To achieve a flawless complexion, one must consider the skin as a whole – and not merely the outside. Here Dr Sly Nedic reports on the best treatments for each layer of the skin.
To improve their skin-ageing problems, many patients often desire one single procedure that is both long lasting and good value for money. However, skin ageing is a complex process involving multiple factors affecting different skin layers – and each of them requires specified intervention that addresses the causes and damage.
Skin layers: what’s affected? In a very simplified way, skin is divided into three layers: the epidermis, dermis and hypodermis. The epidermis is the outer layer that contains skin cells, pigment, and proteins. Due to intrinsic ageing mechanisms (the genetically predetermined shortening of telomeres), cell renewal is lessened by 50% at the age of 50. This leaves the skin looking dull and finely wrinkled. In addition, the reactive oxygen species (ROS) level rises and antioxidant capacity decreases with intrinsic ageing, leading to cell damage from oxidative stress.
The epidermis: The epidermis is very sensitive to the extrinsic factors of ageing such as UV radiation, which is responsible for 80% of facial photo-ageing. UV radiation also destroys anti-oxidant components, mitochondrial activity and telomeres. In addition to this, pollution, malnutrition, smoking, alcohol and andionising radiation can also contrib- ute to epidermal cell damage, which leaves the skin looking coarse, pigmented and wrinkled. Since the dermis provides nutrients to the epidermal layer and is affected by hormonal ageing, menopausal skin will look pale and thin. From knowing the causes of epidermal ageing and understanding the complexity, the following can be used:
- Sunscreens with broad-spectrum coverage and adequate UVA and UVB protection. Preferably, they should be organic to reduce skin photo-ageing. Novelty sunscreens are designed to allow vitamin D production and infrared rays protection.
- Anti-oxidants such as vitamin C, E, B3, CoQ10, retinoids and ferulic acid are used for oxidative stress, have a photo-protective effect and are commonly used topically.
- Polyphenols such as black and green tea, ellagic acid from berries, and resveratrol, genistein, etc. are usually used systemically (as supplements) since they deliver high antioxidant activity – yet they can also be used in skin care products. Resveratrol is my favorite one, and I usually prescribe it to my ageing patients as I know that it’s effective in preventing UV-induced photo-ageing and pigmentation.
- Carotenoids, pigments such as astaxanthin and lycopene, have an excellent profile in minimising skin wrinkles from excessive UV photo-damage when taken orally.
- Superficial chemical peels to increase renewal of the cells.
- Ablative lasers and IPL.
- Stem cell topical treatment.
- LED phototherapy has a profound effect on skin renewal in the epidermal layer.
- Growth factors can be derived from different sources like humans, plants, microbes and animals as they regulate cell proliferation. In one recent study, growth factors that were used topically showed significant improvement of crow’s feet.
The dermis The dermis is the middle section situated directly below the epidermis. It contains nerves, blood vessels and fibroblasts that deliver nutrients and surround sensory receptors. The dermis also provides strength and support to maintain structure of the skin. It is most abundant in collagen (80%) whose primary function is to retain skin firmness, and less in elastin, which contributes to elasticity. The base of the dermis is composed of complex sugars: hyaluronic acid, proteoglycans and glycoproteins. Genetically predisposed intrinsic ageing (telomeres shortening) induces partial degeneration of collagen, as there is a smaller amount of fibroblasts and enzymes involved in the production of collagen from pro-collagen. This affects skin elasticity and firmness, which leads to sagging and thinning of the skin. Nutritional and lifestyle changes designed to decrease telomere shortening can also slowthis process impressively, proving the functional medicine approach: beauty of the skin is what you put inside – not outside. Antioxidant activity is additionally lowered with intrinsic ageing. This may lead to the up-regulation of MMP genes, which code for enzymes that stimulate the degradation of collagen. Hormonal ageing lowers estrogen, testosterone and DAHAs – and is a contributing factor in reducing collagen and elastin content. Estrogen receptors in the dermis are objects of research for new topical compounds, which is for the prevention of collagen deterioration due to hormonal ageing. Advanced glycation end-products (AGEs) are also hugely responsible for collagen loss in the dermis. As early as the age of 20, individuals start producing AGEs at a rate of 3.7%. This is more enhanced in people whose diets are high in sugar and in those who are diabetics. So, it is not uncommon to see premature sagging skin in younger women who consume a large quantity of sugar. UV radiation affects the dermis as well and contributes to collagen and elastin loss (sagging, thinning, pigmentations and wrinkling) via several mechanisms with a higher expression of MMPs. This contributes to collagen distraction, free radical formation, destruction of a skin’s own antioxidant capacity, DNA mutation and down regulation of pro-collagen production. In other words, it does not matter how much collagen you take in and how many collagen enhancement medical procedures you undergo; if you don’t protect your skin from harmful UV radiation, your skin will continue to lose its firmness and elasticity. Lifestyle and environmental toxins: poor nutrition, high alcohol consumption, infrared radiation, psychological and physical stress, persistent organic pollutants and tobacco all use similar mechanisms to disturb collagen and elastin metabolisms in the dermis. How can we stop ageing of collagen and elastin in the dermis, enhance their production and stop the skin from sagging?
- Vitamin C, E, coenzyme Q10, alfa lipoic acid and retinoids used in topical creams can penetrate and improve anti-oxidant capacity of a dermis, indirectly helping to prevent further distraction of collagen.
- Systemic use of carotenoids and polyphenols both have a similar effect, but their concentration is much higher once used orally as a supplement.
- Systemic use of collagen needs to be taken with vitamin C, which is a necessary component in a production of new collagen from pro-collagen.
- Detoxification: patients often report improvement on their skin after a few days of juicing, but actual medical detoxification not only decreases the harmful effects of toxins and heavy metals, it also enhances oxidative capacity of the skin to fight free radical formation (ROS).
- Topical growth factors in different dermaceuticals have limited effects when compared to dermal administration of growth factors via mesotherapy.
- PRP: platelet reach plasma induces fibroblasts to produce more collagen.
- Mesotherapy with growth factors, hyaluronic acids and antioxidants.
- Medium and deep chemical peels.
- Ablative lasers.
- Fractional lasers.
- Radiofrequency: monopolar, bipolar, etc. (e.g. Thermage, Tripolar).
- Infrared tailored light, such as Titan.
- PDO and Silhouette threading.
- Ultrasound therapy.
- Collagen induction therapy with Dermaroller.
- Dermal fillers: primary effect is a tissue integration to enhance the volume of extra-cellular matrix and less of collagen induction.
- Systemic bio-identical hormone replacement (estrogen, testosterone growth hormone, DHEAs).
When a patient wants to address skin laxity problems (sagging), then all of the above methods could be used simultaneously for advanced collagen production. The results will depend on how many factors are involved in a patient’s ongoing ageing. The rate at which collagen is destroyed in a patient who is a smoker, sun lover, sugar consumer, highly stressed and is already in menopause is different from someone who eats organic, low glycemic food, regularly detoxes and use bio-identical hormones. Your dermis mirrors your lifestyle!
Hypodermis The hypodermis is the deepest layer, which contains fat tissue, connective tissue and muscle. Unfortunately, this layer is also prone to ageing – from the degradation or fibrosis of connective tissue, to muscle atrophy (due to growth hormone decline) and the sagging of fat tissue. However, this area is vastly important for 3D face recontouring, liquid facelifts and (what we call in aesthetics) “treating the shadows on the face and not just wrinkles”. This is where we use:
- Botulinum toxin to treat hyperkinetic lines and stop excessive muscle activity.
- Volumising fillers to simulate lifting in areas of enhanced fat tissue sagging.
This basic understanding will allow patients to recognise why achieving flawless skin with superficial chemical peels, for example, does not mean that the sagging of the skin will improve substantially. Every area needs adequate treatment that respects the structure that is damaged.