Nonmalignant Photodamage

Ablative and Nonablative Skin Rejuvenation

Ablative techniques for treating photoaged skin are available through family practitioner consultation to a local dermatologist or plastic surgeon.

Ablative lasers available for photo-rejuvenation include the CO₂ laser and erbium-yttrium-aluminum-garnet.^[46,47] Indications for laser skin ablation include resurfacing of photodamaged and aged skin, removal of superficial epithelial and dermal lesions, pigmentary and melanocytic disorders, scar revision, bloodless surgical field, and treatment of miscellaneous lesions.^[48] All laser-resurfacing procedures generate injured areas with a subsequent risk of bacterial, viral, or even fungal infections.^[49] The CO₂ laser vaporizes tissue to the papillary dermis, with an increase of up to 50% improvement of skin tone and wrinkle severity. This laser also offers tissue contraction, hemostasis, neo-collagenosis, and collagen remodelling with a shortening of collagen to one-third of the original length.^[50,51] Potential side effects include pigment alteration ectropion, scarring, milia, infections, and flare of herpes simplex virus. This therapy is contraindicated in actively infected skin, isotretinoin/acitretin, and keloid history. The erbium-yttrium-aluminum-garnet is also used in skin resurfacing. It offers treatment of superficial epidermal and dermal lesions, mild photodamage, and subtle depigmentation. This laser offers less risk of depigmentation but is poor for wrinkles and has slower, delayed effects on collagen remodelling.^[47]

Nonablative lasers are also available for therapy of photodamaged skin. These laser systems generate heat production within dermal connective tissue without necessarily removing the overlying epidermal skin surface.^[52] However, apart from some tightening due to an initial edema, wrinkle improvement is less remarkable than with ablative techniques unless some degree of dermal fibrosis is achieved. A newer nonablative laser, the Fraxel® laser, is a glass fibre laser producing subablative pulses of light. Over the course of multiple treatments, most of the skin surface can be replaced, with no visible epidermal damage immediately following treatment. The appearance of rhytid scars, pigment irregularities, and vascular lesions improves with each treatment.^[53] The pulsed dye laser is useful in treatment of fine wrinkles, with enhancement of collagen and matrix protein production. Side effects are minimal and include edema, purpura, and transient postinflammatory hyperpigmentation.^[54] The Q-Switched: Nd YAG laser improves fine wrinkles (30%) and aids in photorejuvenation with a 70% reduction in erythema and pigment.^[54] Other lasers in current use include the Smoothbeam®. These lasers offer modest results in treatment of mild to moderate wrinkles, and mild atrophic facial scars with neo-collagenosis and collagen remodeling.^{[55,56,57,58]}

Intensified Pulsed Light is an alternative to laser systems with polychromatic flash lamp sources. The intense pulsed light targets both melanin and hemoglobin. The removal of age-related vascular changes or pigmentary disorders along with a lightening of freckled aged skin surface is useful, with less successful skin tightening or improvement of fine wrinkles and textural changes (type 2 subsurfacing).^{[49,52,59,60]} The intense pulsed light is effective in decreasing fine wrinkles, leaving improved skin texture and pigmentation, as well as fading redness and other sun-induced hyperpigmented skin damage.^[61] Side effects are minimal and usually temporary.^[62,63]

Photodynamic therapy has been used as a less invasive method of improving fine wrinkles, photodamage, and various skin premalignancies and malignancies. The photodynamic effect from aminolevulinic acid (ALA) activation by the light source seems to enhance the results of light treatment alone, allowing the same degree of rejuvenation to be done in fewer treatments.^[61] Treatment of larger areas can achieve some degree of tissue tightening.^[52] In one study, an 82% patient satisfaction of skin texture improvement was noted.

Radio frequency devices (Thermage®) offer deep dermal heating with tightening of photoaged skin, lifts eyelids, and improves cheek and neck laxity approximately 30%.^[65] Offered over a one- to two-centimetre squared area with epidermal and upper dermal cooling, this procedure can heat the deep dermis and subcutaneous tissue, creating a focal zone of thermal injury. This stimulates contraction of the tissue. Clinically, Thermage (ThermaCool™) can be used to flatten nasolabial folds, raise eyebrows, reduce jowls, and tighten neck skin with no downtime.^[66] Apart from slight erythema immediately after this procedure, patients can return to work on the following day without sequelae.

Botulinum toxin (Botox) has become a key component in rejuvenation. It is often the first cosmetic surgery intervention that a patient might receive. It offers excellent efficacy in treating rhytides and has minimal downtime after receiving injections.^[61]

Fillers have been available for two decades with the arrival of bovine collagen (Zyderm®/Zyplast®). Several temporary dermal fillers, including human-derived collagen (CosmoDerm®/CosmoPlast®), have become available recently, with longevity similar to bovine collagen without the risk of allergic reactions.^[61] Last year, two hyaluronic acid-derived products, Restylane® and Hylaform®, were introduced. Restylane is useful for building up lips, filling deep rhytides and folds, and filling depressed areas due to loss of superficial fat with chronologic aging. Hylaform is useful for moderate rhytides and acne scars.^[67] Calcium hydroxyapatite, poly-L-lactic acid, and polymethylmethacrylate microspheres are all under study for tissue augmentation, with some reports of late developing nodules and granulomas. One last alternative is autologous fat transplantation for filling of significant soft tissue defects, dermis, and fascia. Unfortunately, these types of fillers are temporary in nature, with gradual remodelling of the treated area back toward baseline.^[61]

Surgical rejuvenation is the gold standard for improvement of significant skin laxity. Endoscopic facial lifting procedures and bidirectionally barbed polypropylene suture placement offer less invasive alternatives to traditional "face-lift" procedures.^[61]

Geriatrics and Aging. 2006;9(7):494-498. © 2006 1453987 Ontario, Ltd.

Cite this: Nonmalignant Photodamage - Medscape - Jul 01, 2006.