skin colors. In light skinned people, tanning is actually the body's defensive response to sun exposure, producing more melanin (skin pigment) to protect the skin. However, this is a very weak defense, and tanning doesn't adequately protect the skin from sun damage.
The majority of visible skin aging occurs in the face, because it is regularly exposed to the sun. If a person were able to avoid sun exposure their whole life, their face would have few wrinkles and discolorations, even in old age. Some old people who have had little sun exposure look remarkably youthful. The body of a 60 year-old person who exercises regularly and eats right can look as good as that of an average 40 year-old; the same could be true of our faces if we avoided sun exposure. So if you want healthy skin, you need to stay out of the sun, or cover up with clothes, a brimmed hat, and a broad-spectrum UVA/UVB sunblock. This is very important for children and teenagers too, because sun damage is cumulative. Don't use tanning beds; they are only slightly better than baking in the sun. (Despite what tanning salons say, any wavelength of UV light that causes your skin to tan also damages the skin.) If you go swimming, use a beach umbrella when you are out of the water. If you wear very light-weave clothing in the summer, you should apply sunblock underneath, because the fabric may only partially block the sunlight. Wear good-quality UV-blocking sunglasses, since sunlight can damage your eyes and the delicate skin around them. Also ask your optician for UV-blocking lenses if you wear clear prescription glasses.
In this FAQ, I use the term "sunblock" to refer both to products that reduce UV light exposure by reflecting or blocking it (such as those containing titanium dioxide and zinc oxide) as well as chemical sunscreens that absorb UV light. Either of these products work well, however some dermatologists prefer the products with titanium dioxide and zinc oxide because they are less likely to cause any irritation.
Modern sunblocks are true anti-aging products because they prevents sunlight from damaging your skin. However, older "suntan lotions" didn't do a very good job of blocking UV rays, so many middle-aged and older people have skin photodamage, even if they used these products in their youth. Today there are all sorts of very effective sunblock products available from very light gels for daily use, to thick waterproof creams for swimming. (Avoid daily use of sunblocks containing alcohol, which can irritate your skin.) Look for a sunblock that is labeled for both UVA and UVB protection. (UVA and UVB refer to different wavelength ranges of solar ultraviolet light.) It is best to buy brands that have an expiration date printed on the label or bottom of the bottle, since most sunblocks lose potency over time. If you wear makeup, try to find a product line that incorporates sunblock in its products .
Follow the the directions on the sunblock label. Most sunblocks require a number of minutes before they start working, and you need to reapply them after a certain period of time. Some sunblocks may stain clothes, so you should apply some to a similar scrap of fabric and let it sit overnight to check. If you are going to be in the sun for an hour or more, you should use sunblock with a sun protection factor (SPF) of at least 15. Higher values will allow you to stay in the sun longer, but they also expose your skin to higher concentrations of the various sunblock chemicals - some of which may irritate your skin. SPF ratings are a measure of how long the sunblock lasts on your skin, not a measure of "blocking power." So higher SPF values are appropriate if you are going to be in the sun for many hours and don't want to apply more sunblock later. However, if you sweat a lot, you should apply more sunblock after an hour or two no matter what the SPF value.
You should use sunblock on all exposed areas of skin when you are outside. Some people forget to apply it to their hands, ears, and neck. You should also use sunblock lip-balm for your lips, which are very susceptible to sun damage. Be sure to cover your nose well with sunblock, because its angle causes it to receive more intense sunlight during mid-day. (The worst photoaging many people have is on top of their nose.) Sunblock should be used year-round and also on cloudy days, because even diffuse sunlight causes damage. People who live at high altitude should always use sunblock and cover up as much as possible when outside because the intensity of UV light is higher there. High-altitude areas have higher skin cancer rates. Mountain climbers and skiers should shade or cover their faces as much as possible with brimmed hats, wrap-around sunglasses or goggles, nose shields (see bekogear.com), or facemasks.
It is becoming less fashionable for light-skinned people to have a dark tan because of its association with skin damage. However, if you want a tan, today there are many self-tanning lotions that will temporarily dye light skin to various shades of brown. They are much better than older products that produced an orange color. Note that these are not sunblocks, and the dyed skin doesn't provide any sun protection. However, they should be used sparingly, because the active chemical in them, dihydroxyacetone, could be harmful to your skin in high concentration.
If you smoke, quit. This includes marijuana and other smoked drugs as well as tobacco. Doctors say smokers have much worse skin than non-smokers. The toxins in all types of combustion smoke damage skin cells and diminish blood flow to the skin. A medical study showed that smoking was strongly correlated with a much higher incidence of facial wrinkles.
Limit your consumption of alcohol. A medical study showed that heavy alcohol consumption was strongly correlated with a variety of skin diseases and blood vessel abnormalities. Heavy alcohol consumption has adverse effects on nutrition and immune functions, which also affect the skin.
Don't use illicit street drugs. They may contain contaminants and toxins that can damage your organs, including your skin.
There is scientific evidence that diet influences intrinsic aging of the body, including the skin. Healthy immune and cardiovascular systems may prevent skin abnormalities. Both of these systems are improved by a diet rich in fruits, vegetables, low-fat protein, unsaturated fats and low in simple carbohydrates, sugar, and saturated fats. One recent medical study confirmed that healthy skin appearance was correlated with a diet similar to this. You should also avoid processed foods with "partially hydrogenated vegetable oil" or "vegetable shortening" (called trans fats) in the ingredients list; they can clog your arteries. (Liquid vegetable oils, such as olive oil, canola oil, and soybean oil are better for you than trans fats.) Trans fats are in many processed foods sold at grocery stores including many brands of margarine, peanut butter, cookies, crackers, pastries, and bread. Avoid junk- food like chips, candy, and sodas.
Animal studies indicate that cellular aging processes may be slowed down by restricting your daily caloric intake. It is theorized that caloric- restriction lowers the production of free radicals (unpaired electrons) and reduces circulating blood glucose, both of which can damage cells. This is another reason to eat more fruits and vegetables, and reduce your consumption of simple carbohydrates and sugar, which are high in calories and increase blood glucose levels. Simple carbohydrates include foods made from refined grains like sugary breakfast cereals, cakes, white pasta, and white bread. Foods like this which significantly increase blood glucose levels are said to have a high "glycemic index." You can find lists of foods and their glycemic indices on the Net and in some diet books.
Vitamin and mineral supplements that contain the recommended daily allowances (RDA) provide necessary nutrients for skin health. The RDA levels are based on numerous scientific studies. However, large doses of supplements well above the RDA can be harmful, particularly for people with certain diseases or pregnant women. Despite what you may have seen in advertising, scientific studies have not shown that high doses of vitamins and minerals above the RDA prevent disease or slow aging. You can find lists of the RDA online for both vitamins and minerals. The labels on supplement products list the percentages of the RDA. There are products available that contain the full RDA for most vitamins and minerals, so you only have to take one pill per day. If you eat a good diet of mostly fruits, vegetables, low-fat protein, and some whole-grains, you will get most of the RDA in your food; so you may only need to take a pill once per week to get all the nutrients you need.
Moderate exercise strengthens the cardiovascular system, which is important for skin health. If you have a sedentary job, try to do some sort of vigorous aerobic exercise for at least 30 minutes, three times a week. Simply walking at a brisk pace for 45 minutes, five days a week can give nearly the same benefit. Moderate strength training with weights two days per week is also beneficial. For anti-aging benefits, exercise should not be continued to exhaustion. Scientific studies have found that very strenuous exercise greatly increases the production of free radicals and may accelerate other aging processes in cells. Elite endurance athletes and bodybuilders don't age any slower or have fewer wrinkles than people who exercise moderately, and in fact, they may age faster.
You should also get in the habit of checking your skin periodically. There are many types of growths and discolorations that can develop on the skin with aging. Check your skin all over with a hand mirror every few months. Look for any odd bumps, discolorations, or changes in a mole. Many people dismiss all developing marks on their skin simply as "age spots". While most growths are benign, some are skin cancer. Your doctor can give you a brochure showing the most dangerous types of lesions to look for; there are also pictures on various dermatology websites. A quick appointment to have your regular doctor or a dermatologist check a spot could save your life. While all skin cancers must be removed surgically, usually this is inexpensive and relatively painless if it is caught very early while it is still small. If you wait even a few months, some types of skin cancer can kill you. Even with a benign growth, waiting until it gets larger will result in a larger scar when it is removed. If you have it removed early, usually there will be only a tiny scar after healing.
Your doctor can also explain the various types of benign lesions to you and
recommend treatments. Benign, raised growths can be removed surgically and
the skin stitched if necessary. Benign, flat discolorations can be treated
with bleaching creams, alpha-hydroxy acids, retinoids (such as Retin-A),
freezing, curetage (scraping), or resurfacing (chemical peeling, dermabrasion,
or laser). Low-concentration hydroquinone bleaching creams and alpha-hydroxy
acids can be purchased without a prescription at most drug and discount
stores. You can alternate nightly use of both products. However, you should
see a doctor first to make sure the spots are benign. He or she can also
prescribe stronger bleaching creams and Retin-A or you can alternate use of
a strong prescription bleaching cream and an alpha-hydroxy acid. You must use
a sunblock when outside during the day while treating dark spots, and in the
future, or they may show up again.
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Currently, the most-studied topical anti-aging treatment is prescription tretinoin (with brands Retin-A, Retin-A Micro, Renova, Avita, or generic). Tretinoin is also called vitamin A acid or retinoic acid; but it is a different chemical from regular vitamin A - one form of which is called retinol. A prescription is required for tretinoin because it produces significant changes in the structure of the skin. Tretinoin was developed many years ago and is often prescribed for acne because it reduces sebum build-up in pores; but a large number of peer-reviewed medical studies done since the early 1980s also show that tretinoin can also improve fine lines, skin texture, and uneven pigmentation. Tretinoin may also improve the appearance of large pores and some scars. It is has been shown conclusively that tretinoin acts to improve collagen in the dermis, thicken the epidermis, and smooth the skin surface. The effects are modest with most people, but a few people achieve significant improvement. For medical studies, see for example "Treatment of Photodamage with Topical Tretinoin: an Overview", Journal of the American Academy of Dermatology, 36(3 Pt 2), S27-36, 1997 Mar; "Short- and Long-Term Histologic Effects of Topical Tretinoin on Photodamaged Skin," International Journal of Dermatology, 37(4), 286-292, 1998 Apr; "Treatment of Photoaged Skin With Topical Tretinoin," Skin Pharmacology, 6 Suppl 1(), 78-82, 1993; and "Topical Tretinoin Improves the Appearance of Photo Damaged Skin," Australasian Journal of Dermatology, 35(1), 1-9, 1994 (abstracts available free online using the medical index Medline at the National Library of Medicine, and at many other medical websites).
Tretinoin and related chemicals, called retinoids, are some of the most important discoveries in dermatology. In addition to tretinoin, other retinoids are available for treating various skin conditions including adapalene (brand-name Differin) and tazarotene (brand-names Avage and Tazorac). Adapalene is used for acne, and tazarotene was originally used mainly for psoriasis and acne. Currently, there are no published medical studies on adapalene as a treatment for photoaging, but tazarotene has been shown to be effective for this, though it may cause more irritation than the tretinoin. See for example, "Tazarotene Cream for the Treatment of Facial Photodamage," Archives of Dermatology, 137(12), 1597-1604, 2001; and "Efficacy of 0.1% Tazarotene Cream for the Treatment of Photodamage: A 12-Month Multicenter, Randomized Trial," Archives of Dermatology, 138(11), 1486-1493, 2002 Nov (abstracts available on Medline). Results indicate that improvement with 0.1% tazarotene is comparable to 0.05% and 0.1% tretinoin. Tazarotene may work better than tretinoin for some people. Tazarotene is not yet available as a generic in the USA, and the brand-name products Avage and Tazorac are more expensive than generic tretinoin. Other studies may be done to compare the effectiveness of tazarotene to tretinoin for photoaging. You can do a combined search on both words using Medline to check for these studies.
Ortho Pharmaceuticals has published before-and-after photos from the tretinoin medical studies online and in magazine ads that show significant improvement in fine lines and discoloration for some of the test subjects. However, these probably show the best results; most people will have less improvement. In the clinical trials, which lasted from six months to one year, approximately 65% of the test subjects had some noticeable improvement in fine lines and discolorations, and 51% had improvement in skin texture. While the improvement was modest with most test subjects, nearly all showed improvement to their skin under microscopic examination. Net reviews of tretinoin are almost all positive, though people with sensitive skin often complain of peeling and irritation when using the higher concentrations. The results of the medical studies and anecdotal evidence from doctors over the years show definitively that tretinoin is an effective topical treatment for moderate photoaging. However, it is not a wrinkle cure, and it cannot stop or reverse the aging process.
Initially, there was some controversy about tretinoin. It's effects were wildly exaggerated in the media, sometimes with help from doctors. Then the initial manufacturer got into trouble with the FDA in the USA for promoting tretinoin as a prescription wrinkle treatment before it had been approved for that use. Also, many people experienced irritation with some forms of tretinoin. Because of all this, you don't read nearly as much in the media today about tretinoin. Another problem is that now only one brand of tretinoin cream called Renova can legally be advertised in the USA as a treatment for photoaging, though all forms contain the same active chemical. (This is an unfortunate consequence of FDA regulations.) However, doctors can also legally prescribe any other brand of tretinoin for general skin improvement, though this is called an "off-label" use if you don't have acne.
Most of the studies showing skin improvement with tretinoin have been done with a 0.05%-concentration formula. However, many people find that regular 0.05% tretinoin cream initially causes peeling and redness. They often give up on tretinoin because of this. To avoid this possibility, it is best to start out with a tube of 0.025% cream. Initially, apply only a tiny amount to your face at night and check for peeling and redness the next day. You can use moisturizer during the day if necessary. Work your way up gradually to no more than a pea-size amount nightly for the whole face. Apply it evenly by first dabbing your forehead, cheeks, and nose. You can also apply a small amount to any other areas that have received a lot of sun exposure such as your ears, neck, chest, back, arms and hands. (Apply it only lightly to the ears or you will get a lot of peeling.) You can apply it to the fine lines around your eyes, but be careful not to get any in your eyes or it could irritate them (flush them with water if you do.) It is very important not to use tretinoin during the day because exposure to light, especially sunlight, will decrease its potency. You should apply it at least a half-hour before sleeping so it is fully absorbed and won't rub off on your pillow. Don't apply other products to your face at the same time, since they could inactivate the tretinoin.
The regular tretinoin creams are appropriate for most people because they are very light, and don't contain oil. However, if you find the 0.025% cream too irritating, you can try Ortho's 0.02% or 0.05% Renova brand products, which are thicker, emollient creams for dry or sensitive skin. If you have no problems with the regular .025% cream, your doctor can next prescribe the 0.05% cream. People with more skin oil may be able to use the 0.1% cream or 0.1% Retin-A Micro, which is a special time-release formula usually used for acne. There is also a 0.025% gel that is more potent than the creams. The gel does not spread as easily as the creams, and it contains a significant amount of ethyl alcohol (or ethanol), which can be irritating. The gel usually works better than the creams to treat acne and clogged pores. A very potent 0.05% alcohol-based liquid is also available, but most people find it too irritating, and it is easy to accidently spill it.
Remember, you must be patient with tretinoin. While microscopic changes start immediately, it takes about three to six months before you will see any visible improvement in the mirror. After six months, typically you will start to see that deep wrinkles are reduced slightly in depth, fine lines around your eyes are less noticeable, and your skin will feel smoother and firmer when you wash your face. Maximum results are achieved after 12-24 months of nightly use (depending on concentration), and after that you only need to apply it two or three days per week for maintenance. If you stop using tretinoin, the skin will gradually regress. You may want to take before-and- after, close-up photographs of your face to check your progress. People who don't do this often greatly underestimate their results, because the effects of tretinoin are gradual and generally modest. The gradual nature of its effect may be one reason why tretinoin is not used by more people. Even if you are one of those people who does not see significant improvement in the mirror, tretinoin will improve your skin on a cellular level, and can slow down the development of lines, wrinkles, and discolorations in the future. Doctors have found that some people achieve better results using tretinoin and cosmetic acids on alternate nights (discussed below).
With a prescription, you can buy a 45 gram tube of generic tretinoin (0.025% gel or 0.025%, 0.05%, 0.1% cream) at pharmacies for between $50 and $75. This is obviously very expensive, but a 45 gram tube will last at least three months. Only a pea-sized amount is used for the whole face. 20 gram tubes cost between $25 and $40. Some generics and foreign brands may be available in 60 gram tubes. Usually, the larger tubes are a better value per gram. Note that the other effective retinoid, tazarotene, currently costs about $60 for a 30 gram tube. Prices on tretinoin vary widely at pharmacies, so call around for quotes when you get your prescription. Mail-order pharmacies may be less expensive. (Check the consumer websites for recommended mail-order pharmacies.) The Avita brand and generics cost less, but some pharmacies may only carry one concentration in a generic. The Ortho Retin-A, Renova, and Retin-A Micro brands are more expensive. If you are on a low budget, get a prescription for a large tube of the highest-concentration 0.1% generic cream and use only a water-drop-sized amount for your face. You can spread it easier by moistening your face first with a little water. You can make the tube last a whole year this way.
It is possible to buy tretinoin over the Net or by mail from foreign sources at much lower cost than in the USA, but beware that you could get product of dubious quality. There are some reputable Canadian and British mail-order pharmacies which have low prices and quality brands. There is more risk of counterfeit products or shipping losses when buying from countries others than the USA, Canada, and Britain. You can check various consumer websites for Canadian and British pharmacy recommendations. Some of these pharmacies also have websites. Depending on the pharmacy, you will have to mail or FAX them your prescription, or simply give them your doctor's name and address. Beware however, that anyone can set up a P.O. box or website and call themselves a pharmacy, so check them out first. With any mail-order pharmacy you should use a credit card, rather than a check or money order, to protect against fraud. (You can contest the charges on your credit card if your order is not sent.) Also, never use any mail-order pharmacy that asks for your social security number. It is not required by any law and could be used fraudulently.
Some pharmacies in Mexico also sell various brands of tretinoin without a prescription. However, there have been cases of counterfeit pharmaceutical products being sold in Mexico, so examine the box and the tube carefully. All the printing should be clear, and obviously words should not be misspelled. Unless it is a generic product, both the brand-name and the generic name "tretinoin" should be on the tube and box. The concentration (0.025%, 0.05%, or 0.1%) should be printed on box and tube. There should be an expiration date stamped on both the box and the end of the tube. The tube should be made of metal, not plastic, and should be sealed under the cap. There should also be a detailed instruction sheet inside the box. In Mexico, it is best to only buy brand-name tretinoin products made by major USA and European pharmaceutical companies, rather than generics. Beware that even if you follow these guidelines, you could still get bogus products in Mexico. You should also know that on rare occasions, Mexican police have illegally stopped USA citizens leaving Mexican pharmacies with various medications and asked for cash "fines". (Any trip to Mexico carries some risk.)
Under FDA regulations, it is legal to import a "90 day personal supply" of some types of prescription medications purchased in another country across any border if you declare it, and it is clearly labeled with the generic medication name. This includes importation by shipment or personal-carry. Technically, the regulation applies only to the importation of drugs that are not available in the USA. However, Customs inspectors usually allow both shipping and personal importation of tretinoin and other topical skin medications. Three or four large tubes would probably be O.K. More than this could be confiscated at the border, but the inspectors may not care much about illicit skin cream. Be aware however, that there is always a small chance of confiscation of pharmacy shipments or personally-carried tretinoin. Importation of pharmaceuticals is a controversial issue, and the law may change to make the regulations less restrictive or more restrictive.
If you bring the tubes in personally, according to the regulation you should carry with you a signed statement (that is, signed by you) stating the following:
I declare that the items I am carrying are for my personal use only under the June 1988 "FDA Pilot Guidance Scheme" and that they are not for commercial resale. No beneficial or therapeutic claims have been made against any product. The amount does not exceed a three month supply, and they are used with the consent of my physician.
You must also write on the statement the name and address of your personal doctor who knows that you are using tretinoin. It is also a good idea to carry one of your doctor's business cards and a photocopy of your prescription with you just in case there are any questions at the border, though this is not required by the regulation. (Write "copy" on the prescription photocopy so the border inspectors know you are not trying to use it as an original.) Let your doctor know in advance that you may buy your medication from a foreign pharmacy to save money. By the way, don't try to use this method to import any controlled substances, growth or sex hormones, anabolic steroids, or injectable medications. If you do, you could be arrested by federal or state officers.
All tretinoin made by major pharmaceutical companies should have a potency expiration date stamped on the box or the end of the tube. Be sure the expiration date is at least six months away since one large tube may last you this long. Obviously, if you buy a few tubes at one time, you will want an expiration date a couple of years in the future. Tretinoin cream has a shelf-life of about three years from the date of manufacture, and the gel about two years. Keep the tube capped, since exposure to air and light can inactivate tretinoin and cause some of the other ingredients to evaporate. Also store the tube at temperatures under 80 F, or it will degrade faster.
Unless you have tretinoin prescribed for acne, insurance companies usually won't pay for a doctor's visit or a prescription. You can obviously pay for a skincare consultation with your regular doctor or a dermatologist, but you can save money by simply having your doctor give you a prescription at your next insurance-covered visit.
If you have extra money, also ask your doctor for a prescription for a small 30 gram tube of 0.05% or 0.1% tazarotene cream or gel (Avage brand cream or Tazorac brand cream or gel), and compare it to tretinoin on different sides of your face. It costs about $60. Some people may get slightly better results with tazarotene. The Avage brand is FDA-approved for treating facial photoaging, while Tazaroc is approved for treating acne and other skin conditions; but the active ingredient tazarotene is the same in both brands. Avage and Tazaorac cream have nearly identical ingredients, so you can check the pharmacies to see which one costs less per gram. Tazorac also comes in a gel, while Avage is currently only available as a cream. Avage and Tazorac cream are emollient-type creams containing mineral oil, similar to Renova, made for people with dry or sensitive skin. People with more skin oil or acne should use Tazorac brand gel. Unlike tretinoin gel, Tazorac brand gel only has a small amount of alcohol and spreads easier. Doctors can legally prescribe either brand of tazarotene for treating photoaging. With any form, you should initially use tazarotene very lightly since it may cause irritation and peeling. If you get the higher concentration 0.1% product, start by applying only about a water-drop-sized amount to your face at first. Tazarotene seems to absorb slowly, so be sure to apply it at least a half- hour before sleeping or it could rub off on your pillow. Some internists and general practitioners may not yet be familiar with tazarotene as a treatment for photoaging, so you may want to show them copies of the medical paper abstracts on tazarotene listed above. You can also print out consumer medical information on both Avage and Tazorac from the Net.
If you go to a dermatologist, be sure to also ask for free tretinoin and tazarotene samples; they often have small tubes to give away to patients. Since tretinoin is now considered a routine skincare product, your regular doctor may also be willing to call in a prescription to your pharmacy without an exam. Some clinics can also schedule a lower-cost consultation with a nurse practitioner or physician-assistant who can give you a prescription for tretinoin. Always be sure to ask that the prescription specify the maximum number of refills, so you can simply go back to the pharmacy when you need a new tube. When you run out of refills, often you can get the doctor's office or clinic to call the pharmacy to authorize more without having to pay for another visit.
Tretinoin has a good safety record. It has been used daily by thousands of
acne patients without significant reported problems. Animal skin tests
suggest that topical tretinoin application is safe, though some studies have
indicated that it may make the skin more susceptible to UV light damage. On
the other hand, there are only a few small-sample, multi-year human safety
tests, so the specific risks of using it daily for many years are unknown.
For this reason, it is prudent to decrease application frequency after 12
to 24 months (depending on the concentration you are using) to two or three
times per week - which is all that is needed anyway for maintenance. Because
of its effect on pigment cells, tretinoin will also lighten your skin
slightly. With some people, it will significantly lighten freckles after
about a year. You should not use tretinoin if you are pregnant or may become
pregnant. (An excess of vitamin A and related compounds in the body may
cause birth defects.) Don't apply any other medications or moisturizers to
your skin over tretinoin. As previously mentioned, tretinoin should be
applied only at night because light decreases its potency. When using
tretinoin, you must use a sunblock during the day when outside, because of
the possibility of UV light sensitivity. (You should be doing this anyway.)
Similar cautions also apply to the other retinoids such as tazarotene, so be
to read the instructions and safety cautions that come with the tube.
Author code 91587355
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Retinol is the name for a form of vitamin A. This can be confusing because the word "retinol" sounds like the tretinoin brand, Retin-A. Retinol is not nearly as effective as tretinoin, but medical studies have shown that stabilized forms of retinol do have some positive effects when applied to the skin. The studies show that if the retinol penetrates, some may be converted by enzymes in the skin to small amounts of tretinoin, thereby producing similar effects such as improved collagen and a thickened epidermis. See for example, "In Vitro Metabolism by Human Skin and Fibroblasts of Retinol, Retinal and Retinoic Acid," Experimental Dermatology, 7(1), 27-34, 1998 Feb (abstract available on Medline). Retinol can produce a modest reduction in fine lines and a somewhat smoother skin surface. Many retinol products are also inexpensive, so you can experiment with them without spending a lot of money. Net reviews of retinol products are generally positive, but reported results are usually quite modest and very gradual.
Many drugstores and supermarkets have non-prescription retinol products like Neutrogena Healthy Skin Anti-Wrinkle Cream (regular and SPF 15), Alpha-Hydrox Night ResQ, and St. Ives Anti-Wrinkle. These are non-greasy, light creams that are usually applied at night. They cost about $14 for 30 to 40 grams. The Neutrogena products are widely available at drugstores and supermarkets, and Wal-Mart also has a less expensive store-brand called "Equate Anti-Wrinkle" for about $8 with similar ingredients.
Most retinol products are inexpensive compared to prescription tretinoin, and the medical studies indicate they can potentially improve your skin appearance. However, retinol products are less effective than those containing tretinoin. One dermatologist has written that currently-available retinol products are 5-10 times weaker in effect that 0.05% tretinoin. While the medical studies on retinol used concentrations of 0.5% to 1%, most retinol products don't list the retinol concentration. This is silly, but it is a common practice with cosmetics companies because it allows them to skimp on active ingredients and avoid competition with other brands. Also, one well-known skincare expert has written that she is skeptical that the concentration of retinol in most products is comparable to that used in the studies. So unless you find a retinol brand with the concentration listed, you can't compare the potency of the products with those used in the studies.
The instructions included with some retinol products say you can see results in a matter of weeks, but since tretinoin takes months for visible results, this is probably not true. In fact, based on the suspected low retinol concentration in most products, you might have to use it for a few years to get the same noticeable effect as with only six month's use of tretinoin. Because of this, there may not be any long-term cost savings over generic tretinoin.
Don't confuse retinol products with other skin creams that say "multivitamin" or list various other vitamins. Vitamins have to be in certain chemical forms to penetrate into the dermis or cause any significant biological effect, and most skin products do not contain these vitamin forms. In addition, unlike retinol and tretinoin, there is no conclusive evidence yet that other types of vitamins permanently improve the dermis or epidermis. (There have been a few positive studies on special forms of vitamin C, but the evidence for beneficial effects is meager.)
Retinol products are safe for continuous use because they are equivalent in effect to very low-concentration tretinoin creams. However, some brands may have other irritating ingredients, so start by using only a small amount, and see how your skin reacts. Like tretinoin, the directions on most of these products say they should be used only at night, but supposedly Neutrogena's SPF 15 version can be used outside during the day. As with tretinoin, you should use sunblock when outside. You should not use retinol if you are pregnant or may become pregnant. (An excess of vitamin A and related compounds in the body may cause birth defects.)
Retinol products do degrade over time and lose potency after about three
years. Unfortunately, most products do not have expiration dates stamped on
the tubes. Since products can sometimes sit in warehouses and on store
shelves for up to two years, it is best to only buy one tube at a time.
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Copper peptide has been shown in a number of medical studies to promote healing of the skin. A few studies have also suggested that it can improve collagen in the dermis. (See the Net addresses below for references.) It may have some value as an anti-aging skin treatment. There are some positive Net reviews of copper peptide, with some people reporting smoother skin texture or improvement in some types of scars. However, others report only a slight effect. Currently, the positive medical evidence for copper peptide as a treatment for photoaging is not nearly as extensive as for tretinoin.
Copper peptide products are available without a prescription. Some copper
peptide products are sold at high-end department stores, but they are usually
very expensive. Neutrogena makes a low-concentration copper peptide product
called Visibly Firm Night Cream that costs about $17 for 50 grams. It is
available at many drug stores and supermarkets. You can check
neutrogena.com for more information on this product. (Note that some
Neutrogena boxes have a stamped expiration date that indicates a shelf life
of about three years, but other boxes have no date.) The scientist who
originally developed copper peptide skin treatments has medical studies and
extensive product information at skinbiology.com and
skinbio.com.
You can order his products online or by mail, and the prices are reasonable.
His products are generally a better value than the Neutrogena product or those
at department stores because they have a higher concentration of copper
peptide.
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Low-concentration alpha hydroxy acids (AHAs) and salicylic acid (called cosmetic acids) are chemicals promoted to improve signs of photoaging such as rough skin surface texture, fine lines, and uneven pigmentation. Home use of cosmetic acids originally became popular because they provide quick results on areas of rough skin by peeling off or exfoliating the upper layers of the epidermis, exposing smoother skin underneath. In addition, numerous medical studies have also shown that use of low-concentration cosmetic acids results in improvements to the structure of the epidermis and the upper dermis and modest improvements in skin texture and fine lines. They may also stimulate the growth of collagen. See for example, "Epidermal and Dermal Effects of Topical Lactic Acid," Journal of the American Academy of Dermatology, 35(3 Pt 1), 388-391, 1996 Sep; and "Topical 8% Glycolic acid and 8% L-lactic Acid Creams for the Treatment of Photodamaged Skin: A Double-Blind Vehicle-Controlled Clinical Trial," Archives of Dermatology, 132(6), 631-636, 1996 Jun; (abstracts available on Medline). Net reviews of cosmetic acids are generally positive, though some people with sensitive skin report significant irritation.
Note that these acids are more than cosmetic in their effect, but the phrase "cosmetic acid" has become common. You may also hear the invented term "cosmeceutical" applied to acids, retinol, and copper peptide - that is, products which have some effect on skin biology, but don't require a prescription.
There are a variety of cosmetic acid products available for home use. Acid concentrations are typically listed as 2% to 20%, though concentrations are calculated differently among different manufacturers. (The important specification is actually pH or acidity, but manufacturers rarely list this.) Most AHA products contain either glycolic acid, malic acid, or lactic acid. Salicylic acid is sometimes labeled a "beta hydroxy acid," indicating a different chemical structure than AHAs. It is also used in some acne medications. Unlike AHAs, salicylic acid is toxic at high concentration and more caustic, so most salicylic acid products for home use contain concentrations below 7%. Too much salicylic acid applied to the skin can cause salicylism, which is characterized by headache, dizziness, and ringing in the ears. (By the way, salicylic acid is not aspirin, that's acetlysalicylic acid, a different chemical.)
Cosmetic acids are available as creams, lotions, and gels on the shelf at specialty cosmetics stores and most drugstores for less than $15. Some dermatologists, plastic surgeons, and cosmetologists sell the higher concentration products (above 10% for AHAs) in their offices, but prices are usually higher than in stores. One popular, reasonably-priced AHA brand is Alpha Hydrox, in the red boxes. It is available at many drug and discount stores. Alpha Hydrox has 10% glycolic acid products in cream, lotion, and gel formulas (see neotericcosmetics.com; click on Alpha Hydrox.) The products are water-based, and can be diluted with distilled water if necessary. The most potent product is the Alpha Hydrox Oil Free Formula gel; it costs about $11 for 30 grams. Some drug and discount stores also sell a store-brand 8% AHA lotion or cream for about $6.
Light skin exfoliation can also be done using abrasive pads or cleansers. These products are sold in various abrasive textures in the skincare section of drug and discount stores. They can help smooth the epidermis if you have areas of rough skin. However, unlike cosmetic acids, abrasives simply remove the top layers of the epidermis and have little effect on the dermis. The coarser products may also cause redness and irritation to normal skin because the pads pull and stretch the skin, and the abrasive particles can scratch the epidermis. So try the mildest pads or cleansers first. Also be sure to use sunblock during the day when using abrasives, since thinning the upper epidermis can make your skin more susceptible to sun damage.
Cosmetic acids and abrasive pads or cleansers can be used regularly if you have abnormally rough skin due to overgrowth of the top epidermal layers. If you have chronically rough and dry skin, you should also try various moisturizers including special urea-based moisturizers like Carmol 20, available from pharmacists. (A higher strength, Carmol 40 is also available by prescription.) However, despite what some advertising says, people with normal skin should limit their use of cosmetic acids and abrasives. The upper epidermis provides an important environmental barrier and protection from UV light, so removing it every day for the rest of your life with acid or by scrubbing doesn't make sense. FDA studies have confirmed that AHAs make the skin more sensitive to solar UV light damage (though the effect is reversible when use is discontinued). Also, some doctors have raised questions about the safety of long-term cosmetic acid use. The continuous cell turnover that they produce could potentially accelerate some intrinsic skin aging processes. You should also know that there are Net reports of AHA use preceding the development of rosacea, which is sometimes triggered by skin irritation. If you have a family history of rosacea, you should probably not use cosmetic acids.
With cosmetic acids, one reasonable and safe strategy for skin improvement would be to use a cosmetic acid nightly for three to 12 months (depending on concentration), and then discontinue use or apply it only only occasionally. Remember, cosmetic acids should not be used continuously. Another very effective initial strategy recommended by some doctors is alternate use of a cosmetic acid and tretinoin. See for example, "Retinoid Therapy: Compatible Skin Care," Skin Pharmacology and Applied Skin Physiology, 12(3), 111-119, 1999 May-Jun (abstract available on Medline.) While this study used tretinoin at night and acid during the day, it is best to only apply the products on alternate nights to reduce sun-sensitivity. This combination strategy is believed to be more effective than using either product alone. Application frequency or concentration of the products may have to be reduced if you get irritation, peeling or redness. In any case, after about 12 months, decrease application of the tretinoin to twice per week, and discontinue use of the acid, or apply it only occasionally. Whatever schedule you use with cosmetic acids, if your skin looks red and irritated during the day, simply decrease the application frequency, use a lower-concentration product, or dilute it with distilled water. When using AHAs daily or alternating with tretinoin, most people will need to limit concentration to 12% or less. If you use this strategy with salicylic acid, select a product with a concentration under 5% to avoid potential toxicity. Higher-concentration salicylic acid products usually aren't practical for long-term use anyway, because they often cause a lot of crusting and peeling of the skin.
AHAs and salicylic acid produce different effects on pore appearance. Contrary to some advertising, AHAs are not a treatment for large pores and do little to dissolve sebum-keratin plugs in the pores. In fact, peeling off the upper epidermal layers with AHAs may temporarily make your pores look slightly larger. Salicylic acid, on the other hand, can help dissolve sebum- keratin plugs that clog pores. That is why it is used in some acne medications like Neutrogena's Clear Pore Treatment (with 2% salicylic acid). There is some research suggesting that the ability of salicylic acid to penetrate into pores may make it more effective than AHAs of comparable acidity for treating photoaging. If you have a problem with clogged pores, you can use the combination strategy of alternating nightly use of 2%-4% salicylic acid and tretinoin. The 56 gram, 2% Neutrogena Clear Pore Treatment Gel is the most widely available salicylic acid product in drugstores and supermarkets; it costs about $7 (look in the acne treatment section). You can find other products with 3% or 4% concentration at specialty cosmetics stores or on the Net. Avoid salicylic acid products that have alcohol listed first or second in the ingredients list, indicating a high concentration. It can be very irritating. (Note that in prescription medicines like tretinoin, ingredients may be listed in the opposite order from non-prescription products, that is, from lower to higher concentration.)
You should only use cosmetic acids at night, since they cause sun sensitivity. It is very important to always use sunblock when outside while using cosmetic acids, or you will defeat any benefits you gain by allowing more sun damage. Don't apply cosmetic acids with any other products since the acids can react with other chemicals. Be careful not to get any acid in your eyes. The first time you try a cosmetic acid, do it on a night when you won't have to work the next day; otherwise, you could wake up with a very red face. Start out with a low concentration, or dilute the acid and work your way up to full concentration gradually. Also, stand next to a sink when you apply the acid so you can flush your eyes and face with water if you get any in your eyes or if your face starts to sting badly. (There may be an initial mild stinging sensation, but it should subside quickly.) Also be aware that cosmetic acids may lighten your skin slightly with long-term use. Women who are pregnant or may become pregnant should not use salicylic acid because of the possibility of salicylism, and AHA use should be limited to low- concentration formulas.
There are some sources for high concentration AHA and salicylic acid products, but they may not be safe for general home use. These are similar to the solutions used by doctors for light and medium chemical peels. However, using high concentration acid solutions without specialized knowledge is very dangerous. Some of these products may not be medical-grade and might contain impurities or toxins that could damage your skin. Some high concentration solutions can only be left on the skin for a short time and then must be quickly washed off or neutralized with a base solution to prevent burns, scarring, and possible infection. It only takes minutes for some solutions to penetrate through the thin epidermis into the dermis and cause permanent scars. They can also cause permanent damage if they get into your eyes. So unless you have specialized medical knowledge on how to use high concentration acids, only use AHA products under 20% concentration or salicylic acid under 7% available from reputable stores or from cosmetologists and doctors. If you want to get light or medium resurfacing, have it done by someone with experience. Don't risk scarring your face.
Most cosmetic acids are not stamped with expiration dates, but manufacturers
say they start to degrade after about three years. It is best to only buy one
tube at a time to assure potency.
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There are many other non-prescription topical products for sale in stores or on the Net that claim to improve skin health. Most are simply cosmetic products that may temporarily improve the appearance of the upper epidermis without affecting skin structure. Recent network news programs have reported that many of the expensive skincare products sold at department stores are simply moisturizers and contain no ingredients proven to improve skin structure. The ingredients were similar to those in products that you can buy at drug or discount stores for under $10. They also found that sales people at the department stores often made false claims, and some also offered a bogus skin examination to promote their products. While it may not be illegal, a lot of skincare advertising is simply deceptive. Advertising can make all sorts of vague claims about skin improvement so long as it doesn't claim the product affects the "structure or function" of the skin. Many people believe the advertising and waste money buying ineffective skincare products. Unless you can confirm that the claims made for a product's ingredients are supported by medical studies published in peer-reviewed medical journals (like those listed on Medline), you shouldn't expect any permanent effect on your skin.
There are also some topical non-prescription products on the market that have been tested in a few preliminary medical studies. They may improve skin structure in some way, but the evidence is not definitive. This group includes products containing special Vitamin C formulations, alpha-lipoic acid, green tea, palmitoyl pentapeptide, epidermal growth factor, and furfuryladenine (Kinerase and Kinetin). Generally, the claims made for these products include delivery of antioxidants into the dermis, smoothing of the epidermis, or improvement of collagen and elastin.
These products are more expensive than retinol, copper peptide, or AHAs, and many are more expensive than prescription retinoids. Before you spend a lot of time and money on these products, you should have some assurance that they actually work. Most of preliminary studies on these products are not double-blind, or only use a small number of subjects, so the results are not considered conclusive or even statistically significant. In fact, positive results in small-sample studies with no control group can be due to the placebo effect, where some improvement is reported even with skin creams that have no active ingredients. (In the tretinoin clinical trials, approximately a third of the large control group seemed to have some improvement in fine lines and skin texture after using only sunblock and an inactive cream for 24 weeks.) There are also no long-term tests yet on any of these products. So unlike retinoids and cosmetic acids, dermatologists do not yet agree on their effectiveness, biochemical action, or safety. Net reviews from users of these products are all over the map, with some people reporting improvement and others reporting no effect at all. Some of these products may work, but unless you are wealthy and have money to spend experimenting, it is better to wait until there is more scientific proof of their effectiveness and an understanding of how they affect skin cells.
We can anticipate new chemicals will be discovered in the near future that can treat photoaging, improve skin structure, and slow the aging process. These chemicals will be tested by medical researchers and physicians, and the results will be reported in medical journals. So if you hear about a new skin product or want to investigate any of the products mentioned above, you can check for medical studies using the Internet medical index Medline (available free on many websites such as the National Library of Medicine, with short study abstracts). Do a combined search on the chemical name of the active ingredient in the product and terms such as "skin," "photoaging," and "photodamage." You can also call or e-mail your dermatologist's office to ask about new products for treating photoaging. Beware however, if your dermatologist tries to sell you an expensive "skincare system" with various cleansers and creams. A few unscrupulous dermatologists make extra money selling overpriced products out of their offices.
There are also two other effective, proven topical skin treatments that should be mentioned, if only because they are so inexpensive. There are a variety of chemicals that have been found to improve epidermal growth after skin abrasions. Two of these cost only a few dollars and are available at drug stores. Both cod liver oil and zinc oxide have been found in animal studies to significantly improve epidermal healing when compared to unmedicated products like plain petroleum jelly. One study also found them to be synergistic when applied together. See for example, "Improvement and Retardation of Wound Healing: Effects of Pharmacological Agents in Laboratory Animal Studies," Veterinary Dermatology, 10(2), 83-88, 1999; "Topical Application of Cod Liver Oil Ointment Accelerates Wound Healing," Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 34(1), 15-20, 2000 Mar; and "Enhancement of Re-Epithelialization with Topical Zinc Oxide in Porcine Partial-Thickness Wounds," Journal of Surgical Research, 50(2), 101-105, 1991 Feb (abstracts of last two articles available on Medline).
Cod liver oil and zinc oxide won't do anything for lines and wrinkles in the
dermis, but they may help smooth the epidermis after recent skin abrasions,
burns, and other wounds. (You should wait to apply them until new skin has
started to heal over the wound; antibiotic ointment should applied initially
to prevent infection.) There are some ointments and creams available in drug
stores that contain both cod liver oil and zinc oxide. Plain white zinc oxide
ointment is also available. These are usually in the first-aid or baby-care
sections. However, some of these products have too much fragrance for most
people because they are marketed for diaper-rash. Try to find one without
fragrance listed in the ingredients; some generic drug store-brands have no
fragrance. Cod liver oil (in capsules or bottles) is also available in the
dietary supplements section, but it doesn't adhere very well to the skin and
has a slight fish odor. It is best to use these products when you are at
home or else under a bandage, because they usually leave a noticeable film on
the skin. They may also stain clothes and bed sheets.
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Skin resurfacing is the removal of skin layers by abrasive dermabrasion, chemical acid peeling, or laser. When the skin regrows, the skin may appear smoother. Numerous medical studies have shown that resurfacing can potentially reduce the appearance of wrinkles, remove benign discolorations, improve skin texture, and improve some scars. See for example, "A Clinical and Histologic Evaluation of Two Medium-Depth Peels: Glycolic Acid Versus Jessner's Trichloroacetic Acid," Dermatological Surgery, 22(9), 781-786, 1996 Sep; "Manual Resurfacing and Trichloroacetic Acid for the Treatment of Patients with Widespread Actinic Damage: Clinical and Histologic Observations," Dermatological Surgery, 23(5), 373-379, 1997 May; "Salicylic Acid Peels for the Treatment of Photoaging," Dermatological Surgery, 24(3), 325-828, 1998 Mar; and "Histologic Effects of the High-Energy Pulsed CO2 Laser On Photoaged Facial Skin," Plastic and Reconstructive Surgery, 99(7), 2036-2055, 1997 Jun (abstracts available on Medline).
Light resurfacing removes only part of the epidermis and can improve skin texture and very fine lines in much the same way as long-term use of cosmetic acids. Medium resurfacing penetrates through the epidermis to the upper dermis. This stimulates new collagen growth in the upper dermis, eliminating fine lines and reducing wrinkles. Even though all or part of the epidermis is removed in resurfacing, the face has the remarkable ability to regenerate the epidermis with cells migrating from inside the pores and sweat gland openings. With medium resurfacing, the potential for improvement is much greater than using topical treatments like tretinoin or cosmetic acids. Deep resurfacing extends further into the dermis. It can remove more wrinkles, but it is rarely done due to the high risk of scarring and loss of skin pigment. (This FAQ doesn't cover deep resurfacing.)
Light resurfacing is usually safe, but medium resurfacing has increased risk of scarring, pigmentation changes, and pore enlargement. Even though the potential effect is not nearly as great, it is far safer to have one or more light resurfacing procedures rather than one medium procedure. Net reviews of light resurfacing are generally positive, but the effects are modest. Net reviews of medium resurfacing vary widely with results ranging from great improvement to permanent disfigurement. You can see many before-and-after pictures of resurfacing at dermatology and plastic surgery websites. (Remember though, that they don't post pictures of the complications.) There have been a number of recent news reports about lawsuits against doctors for causing permanent facial scarring with medium resurfacing that penetrated too far into the skin. (As in any profession, most doctors are skilled, but some are incompetent.)
In advertising, some doctors claim medium resurfacing can reduce the size of pores. The effect of medium resurfacing on pore appearance is highly variable, with some people reporting improvement, but many reporting no change or permanent enlargement. Improvement in skin elasticity that results from resurfacing can sometimes make pores less noticeable. However, in other people, aberrations in epidermal healing following resurfacing can make pores appear larger than before the procedure (more on this below). Medium resurfacing should therefore not be used as a treatment primarily for large pores, because it can sometimes make them worse. If you have large pores, the combination strategy using tretinoin and salicylic acid often helps by improving skin elasticity and reducing sebum buildup inside the pores.
No matter what your skin type, before you consider either light or medium resurfacing, it is best to first try the tretinoin and cosmetic acid strategy (using either salicylic acid or AHA) for about a year to see if get the improvement you want. It can't produce the potential results of medium resurfacing, but it will often produce better results than light resurfacing due to tretinoin's ability to penetrate the dermis and improve collagen. It is also less expensive and involves almost no risk. Many people with light or moderate photoaging who have used this combination treatment are satisfied and have saved a lot of money.
I will cover the specifics of medium and light resurfacing separately.
Medium Resurfacing:
One type of medium resurfacing called dermabrasion is traditionally done using small motor-driven instruments with abrasive heads. However, some doctors do dermabrasion manually with sterilized, fine-grit silicon carbide sandpaper. While this is much slower, it allows penetration depth to be carefully controlled by observing signs that the lower epidermis or upper dermis has been reached. With either technique, dermabrasion is a rather bloody procedure, so careful attention must be paid to infection control during and after the procedure.
Medium chemical peels are usually done with a combination of high- concentration trichloroacetic acid and either glycolic acid or Jessner's solution (a combination of salicylic acid, resorcinol, and lactic acid.) The acids must be carefully and uniformly applied using swabs. Chemical peels are the most difficult resurfacing procedure to control, because the doctor must judge penetration depth using acid concentration, application time, and skin appearance.
Laser resurfacing is rapidly becoming the most popular method of medium resurfacing since it is more convenient to perform than a chemical peel or dermabrasion. It may soon replace these other two methods entirely. With a laser, the doctor doesn't have to handle messy acids or bloody abrasives, and can concentrate fully on controlling penetration depth. There is somewhat less risk of infection because the heat of the laser coagulates tissue and blood. Many doctors also believe that the laser produces some contraction of collagen in the dermis, giving a better result than a chemical peel or dermabrasion of the same penetration. The two types of lasers currently in common use are the erbium YAG laser and the carbon dioxide (CO2) laser. ("Erbium YAG" means erbium, yttrium, aluminum, and garnet - materials inside the laser.) The erbium YAG laser is preferred by some doctors because it allows very precise control of penetration depth. See for example "Achieving Superior Results with the Erbium:YAG Laser," Archives of Facial Plastic Surgery, 4(4), 262-266, 2002 Oct-Dec (abstract available on Medline.) Other doctors prefer CO2 lasers, because they believe they are more effective on deep wrinkles. However, there are many brands of both types of laser with different characteristics, so these are only general observations. (You can discuss the different types of lasers with the doctors you consult.)
To understand the risks of medium resurfacing, you should think of the procedure as a controlled surgical wound, not as a "spa treatment." For it to be successful, penetration must be carefully controlled, and then the skin must heal well. Excessive penetration into the dermis in an effort to remove deep wrinkles can cause uneven, scarred skin. If this happens, the resulting permanent scars are similar to those caused by second-degree thermal burns. Infection following the procedure can cause scarring too. Pigment cells can also be affected by medium resurfacing, producing uneven skin color or permanent lightening. Medium resurfacing complications are often diminished in consumer information, but they have been reported in medical journals and are mentioned in most patient consent forms. See for example, "Thermal Injuries As a Result of CO2 Laser Resurfacing, "Plastic and Reconstructive Surgery, 102(4), 1247-1252, 1998 Sep (abstract available online on Medline). Articles in newspapers and magazines have described some patients' poor results with medium resurfacing including pigmentation problems and scaring (see for example "Face Off," Elle, October 2002, p. 202).
People who have taken the oral acne drug Accutane should not have medium resurfacing done for at least a year, since it reduces the ability of the skin to heal and can cause scarring. Pregnant women should also not have medium resurfacing performed due to the risk of complications, especially infection. People who have rosacea or a family history of rosacea should not have medium resurfacing done, since it can exacerbate or initiate the condition.
There is another little-publicized, but significant risk with medium resurfacing. Doctors have discovered that medium resurfacing does not work well on a significant fraction of the population and can make their skin appearance much worse. Even if penetration is not excessive, in some people, particularly those with large pores and a lot of skin oil, the epidermis may not regenerate well, resulting in a much worse surface texture than before the procedure. This is due to variations in the way new epidermal cells grow outward from the pores and sweat gland openings. Also, the basal or bottom layer of the epidermis, which forms new skin cells, may not return to it's normal pre-operative state. Even though wrinkles may be reduced, up close the resulting epidermis may be thin and have an uneven, orange-peel appearance. The pore openings may appear larger than before with tiny fissures around them, particularly in the center of the face. Loss of pigment can also make large pores appear more prominent. If you have any healed abrasions or chemical and thermal burns, you may see a similar difference in texture compared to your normal skin. Long-term use of tretinoin may help this problem somewhat, but the skin texture may never look smooth up close. These serious risks of poor skin texture and enlarged pores are mentioned in some patient consent forms and journal articles on resurfacing, but are usually not covered in consumer information. See for example, "The Prevention and Management of Postdermabrasion Complications, "Journal of Dermatological Surgery and Oncology, 17(5), 431-437, 1991 May (abstract available on Medline). Even though this is a major problem, inexplicably, some medical textbooks on resurfacing don't discuss this risk, and many medical websites that cover resurfacing also say nothing about it. If you have large pores and a noticeable amount of skin oil or any acne, you should probably not have medium resurfacing for photoaging. Instead, you should use the topical treatments mentioned previously or nonablative treatments (see below). Don't risk scarring your face.
No matter what your skin type or what type of medium resurfacing you are considering, resurfacing a small test area is necessary to see how your skin responds. There is a large variation in people's skin thickness and healing ability, so you need to check for scarring, loss of pigment, and healing problems. Medical textbooks recommend a test area, particularly for darker skin, since medium resurfacing can destroy some pigment cells; this can cause an unsightly spotted or mottled appearance. You will have to wear a small bandage on the test area for about ten days. Allow the area to heal for about six weeks. It should be smooth and only slightly lighter in color than your other skin. If the pores look larger or the surface is uneven or discolored, medium resurfacing is not appropriate. Instead, you can try very light resurfacing or use the combination strategy of tretinoin and low-concentration salicylic acid. Another option is to find a doctor who has a nonablative laser, intense pulsed light source, or radio frequency device. ("Nonablative" means that no skin is removed.) These devices may improve the condition of the dermis moderately without burning off the epidermis. (More information on this below.) Many doctors who do medium resurfacing will also have access to a nonablative device.
If a doctor will not do a test area for medium resurfacing, go to another doctor. Some doctors will assure you that the electronic power settings on lasers eliminates the need for test areas. This is definitely not true of CO2 lasers, and questionable even with the more precise erbium YAG lasers. While erbium YAG lasers allow close control of penetration depth, the doctor still ultimately determines how deep the resurfacing will go. Don't risk scarring your face.
With medium resurfacing, you can minimize risk and cost by resurfacing only the areas where you have wrinkles or benign skin discolorations. However, the doctor must blend the resurfaced areas with the untouched areas or you may have a visible textural border between the two. Some doctors prefer to do the whole face, and adjust the penetration depth as needed for different areas. For wrinkles, the areas with the best results seem to be the sides of the eyes, forehead, rear cheek area, and around the mouth. Note that dynamic wrinkles in these areas, due primarily to facial expressions, will usually reappear in a few years. Results seem to be variable directly under the eyes and may be dependent on whether the wrinkles there are largely dynamic or due only to photoaging; the skin in this area is also delicate and can scar easily if penetration is excessive. (If you have large bags under the eyes, or loose skin on top of the eyes, it must be treated with different plastic surgery procedures.) Because everyone's skin has more oil and larger pores on the nose and front cheeks, the doctor should resurface the skin lighter in these areas to avoid an orange-peel texture after healing. Areas where the skin may be stretched tight over bones, such as the top of the nose, must only be very lightly resurfaced. The neck is usually only lightly resurfaced because it does not heal as well as the face. These are only general rules, and the depth of resurfacing done on different areas is dependent on your skin type and the amount of sun damage you have. You should obviously discuss all this with your doctor.
Depending on the type of procedure, medium resurfacing will require some type of anesthetic during the procedure for pain. You will usually be given topical or local (injected) anesthetic, and a sedative. The degree of sedation will depend on the type of resurfacing to be done. Someone will have to take you home after the procedure because you will have bandages on your face and the sedative will make you drowsy for a while. If you have a medium chemical peel, be sure the doctor has a large bottle of water nearby in case any acid gets in your eyes. You also don't want to be so heavily sedated during a chemical peel that you can't tell the doctor if this happens. If you have laser resurfacing, your doctor should put opaque shields over your eyes to protect them from the intense laser light.
If you do get medium resurfacing, the recovery period can be long and somewhat uncomfortable. Any pain can be managed with mild pain medication, but you should be prepared to look awful for at least 12 days (with swelling, red skin, crusts forming, and peeling). You will need to stay home from work for at least two weeks. Be prepared to take even more time off if you have any complications. You will have to wash the skin very gently and keep it moist with antibiotic ointment. While you may be somewhat presentable after two weeks, the complete healing process can be slow. In light-skinned people, the skin will be pink for many weeks and possibly a few months. With darker skin, pigmentation may be uneven for the same time. Make-up will be needed if you want to hide the pink color or uneven color. You must stay out of the bright sun until your skin is fully healed. Ask your doctor when you can resume outdoor activities and what kind of sunblock you should use since some brands may irritate the new skin (for example, those with alcohol). In the future you will need to always use sunblock when outside during mid-day because the new skin may be more easily damaged by solar UV light.
Results of medium resurfacing will usually last for many years, and if you stay out of the sun, some improvements may be permanent. You can prolong the effects after you have fully healed by using tretinoin on the schedule discussed above, so be sure to get a prescription from your doctor. To be safe, cosmetic acids should probably not be used at home following medium resurfacing. Continual removal of the upper epidermis with cosmetic acids following medium resurfacing could accelerate some intrinsic skin cellular aging processes. Currently, you should also be cautious about repeating medium resurfacing, even after many years, until there is more medical information available about the safety of multiple procedures. Multiple procedures could potentially produce an unnatural surface texture and an unacceptable lightening of the skin.
If you decide to have medium resurfacing, it is important to select a board- certified plastic surgeon or dermatologist. Because of the risks of infection and scarring, you should select a doctor just as if you were having major surgery. First, you should check ABMS.org or the American Board of Medical Specialties (ABMS) directory at your library. (The ABMS directory at the library generally lists more details about the doctors' education and training than the website.) ABMS-certified doctors have passed rigorous exams in their specialty beyond what is required for state licensure. Some doctors who were originally trained or certified in other specialties also do resurfacing because it can be very lucrative in large cities. There are a few other competing medical boards that will certify doctors to practice in areas out of their specialty training. These doctors may in fact be highly skilled, but it is safer to go to an ABMS-certified plastic surgeon or dermatologist for resurfacing since they have extensive training in skin anatomy and healing processes. Establishing a relationship with a plastic surgeon or dermatologist is also good if you or your family need to consult them in the future for other more serious medical problems.
If you are over age 50 and have creases, folds, sagging skin, or bags under your eyes, you should consult only plastic surgeons. They can recommend other surgical procedures to remove excess skin and tissue which will give much greater aesthetic improvement than resurfacing. In these cases, it is usually a waste of money to do resurfacing, because the improvement in skin elasticity is insufficient. If necessary, resurfacing can be done after other plastic surgery procedures. Some plastic surgeons will do medium resurfacing at the same time they do other facial procedures. However, this significantly raises the risk of complications such as infection, so it is best to do resurfacing only after you have fully healed from the surgery. After a facelift, you may not need medium resurfacing anyway; light resurfacing or use of cosmetic acid and tretinoin may be sufficient. If you are considering these other types of plastic surgery, you should do some research online and at the library so you understand the specific procedures and potential risks. Many plastic surgeons will give you a free or low-cost initial consultation and discuss all your options.
Once you have identified the ABMS-certified plastic surgeons and dermatologists in your area, you can refine your list. There are lots of other things you can do to check doctors' qualifications. Ask your other doctors, dentists, and friends who they would recommend. Check the yellow pages ads under "Physicians - Surgery, Plastic and Reconstructive" and "Physicians - Dermatology." Some doctors may also have an ad under "Skin Care." See if the ad lists a website you can visit. Use a search engine to do an Internet search on the doctor's name and medical specialty. You may find titles of books or papers he or she has written. You can search the Internet medical index Medline with their last name and initials to see if they have written any medical journal articles. Your county may have a medical society that publishes a brochure listing all the local doctors and their qualifications. Ask the reference librarian at your local library what information they have on selecting doctors. They may have reference publications listing the best doctors in various fields. If you live a in a large city, a local magazine may also have an annual "best doctors" issue. Check with your state medical licensing department to see if the doctors you find have had any disciplinary actions. You can also check with the state or local court clerk if any malpractice lawsuits have been filed against these doctors in your state. (Note that some suits filed against doctors are frivolous, so you can ask to read the court files if there are only one or two cases.) All of this will probably narrow your list down to a few doctors, so you can make appointments for consultations. Be aware that some of the older, prominent doctors on your list are probably going to charge more than young doctors who have only recently obtained their board certification. These younger doctors may actually be better trained in the latest resurfacing techniques. Obviously, not everyone will do all this work. However, the more research you do in selecting a qualified doctor, the less risk you will be taking with medium resurfacing.
If you live near the doctors' offices, you can simply stop by before making an appointment. You want to talk to the staff about the about following: 1. What type of medium resurfacing procedures they do - chemical peels, dermabrasion or laser. Ask if they also use a nonablative device. They may have a price list they can give you for the various procedures. 2. See if they have brochures they can give you on the procedures or a website you can visit. 3. Ask if they do a lot of resurfacing at their office. You want to find a doctor who does resurfacing as a regular part of their practice and is interested in skin aesthetics. Many dermatologists concentrate on treating skin diseases and don't do much cosmetic work. 4. Ask how much a "cosmetic consultation" to discuss resurfacing will cost before you commit to an appointment. As previously mentioned, some plastic surgeons will give you a free or low-cost initial consultation and price quote on resurfacing. This is less common with dermatologists. Since doctors make a significant profit on resurfacing, you should avoid doctors that are also going to charge you a lot of money for a consultation.
If you don't live near the doctor's offices, alternatively, you can send a letter or e-mail requesting the above information. A telephone call is often less helpful because you may only talk to an appointment clerk.
Depending on the type of response you get to your initial inquiries, the information they provide, and how much they charge, you can decide which doctors to see. When you meet the doctors and their medical staffs, it will be easy to tell if you like their personalities. They should be friendly and courteous. This is very important in case there are any complications with your procedure. You should also choose a doctor who will explain everything to you personally . The doctor should take time to examine your face carefully for a few minutes and then discuss the resurfacing procedure and its risks, and answer all your questions. Some doctors will have a nurse or physician-assistant talk to you first to give you basic information about the procedure and take a medical history. If a doctor just has you watch a video and gives you a five-minute sales pitch, you should choose another doctor. Ask if the doctor is willing to do a small test area first to see how your skin responds. (You may have to pay a small charge for the test area to be done because it requires set-up of the resurfacing equipment.) Ask how many resurfacing procedures of the type you are considering the doctor has done. The doctor should offer to show you some before-and-after pictures of other patients he or she has treated - not just printed sample pictures of someone else's patients in a pamphlet or book. If a doctor seems insulted when you ask about experience and qualifications, you should choose another doctor.
After your consultation, the doctor's staff should give you a written, complete price quote so there are no surprise extra charges added later. If the staff won't give you a firm price or tells you that you must make an appointment for resurfacing that day, politely decline and choose another doctor.
Full-face, medium resurfacing is expensive, and you will probably get quotes from $800 to $3500, depending on the resurfacing method and your location. Resurfacing on smaller areas of the face will be less. Laser resurfacing is the most expensive procedure due to the high cost of the laser equipment. Insurance generally does not cover skin resurfacing or nonablative treatments unless they are to treat blemishes or scars associated with a congenital defect, medical condition, or injury. (Check the specific provisions in your policy and get written approval if you think you are covered.) Even with the same treatment method, you may find that prices vary widely, so make your decision based on the doctor's training, experience, and personality. High prices or fancy offices don't necessarily correlate with medical qualifications or skill. Before making a final decision on treatment, you should also consider that the current cost of one medium laser resurfacing procedure will buy a lifetime supply of home topical treatments such as tretinoin, cosmetic acids, and any similar products that are developed in the future.
Light Resurfacing:
Light resurfacing is far less traumatic and has fewer risks since it only removes part of the epidermis. There is usually no anesthetic used and less complex infection control. At around $80 to $200, light resurfacing is much less expensive than medium resurfacing. Light resurfacing is usually done with low-abrasive dermabrasion or a medium-concentration chemical acid peel (typically glycolic acid or salicylic acid).
While a single light resurfacing procedure has no effect on wrinkles, after the upper epidermis regenerates, it is often smoother in texture than before. Some studies have shown that a few light resurfacing procedures, spaced a few weeks apart are more beneficial than a single procedure and may reduce fine lines.
Total healing time is only about two weeks, and usually you only look like you have a sunburn for about a week. The pores will often appear slightly larger until the skin completely heals. If you have a light chemical peel, you may have to stay home from work for a few days because some acid solutions will cause the upper skin layers to harden slightly and peel off after about three days. You should stay out of the bright sun for a few weeks, and use sunblock in the future.
As mentioned previously, if you have large pores and a lot of skin oil, there is a possibility of epidermal healing problems with resurfacing. Light resurfacing may make your pores and skin texture look slightly worse, at least temporarily. So if you have this skin type, you should ask for the lightest resurfacing available until you see how your skin responds. This will mean fewer passes with the abrasive material or dilution of the acid. If your skin texture looks worse after a few weeks, you should instead use the topical treatments mentioned previously or nonablative treatments (see below).
Most people just get one or two light resurfacing procedures every few years, but some dermatologists recommend a series of procedures over many months for greater effect. Before you make a commitment to multiple procedures, it is best to wait about a month after your first procedure to see how your skin responds.
The results of light resurfacing will usually last for one to five years, depending on the number of procedures. You can prolong the effects by using tretinoin on the schedule discussed above, so be sure to ask for a prescription if you go to a doctor, nurse, or physician-assistant. To be safe, cosmetic acids should probably not be used at home following many repeated light resurfacing procedures. Continual removal of the upper epidermis with cosmetic acids following multiple procedures could accelerate some intrinsic skin cellular aging processes. Also, the safety of repeating a series of multiple light resurfacing procedures many times over a person's lifetime is currently unknown, and the same cautions about continual removal of the upper epidermis apply. Pregnant women should probably not have light resurfacing done, since there is still a slight risk of infection. People who have taken the oral acne drug Accutane should probably not have light resurfacing done for at least nine months, since it reduces the ability of the skin to heal. People who have rosacea or a family history of rosacea should probably not have light resurfacing done, since it could exacerbate or initiate the condition.
You can use the same process described previously to find a doctor that does light resurfacing. However, light resurfacing is often done by a nurse or physician-assistant working under the supervision of a plastic surgeon or dermatologist. You may not meet the supervising doctor at all in this case. If so, when you visit the office for information, you can ask the nurse or physician-assistant for their business card and check the status of their state license and any disciplinary actions with the state medical licensing department.
If the doctors' offices in your area don't do light resurfacing, they may be able to recommend a cosmetologist. Cosmetologists are usually listed in the yellow pages under "Skin Care" and "Beauty Salons and Services." If you use a cosmetologist, you can also visit their office and ask for a business card to check their state licensure or private certification. Private certification should be listed on their card, and some certifying organizations and schools have websites with a number you can call to confirm current certification and ask about training. With a cosmetologist, it is best to ask for the lightest resurfacing available until you are confident with their work. This may only be application of a low-concentration cosmetic acid, but if there are no problems, you can then return later for a stronger peel. Some people may think it's unnecessary to check licensure or private certification for light resurfacing, but problems can still occur, and you don't want to risk scarring your face.
Light resurfacing generally does not require topical anesthetic, and you should not feel any more than a strong stinging sensation on the skin. If you feel any intense pain, signal for them to stop the procedure and figure out what is wrong. Even with light resurfacing, mistakes such as high acid concentration can happen. Also, if you are having a chemical peel, there should be a large bottle of water nearby in case any acid gets in your eyes.
If you want to get light resurfacing, beware that some doctor's offices and
many cosmetologists may try to pressure you into signing up immediately for
multiple procedures or buying other expensive "special" or "secret" skincare
treatments and products. They may try to sell you some of the unproven
products mentioned previously in this FAQ. There are all sorts of high-
profit cosmetic "skincare systems" sold by some doctors and cosmetologists.
This sort of sales pitch is more common at the spas that some doctors have
opened and with many cosmetologists. Other than the higher-concentration
cosmetic acids, you can buy similar products for much less at specialty
cosmetics stores and some drug stores. You should select a practitioner who
doesn't pressure you to buy unnecessary products and services.
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As mentioned previously, there are also nonablative lasers, non-laser intense pulsed light (IPL) sources, and radio frequency (RF) devices used by some doctors which are designed to stimulate collagen production in the dermis without removing (or ablating) the epidermis. See for example, "Noninvasive Rejuvenation of Photodamaged Skin Using Serial, Full-Face Intense Pulsed Light Treatments," Dermatological Surgery, 26(9), 835-842, 2000 Sep (abstract available on Medline.) Most of these devices require multiple treatments over a few months to produce a noticeable effect. Doctors generally say that improvement with nonablative methods is modest. Results are usually better than light resurfacing, but not nearly as significant as with medium resurfacing. Fine lines can be reduced and wrinkles reduced in depth. Some devices also produce modest improvement in skin texture, discolorations, small capillaries and acne. (There are also some specialized light treatments specifically for acne, but these are different than nonablative treatments for photoaging.)
The advantages of nonablative methods over medium resurfacing are minimal risk of infection and scarring, and much reduced healing time and skin redness. The procedures may not require any anesthetic or just a topical cream or gel. If you can't afford to take time off from work and don't want temporary pink or discolored skin, this is an option. You can usually have the procedure done on Friday, and return to work on Monday or Tuesday. It is also an option for people with dark skin or those with large pores and a lot of skin oil who could have discoloration or healing problems with resurfacing. A series of nonablative laser or IPL treatments will cost between $700 and $3000 depending on the device used, the number of treatments, and the area to be covered.
Nonablative treatments are performed by the same doctors that do medium resurfacing. A nurse or physician assistant can also do the treatments under a doctor's supervision. You can use the same methods described previously to find a doctors office that offers these treatments. Beware that some cosmetologists may also advertise "high-tech" skin treatments that sound like nonablative laser, IPL or RF, but are actually not very effective. Effective nonablative devices are expensive, and most cosmetologists do not have access to this equipment unless they are affiliated with a doctor's office.
Results with nonablative devices vary widely and are dependent on the type of device used. There are many different nonablative devices available with brand names such as N-Lite, Cooltouch, Smooth Beam, V-Star, Aramis, EsteLux, ThermaCool TC, and Photoderm. Some of these produce better results than others, and there are new improved models coming out every year with different characteristics. Some doctors have said in news stories that the effects from nonablative devices last only about three years. Other doctors have reported on their websites that a significant fraction of their patients did not get any visible results with some brands of nonablative devices. So before you commit to treatment, do some research. Do a search of the Net, newsgroups, and Medline using the exact name of the device the doctor uses to check for studies and patient reviews. Also ask the doctor to show you some before-and-after photos of other patients, not just pictures in a marketing brochure. Due to the myriad of new devices now available, it may be prudent to wait a few years to see which devices are reported in medical studies to be most successful.
Because of the large number of different nonablative devices, it is difficult
to generalize about their risks. Temporary skin redness is possible, and
there is still the possibility of scarring if too much energy is introduced
into the dermis. You should wait at least a month after your first treatment
to see how your skin responds before having a second treatment. There are no
long-term safety studies yet. You can check for new medical studies on these
devices by searching Medline using "nonablative" and either "skin,"
"photoaging" or "photodamage". Ask your doctor about any specific risks for
the particular device being used, including cautions for Accutane patients
and pregnant women. Doctors are currently experimenting with schedules to see
if it is safe to repeat a series of treatments after a number of years. To
help maintain results, tretinoin and cosmetic acids can be used following
nonablative treatments on the low-frequency maintenance schedule described
previously.
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Skin oil, or sebum, is produced by sebaceous glands attached to your skin pores and prevents your skin from drying out and flaking. As adolescents, most people get a temporary increase in sebum production and some acne. This is due to an increase in androgen (male hormone) levels in both males and females that stimulate the sebaceous glands. However, many adults continue to have low-level acne throughout life, and some experience an increase in sebum as they age.
If your skin is just "shiny", but your pores are small and you don't have acne, you don't really have a skin problem (though cosmetics companies may want you to think so.) Just having oil on your skin is not a bad thing; people with dry skin who must constantly use moisturizers wish they had more skin oil. In this case, excess sebum on the surface of the skin can be removed by simply washing a few times a day or using absorbent pads (but avoid excessive use of alcohol-based astringents, which can irritate the skin.)
In some people, excess sebum is a real medical problem. It can become impacted in pores, temporarily enlarging them and leading to acne symptoms like blackheads, whiteheads or inflamed areas. Mild cases of acne can be treated with non-prescription topical benzoyl peroxide, which helps prevent bacterial inflammation and causes drying and peeling of the epidermis. Some doctors also prescribe oral or topical antibiotics. In addition to producing an inflammation reaction, bacteria also cause chemical changes in the pore that can contribute to the formation of a sebum plug. So in many cases, a few-month course of oral tetracycline or other antibiotic can be helpful. However, even if the bacteria and inflammation are eliminated, pores may still appear larger and darker than normal due to impacted sebum. (The dark color is due to oxidation of the sebum, not dirt.) Soaps, cleansers, and abrasive scrubbing usually will not remove sebum that is impacted in pores. (That's like trying to remove some clay packed inside a pipe by washing the open end.) Excessive sebum has to be treated with topical or oral medications.
The best topical treatments for sebum impacted in pores are prescription retinoids like tretinoin (Retin-A, Avita, or generic), tazarotene (Tazorac gel), or adapalene (Differin). (Tretinoin and tazarotene were described previously as effective treatments for photoaging.) You need to go to a doctor, preferably a dermatologist, to get a prescription for these medications. While they don't significantly reduce sebum production, prescription retinoids allow sebum to be shed more easily from the pores. Over time, this can make the pore opening appear smaller, because it is not distended with sebum. Usually, acne will get slightly worse when you first start using retinoids, so you have to use them for a few weeks before you see any improvement. As mentioned previously, you can treat clogged pores by alternate nightly use of a retinoid and non-prescription, low-concentration salicylic acid gel. A very effective strategy for treating whiteheads and inflammatory acne is alternate use of a retinoid and non-prescription benzoyl peroxide. Store-brand benzoyl peroxide cream or lotion in 5% or 10% concentration can be purchased at most drug and discount stores for only about $4 for 30 grams. The 5% concentration is usually sufficient and causes less drying and peeling than the 10% concentration. If necessary, you can dilute the 10% lotion with distilled water.
The different retinoids work in slightly different ways, so one may work better than the others in your case. Generic tretinoin cream (0.025%, 0.05% or 0.1%) or gel (0.025%) is usually the least expensive so you should try it first. It costs about $25 for 20 grams. Most people prefer the cream form because tretinoin gel contains a lot of alcohol, which can be irritating. The gel also doesn't spread as easily as the cream. However, the gel may work better for some people to clear pores. Adapalene gel (0.1%) costs more, but usually causes less irritation than tretinoin or tazarotene for people with sensitive skin. Adapalene only comes in a gel, but it doesn't contain alcohol. It costs about $25 for 15 grams. Tazarotene gel (0.05% and 0.1%) is the most expensive, but some doctors say it may work better than tretinoin or adapalene on blackheads. It costs about $60 for 30 grams. Tazarotene gel contains only a small amount of alcohol. Tazarotene also comes in an emollient cream, but it isn't appropriate for acne because it contains mineral oil. If you find one of the retinoids that works well, you can save money by next buying a larger tube. They usually cost less per gram than the smaller tubes. You can also save money by buying the highest concentration available and simply using a smaller amount than normal on your face. You can spread a small amount easier by first lightly wetting your face and dabbing the medication on your forehead, cheeks and nose. You should also ask your dermatologist for free samples of tretinoin, adapalene, and tazarotene. They often have small tubes to give away. As mentioned previously, retinoids should not be used by women who are pregnant or may become pregnant.
If absolutely necessary, large blackheads and whiteheads can be removed manually. You shouldn't squeeze them out with your fingers or you can cause bruising, scarring and pore enlargement. A better method is to use a wire- type tool, sterilized with rubbing alcohol. A good brand is the Tweezerman Skin Care Tool, sold at drugstores (or see tweezerman.com). However, it is still possible to damage your skin with these tools, so follow the directions carefully. If you can't remove the sebum with a light pressure, wait a few days for your topical medication to loosen it. If you press hard and crush the skin around the pore, you can badly damage the skin and even cause the pore to enlarge permanently. Unless the spots are large and unsightly, many doctors say that it is better simply to let the medication remove them, rather than risk skin damage by using the tool. Retinoids, salicylic acid, and benzoyl peroxide will usually loosen the sebum plugs in a few days so they can be washed off. An alternate manual method for removing blackheads with less risk is use of special adhesive pore strips (sold in the acne-care section of stores). These have a special glue that is supposed to adhere to sebum plugs and lift them out. This seems like a good method, but results reported on the Net by users of pore strips are variable. Some people say they work, but others report that they usually only remove a small number of blackheads. They are also expensive if you use them frequently. There are a few different brands, so you can try them to see if they work for you.
For some people, retinoids alone are insufficient to treat the impacted sebum that clogs pores. Also, resistant impacted sebum can be an early sign of some conditions like seborrhea, in which the sebaceous glands enlarge abnormally, particularly in the center of the face. There are effective oral prescription treatments that act directly to reduce sebum production by the sebaceous glands. However, these medications can have side-effects, so you should first try each of the various retinoids for at least three months. If none of the retinoids work for you, and you still have persistent daily blackheads or whiteheads, your sebaceous glands are abnormally producing too much sebum. This is a medical problem, not just a cosmetic one, and your doctor should be willing to prescribe oral medications. However, you may have to search for a doctor that will take this problem seriously enough to prescribe these. Some doctors also resist prescribing oral medications for excess sebum because they are concerned about potential legal liability for side-effects. (There are some patients who sue doctors even after all the risks of side-effects are carefully explained to them.)
Sebum production is partially controlled by androgens which stimulate the sebaceous glands. In females, chronic elevated androgen levels can lead to acne, excess body hair, loss of head hair, and menstrual problems. Even androgen levels that are at the upper level of the normal range can cause excessive skin oil. A doctor can reduce sebum production in women with oral medications that affect androgen production such as anti-androgens, glucocorticoids, or oral contraceptives. The FDA has approved some oral contraceptives specifically for this purpose (for example, Ortho Tri-Cyclen). You can discuss this treatment option with your dermatologist, gynecologist, or your regular doctor. However, it may be better to see a endocrinologist for this treatment, since they have much more experience in performing the required tests and prescribing the appropriate medications. An endocrinologist is a physician who specializes in the treatment of hormonal problems. Your regular doctor or dermatologist may not be sensitive to this problem, so you may have to find an endocrinologist yourself. See ABMS.org for certified endocrinologists in your area. For further information see "Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Hyperandrogenic Disorders," Endocrine Practice, 7(2), 120-134, 2001 Mar-Apr (full text available on the American Association of Clinical Endocrinologists website).
In adult males, excess sebum production is usually due to increased sebaceous gland sensitivity to androgen stimulation, rather than to elevated androgen levels. Pharmaceutical companies are currently working on medications that can be taken by both men and women which block the effects of androgens on the sebaceous glands. These experimental medications are similar in concept to prescription finasteride (Propecia and Proscar) which blocks the harmful actions of the hormone dihydrotestosterone (DHT). (DHT causes hair loss and prostate enlargement in men.) You can ask your dermatologist if any of these medications have been approved, or periodically check the newsgroup alt.skincare.acne and websites that discuss acne treatment. If these medications can be perfected, they will revolutionize the treatment of acne and excess sebum. In rare cases, excess sebum in males may be due to adrenal gland dysfunction and hyperandrogenism. See for example "Acne in the Male Resistant to Isotretinoin and the Responsibility of Androgens: 9 Cases, Therapeutic Implications," Annales de Dermatologie et de Venereologie (France), 126(1), 17-19, 1999 Jan (English abstract available on Medline). This is usually discovered in men after multiple courses of the prescription drug Accutane have failed (see below). In these cases, an endocrinologist should be consulted. These cases require specialized treatment and monitoring, since anti-androgen therapy can cause feminizing effects in males.
The most potent medication available to reduce sebum production is oral isotretinoin, brand-name Accutane, a chemical related to vitamin A. It acts directly to shrink the size of the sebaceous glands and reduce sebum production. Sebum production is usually permanently reduced after Accutane is taken for a number of months. It can be taken by both men and women, however, it can have significant side-effects similar to those of vitamin A toxicity. The possible side-effects include birth defects in pregnant women, ocular effects (including some reports of cataracts), effects on bones and joints, severe headache and fluid pressure in the head, mental depression, increased blood triglycerides or cholesterol, and a worsening of the skin condition known as keratosis pilaris. As previously mentioned, Accutane can also temporarily affect skin healing, so you must wait at least a year before having any type of resurfacing procedure. Because of the possible side- effects, doctors are generally reluctant to prescribe Accutane except for severe inflammatory acne. However, because sebum production is significantly reduced, Accutane also works very well on blackheads and whiteheads, eliminating them permanently in many people. So some doctors will now prescribe Accutane for persistent moderate adult acne. See for example, "Treatment of Acne With Intermittent Isotretinoin," British Journal of Dermatology, 137(1), 106-108, 1997 Jul; "Roaccutane Treatment Guidelines: Results of an International Survey," Dermatology, 194(4), 351-357, 1997; and "Acne Vulgaris in the Elderly: the Response to Low-Dose Isotretinoin," British Journal of Dermatology; 139(1), 99-101, 1998 Jul. (Note that "Roaccutane" is one European brand-name for Accutane or isotretinoin.) You can download abstracts of these papers from the Internet medical index Medline and discuss them with your doctor.
While most people do not develop severe side-effects with Accutane, you must be willing to accept their risk and not blame your doctor if you have problems. Your doctor may have you sign an informed consent form before prescribing Accutane and will usually want you to have periodic blood tests to check for certain side-effects. Women who are pregnant or who may become pregnant during treatment must never use Accutane because of the high probability of serious birth defects. Doctors will require a woman to take a pregnancy test and agree to abstain from sex or use birth control methods before prescribing Accutane. Do not use tetracycline or similar antibiotics while taking Accutane, since the combination may cause increased pressure in the brain.
As mentioned, Accutane may also worsen the acne-like condition known as keratosis pilaris, which produces small non-inflamed bumps of dead skin cells and sebum on the upper arms, thighs, chest, back and rear. This is not mentioned in medical information on Accutane, however, it has been reported by some patients. This possible side-effect is unexpected because Accutane has been used to treat skin disorders similar to keratosis pilaris. While Accutane still reduces facial sebum in people with this condition, the keratosis pilaris often appears on larger areas of the back, chest, and rear soon after finishing an Accutane course. This can last for many months or even be permanent. To treat keratosis pilaris, doctors recommend tretinoin, prescription lactic acid products, glycolic acid, and abrasive scrubs to, but the condition can be persistent and very annoying.
Accutane dosage is calculated by your body weight, however, some research indicates that daily dosage can be reduced so long as the total accumulated dose over the course of treatment (that is, the number of pills taken) is the same. So you can reduce the risks of taking Accutane by starting out with a low daily dose to see if there are any serious side-effects. Some side effects are normal such as dry skin, chapped lips, dry nose, and dry eyes. Often you will also see an increase in the number of blackheads or whiteheads right after you start taking Accutane, but this is normal and stops within a few weeks as your pores clear of accumulated sebum. Serious side-effects to report immediately to your doctor while taking Accutane include severe headaches, nausea, vomiting, or vision problems. If you don't have any problems, your doctor can have you gradually increase the daily dose, and adjust it again later if needed. To minimize side-effects, it is also advisable when finishing a course of Accutane to taper off the dosage gradually over a few weeks rather than stopping abruptly. This can be done by taking fewer low-dose pills each day or taking high-dose pills only on alternate days.
According to medical research, the majority of people who take a course of Accutane will see a permanent reduction in sebum production of about 40%, although their skin will not remain nearly as dry as it was during the course of treatment. However, even though sebum and acne will be significantly reduced, most people will need to continue regular or occasional use of topical retinoids like tretinoin or tazarotene to keep their pores clear. About 20% of people will relapse in the future and require a repeat course or multiple courses of Accutane. If sebum production quickly returns to pre-treatment levels following a course of Accutane, elevated androgen levels should be suspected in both men and women, and an endocrinologist should be consulted. If androgen levels are normal, and a patient relapses following multiple Accutane courses, some doctors will prescribe a low dose of Accutane to be taken continuously (with regular blood tests). If elevated androgens are the cause of excess sebum, it will only be temporarily suppressed by Accutane. This is more likely with women, so to avoid wasting money on Accutane, all women should have androgen levels checked before starting an expensive Accutane course. Elevated androgens in women should be treated before Accutane is considered.
All oral treatments for excess sebum can be expensive. Insurance companies will usually pay for hormonal treatments and oral contraceptives if a doctor prescribes them for acne (which includes blackheads and whiteheads) or an identified hormonal dysfunction. However, Accutane is very expensive, and most insurance companies will not pay for it unless it is prescribed for severe acne that does not respond to retinoids. You may have to pay for it yourself if your dermatologist is treating you for excess sebum and mild acne. You will also have to pay for any blood tests your doctor requires while on Accutane.
Accutane is now available as a generic, so have your doctor prescribe it using the generic name isotretinoin. An isotretinoin course will cost at least $200 per month (depending on your body weight), and you will need to take it for at least four months to prevent relapse. So compare prices at local and mail-order pharmacies.
Prices for isotretinoin are usually much lower at Canadian and British mail- order pharmacies than at USA pharmacies. Pharmacies in Canada and Britain generally have isotretinoin made by Roche Laboratories and equivalent generics, but beware that pharmacies in Mexico and many other countries could have isotretinoin of dubious quality. There have been a number of news reports on foreign pharmacies selling bogus expensive medications like isotretinoin in convincing counterfeit packaging. See the cautions listed previously in Section 4 regarding foreign pharmacies.
As previously mentioned, USA law and FDA regulations govern the importation of prescription drugs. Whenever importing medications, the FDA regulations limit you to a three month supply. As mentioned previously, drugs that are also available in the USA can be confiscated by Customs agents if they choose to strictly enforce the law. There is also an FDA policy that strongly discourages USA importation of certain prescription drugs with potentially serious side-effects, including isotretinoin. If an imported package containing isotretinoin is inspected by Customs agents, it will probably be confiscated. You may not be able to contest the charges on a pharmacy credit card order, and you could lose the money you spent on the medication. So check first with any Canadian or British mail-order pharmacy for their policies on shipping isotretinoin before ordering. Usually they will say that they can legally mail the product from their country, but they can't guarantee that it won't be confiscated. They usually won't refund your money if a package is confiscated.
If you cross the border yourself with isotretinoin, be sure to have with you a copy of your prescription, your doctor's business card, and a signed statement like the one described previously for importing tubes of tretinoin. You are limited to importing a three month supply. Even if you have all this, confiscation is still probable under the FDA policy.
You should always let your doctor know in advance that you will be having your prescription filled by a Canadian or British pharmacy or be crossing the border with your prescription, just in case Customs calls the doctor to confirm your prescription. Tell the doctor that you want to do this to save money. Because of the very high cost of pharmaceutical drugs in the US, many doctors are used to their patients getting their drugs from Canada or Britain. As mentioned previously, importation of pharmaceuticals is a controversial issue, and the law may change to make the regulations less restrictive or more restrictive.
If you can't afford generic isotretinoin and have severe acne, your doctor
can help you apply to Roche Laboratories or a generic manufacturer to obtain
Accutane at reduced cost under the companies' "Patient Assistance Programs."
See pparx.org/ for more information.
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Wounds or surgical incisions that penetrate into, or through, the lower dermis are likely to cause scars. The scars that form are classified as hypertrophic (raised) or atrophic (depressed or flat). Keloid scars are hypertrophic scars with especially hard and prominent tissue. Following a wound, it can take a long time for the skin to fully heal. Non-keloid scars that form from a wound will often become less prominent over time, but this can take many years. Most of the treatments to minimize scars are best performed either when the wound is closed, early in the healing process, or soon after the scar forms. Old scars can still be treated, but there are fewer options.
In treating scars you should have a realistic goal of achieving improvement in the skin's appearance, rather than expecting the scar to disappear. Topical treatments generally will "soften" the appearance of scars, but they will still be noticeable. With topical treatments you must also be patient, because it will usually be a few months before you see any improvement. The greatest improvement can be achieved with surgical or resurfacing procedures performed by a doctor.
As a wound heals, you can minimize scar formation by keeping it moist and free of infection. After the wound is cleaned and closed (if necessary), apply non-prescription Neosporin, Polysporin, or a similar antibiotic ointment under a bandage. For burns, you can also ask your doctor for prescription Silvadene ointment. Gently wash every day with soap or an antibacterial cleanser, and apply a new bandage and ointment. Don't let the wound dry out, or the resulting scar will be worse. Don't pick off any scab that forms, let it fall off by itself. Applying an ointment or cream with cod liver oil and zinc oxide after the skin has started to heal over may also help the epidermis regrow. Large burns, cuts, or lacerations must obviously be treated immediately by a medical professional; there are many new specialized techniques and wound dressings that can minimize scar formation in large injuries. If you have a cut or laceration that is likely to cause a large noticeable scar, particularly on the face, you can request that a plastic surgeon close the wound. Some emergency-room doctors may not be as skilled in minimizing scars. Insurance may not cover the difference in cost of a plastic surgeon, but it is usually worth the money to have a less-noticeable scar.
If you have a new, moderately-raised scar, daily massage of the scar using a moisturizer or oil can help soften the stiff scar collagen. Vitamin E oil is sometimes recommended for massaging into scars, but regular moisturizers may work just as well. Medical studies have generally found that vitamin E oil has no special effect on scars, but many Net posters say it has improved their scars when rubbed in daily.
Some Net reviewers have reported success using non-prescription Mederma gel on new, moderately-raised scars ( mederma.com, available at pharmacy counters). However, others have reported little effect. The active ingredient in Mederma is onion extract, which has been shown to inhibit the growth of collagen in test tubes (possibly resulting in a flatter scar). Mederma costs $15 or $25 (depending on tube size). You have to use it for a few months to see any effect. Mederma may inhibit epidermal healing when used on new wounds, so it should only be used after the skin has healed over the wound and a raised scar seems to be forming. Mederma doesn't work on depressed or pitted scars. (On depressed scars you don't want to inhibit collagen growth.) In the past, Mederma has offered a money-back guarantee, so check the box or the instructions before purchasing, and keep your receipt.
You can buy medical-grade silicone sheets for scar treatment that are taped over moderately-raised scars to flatten them over time (however, they won't work on keloid scars.) They may also help flatten uneven areas from second-degree burns. There are many medical studies that show this method improves the appearance of new scars, though the mechanism is unknown. It doesn't seem to work as well on old scars. It has been quite successful with new surgical scars. See for example, "Effectiveness of Silicone Sheets in the Prevention of Hypertrophic Breast Scars," Annals of Plastic Surgery, 37(4), 345-348, 1996 Oct; and "Effect of Four Treatment Variants on the Functional and Cosmetic state of Mature Scars," Journal of Wound Care, 9(7), 319-324, 2000 Jul (abstracts available on Medline). You need to keep the scar covered with this material for at least 10 hours per day for about eight weeks to see results. The longer you use the mater