Vol. 15 •Issue 10
• Page 53
Aging Gracefully
Skin Care for Midlife and Older Women
By Donna Rinker, NP
The skin provides protection from foreign bodies, bacteria, viruses and fungi, regulates body temperature and facilitates synthesis of vitamin D.1 In a healthy person without disease, the skin repairs itself as part of a continuous cycle of cell renewal and remains resilient despite a variety of environmentally imposed stresses.
Skin function is determined by factors such as genetics, race, environmental exposure, lifestyle, nutrition intake, medications, exercise and daily preventive measures.2 The external appearance of skin is a reflection of internal health and often is an integral factor in self-esteem.3
A Primary Care Issue
A 2006 roundtable of dermatologists concluded that primary care professionals have clinical opportunities to provide more thorough skin assessments and skin care education to patients, but many are limited by time, reimbursement issues and lack of education about skin health.3 Recent data show that 52% to 67% of primary care visits each year are made for skin problems — and that patients are confident their primary care providers can adequately diagnose and treat these problems.4
Throughout my primary care encounters in family practice and in my separate skin care clinics, patients ask me about strategies to look younger. In particular, women want immediately visible results with minimal downtime and little discomfort. They are generally willing to experiment with a variety of treatments, procedures and products to achieve this goal.
Skin History and Assessment
The annual physical is an opportune time to address how aging affects skin health. Begin by taking a skin history (see Table 1). The subjective data obtained from a verbal or written questionnaire provide valuable information about the patient's knowledge of skin health and her interest in skin treatment.
Next, perform a skin assessment. Cleanse the face and neck prior to inspection, using a mild unscented facial cleanser, tepid water, a soft nonabrasive cloth or the Clarisonic cleansing brush. This device uses sonic oscillating brushes to deeply cleanse the skin without harming or stripping protective layers.5
Follow the basic rules of skin inspection to examine the face and neck under natural lighting and light from a lamp. Palpate the skin to determine overall texture, resilience, temperature, skin type (oily versus dry) and hydration status. Digital photographs provide important objective data that can be transferred into the patient record. Don't forget to obtain consent.
Skin Typing
The identification of skin type is an essential step in choosing the most beneficial products and treatments for skin.6 Dermatologist Leslie Bauman, MD, has developed a skin typing system that classifies skin in four ways: oily-sensitive, oily-resistant, dry-resistant and dry-sensitive. Each category is then divided into subgroups based on pigmentation and wrinkling. When included in the patient assessment, skin type classification facilitates a treatment plan that is cost effective as well as clinically effective. A questionnaire to determine skin type is available in Baumann's book, The Skin Type Solution: A Revolutionary Guide to Your Best Skin Ever (Bantam, 2006).6
Why Does Skin Age?
Skin problems may result from emotional stress, excess caffeine, refined foods and sugars, insufficient water intake, food and environmental allergens, toxic cosmetic ingredients, previous sun exposure, sleep deprivation, insufficient essential fatty acids, hormonal changes and various medical disorders.
Reviews of charts in my family practice and skin care practice show that the most common findings on skin exams are as follows:
dull skin tone
large pores and oily skin
texture changes
brown spots
pigmentation changes
wrinkles
deep facial lines
sagging skin
rosacea
unattractive veins
adult-onset acne
stretch marks
cellulite due to weight loss or gain.
The stratum corneum, which is the superficial layer of the skin, is a primary line of defense against environmental stress and acts as a barrier to subcutaneous absorption.7 Retention of adequate water levels within the stratum corneum is crucial for maintaining proper moisture balance. In women of all ages, breakdown of the stratum corneum presents as dry, itching, red, chapped, flaking, tight skin.
Renewal of the epidermis cell cycle slows by 30% to 50% during the third and fourth decade in a woman's life, producing dull, rough skin and wrinkles.8 The natural moisturizing factor of the upper cells in the epidermis holds moisture, and the middle cells of the epidermis form a protective barrier to hold water in. The cell renewal process slows with aging, causing the skin to appear dehydrated until the cell cycle is stimulated by topical or systemic nutrients.
The major structural component of the dermis is collagen, a strong natural protein that strengthens and supports the skin.1 Our skin cells have estrogen receptors, which increase blood supply and improve the structure of the elastic fibers. The 30% estrogen decline that occurs in the first year of menopause decreases the production of elastin and collagen in connective tissue.9 This explains the appearance of deep nasolabial folds, thinner lips, sagging skin above the knees, etc.
Estrogen also increases the skin's water content by increasing the production of hyaluronic acid.9 This substance contributes to skin softness and thickness. Many topical skin products that contain hyaluronic acid hydrate the skin but never penetrate deep enough to replace what is depleted. Dermal fillers can achieve this and are discussed later in this article.
Pigmentation Changes
Pigmentation and skin tone changes are determined by melanin content and the effects of sun damage and irritation.10 Common skin conditions in people with fair skin tones are uneven pigmentation, ruddiness (redness), broken blood vessels and rosacea with or without acne. Rosacea, once thought to be vascular in origin, now is phenotyped as erythema-vascular, sebaceous-rhinophyma and inflammatory and ocular.11 The exact cause of this skin disease is still unknown, despite several recently circulated theories.12
The first-line treatment approach to rosacea is avoidance of triggers. Low-dose topical tetracycline, topical or systemic retinoids, antiparasitic agents, H. pylori eradication and second-generation macrolides are options that can produce favorable outcomes.12 In addition, patients with rosacea should apply sunscreen that contains antioxidants and anti-inflammatory ingredients. These sunscreen combinations protect the epidermal barrier and avoid transepidermal water loss. Mild glycolic and salicylic acid peels (antioxidant compounds) are recommended over microdermabrasion, which causes more inflammation.12
Advanced treatments for rosacea include pulsed laser therapy and phototherapy.13 These can decrease redness and blood vessels and increase collagen production to smooth and fill in the skin. When standard protocols fail, refer the patient to a dermatologist.
Some pigmentation changes may be symptoms of an underlying disorder in the endocrine or autoimmune system. Women with darker skin are prone to hyperpigmentation that worsens with injury and inflammation. Black women may be bothered by keloids and increased pigmentation from previous acne lesions, allergic skin lesions or scars resulting from injury. Melasma is more common in women who take oral contraceptives or estrogen therapy or are pregnant. The goal of treatment is to limit and protect the skin from sun exposure, to regulate hormones and to lighten the skin. Lightening can be achieved with products such as retinoids, low-dose glycolic acid and 2% to 8% concentrations of hydroquinone.7 (A pending FDA order to remove hydroquinone from the U.S. market is controversial among many dermatology experts.)
Recent research shows that glucosamine may reduce the appearance of solar lentigines and pigmentation by blocking biosynthesis of melanin, a building block for hyaluronic acid, which is a component of connective tissue.14,15 Skin care products that contain antioxidants and nicotinamide adenine dinucleotide, which is formulated from niacin, can penetrate the fat-soluble skin layer to repair DNA in sun-damaged skin, improve skin barrier conditions such as rosacea, and reduce hyperpigmentation.6 Combination approaches that incorporate controlled chemical peels, reduced sun exposure, daily sunscreen use, topical antioxidants and laser therapies can also lighten the skin and destroy these lesions.
Unwanted Hair Growth or Loss
Excess hair growth on the face, neck and other areas may be caused by genetics, estrogen imbalance, androgen levels or the aging stage of the hair.7 Hair removal is one of the most desired and common aesthetic treatments today.
Among older women, more common concerns are thinning or loss of hair on the scalp and loss of eyebrows or eyelashes. Estrogen loss, illness, weight loss, nutritional deficiencies and side effects of medicines may be factors in or causes of hair loss. Finding and treating the underlying illness is the most important step. Dermatology specialists recommend topical agents (minoxidil [Rogaine] or finasteride [Propecia]) and strategies such as changing hair styles and hair products. Daily dosing of spironolactone (Aldactone) can also be beneficial.
Studies of hair transplantation in women show that this treatment is less effective than in men due to donor region, increased risk of telogen effluvium and intact hairlines in the frontal, temporal and posterior area.
Varicose Veins
The emergence of telangiectasia and varicose reticular leg veins may result from genetic factors or increased weight or pressure. As the vessels weaken, blood leaks and collects, causing the appearance of bulging, enlarged veins.
Treatment for varicose leg veins is determined by the size, blood flow and hydrostatic pressure of the veins. Reticular or large varicose veins are best treated surgically or with endovenous ablation.16 Sclerotherapy is the standard treatment for smaller veins.16 Endovenous procedures are performed by vascular specialists, who use ultrasound-guided catheters and radiofrequency or intense light to destroy blood flow to the offending veins. In many patients, laser therapy and sclerotherapy are often used in combination to achieve optimal results.
Stretch Marks, Cellulite
Although cellulite is not a debilitating condition, it affects the psychological well-being of 85% of women.17 Factors leading to the development of cellulite include genetics, gender, ethnicity, hormones and age when fat growth first occurs. Estrogen plays a significant role in the etiology of cellulite and has a direct effect on the blood vessels of the body and skin. Cellulite results from breakage in the microcirculatory system.
Stretch marks result from overstretching of the skin. Stretch marks differ from striae in etiology and clinical presentation. Striae are dark purple, and they are associated with an underlying metabolic disorder. Stretch marks vary in color depending on skin type and are associated with pregnancy, weight gain and significant weight loss.
Research shows that women with stretch marks have deficiencies in total DNA and total protein that decrease the ability to reproduce or repair stretch-dependent skin injuries.18 Each woman's causative factors and skin type help determine her response to topical antioxidants and laser light therapy.
A healthy lifestyle built around a balanced diet and regular exercise may reduce fat volume in connective tissue, diminishing unsightly puckering of the skin. But this approach has demonstrated no significant clinical benefit in the reduction or elimination of cellulite in the underlying tissue structure.19 Likewise, studies of topical antioxidants, vasodilators, vitamin C, aminophylline, retinoids and herbal preparations alone or in combination have documented little effect on cellulite.
Mesotherapy is a newer approach designed to reduce cellulite by destroying fat cells with a combination of chemicals delivered in a series of injections. It is available on a limited basis in the United States but appears poised for growth. Mesotherapy was introduced in France in 1945 to treat deafness, infection and vascular and rheumatology disorders. Today, a mixture of phosphatidylcholine and deoxycholate (Lipodissolve) is undergoing evaluation for cellulite treatment in the United States.20 The mixture already has an FDA indication for nonsurgical induction of fat lysis.
On the laser treatment front, the Velasmooth and Triactive are the only two FDA-approved laser devices marketed for cellulite treatment. These devices use infrared radiofrequency in combination with manual or ultrasound manipulation of the skin to improve blood flow and breakdown of fat cells. Short-term research has documented improvement, but long-term data are not yet available.19
Liposuction, which has the support of long-term data, is a preferred procedure for reducing cellulite. SmartLipo is the first laser lipolysis technology that disrupts localized fat cells through a thermal and photomechanical action. It heats and ruptures the fat cell membrane.20 The provider inserts a heated cannula into the deep tissue using a repetitive technique to break down connective tissue and adhesions. This reduces fat volume and improves the contour of the body area being treated.
Adult-Onset Acne
Acne is a bothersome inflammatory skin disorder that affects self-image at any age. Sixty-three percent of women surveyed in one study reported a 25% increase in inflammatory lesions just before menstruation.21 The pathogenesis of acne results from an increase in androgen, which acts on the sebaceous glands. Increased levels of cortisol may correlate with emotional stress in patients with acne.22 This lends support to the concept that the neuroendocrine system plays a role in sebaceous gland activity.22
Many women with acne also have skin conditions such as atopic dermatitis, psoriasis, chronic pruritis and allergies to foods and products. Studies show that adolescents who reduce milk intake may also experience a reduction in acne.23 Ask older women to reduce milk intake and monitor any changes to their acne.
Controlling the inflammation that causes acne is a critical component of overall treatment. Oral and topical antibiotics, along with improved skin care practices, are generally effective. Adjunct use of benzoyl peroxide can enhance treatment outcomes.24 Due to resistant strains of acne pathogens, new antimicrobial agents are available in low-dose daily regimens for patients who may require chronic use (doxycycline [Oracea]).
Retinoids (tretinoin [Retin-A]) alone and in combination are still considered first-line treatment for the initial and long-term management of acne. These drugs have anti-inflammatory and comedolytic activity. Lower-dose retinoids can be effective for patients who do not respond to standard protocols. The most recent advancement in topical treatment is a combination gel consisting of clindamycin phosphate and tretinoin (Ziana).
Topical antibacterial preparations containing benzoyl peroxide (clindamycin [Benzaclin]) or retinoid combinations (adapalene [Differin]) also have a role in the management of moderate acne.
For moderate to severe acne, the treatment goal is to reduce sebum production. In menstruating women, a good choice for this is oral contraceptives (OCs).24 Four OCs are indicated for acne: Yaz, Estrostep, Ortho Tri-Cyclen 28 and Tri-Sprintec. Anecdotally, some patients report fewer acne breakouts with the 90-day OC regimens.
Spirolactone can block androgen and sebum production in patients with adult-onset acne, endocrine or metabolic issues and can be a useful treatment option as well.
Identifying an appropriate skin care regimen for a woman with problem acne can be challenging at any age. The overriding goal is to improve and maintain epidermal barrier function and prevent transepidermal water loss. Education should focus on the importance of compliance with the recommend oral and topical regimen, along with specific information about what, when and how to use the treatments. To manage irritation, most topical tretinoin formulations should be applied in the evening, and benzoyl peroxide cleansers or gels should be applied in the morning. Products that contain plant-based oils and extracts may be irritating to the skin and cause further problems.25 No clinical data support the use of herbal preparations for acne.
Lasers, light sources and heat-based technologies now play a significant role in acne treatment. Photodynamic therapy is a nontraditional acne treatment in which the provider applies a photosensitizer agent of 20% aminolevulinic acid (Levulan) to the skin prior to treatment with light. Light sources include intense pulsed laser, variable pulsed light, radiofrequency, pulsed blue light and infrared heat. An infrared laser can activate medication to inhibit the bacteria that cause acne and inflammation at any stage and improve acne scarring and skin texture.16,26
Cosmeceuticals
The term "cosmeceuticals" is a functional nonlegal term that refers to topical ingredients sold as cosmetics and marketed to improve skin appearance.14,27 The ability of any cosmeceutical to enhance skin function depends on its formulation. It must maintain the integrity of the active ingredient, deliver it in a biologically active form to the skin, reach the target site in sufficient quantity, produce effectiveness, and properly release the carrier vehicle.
Many newer skin care products contain antioxidants. No single antioxidant ingredient has proven to be effective for the skin, but the combination of many antioxidants can exert a synergistic cumulative action.28 Table 2 lists some of the antioxidants proven effective thus far.
Vitamins and nutrition that protect, support and restore skin structure and strengthen the skin matrix are important to skin health but have only short-term effects when taken orally.15 Topical application of the proper formulation, delivery and penetration of a vitamin can produce more definitive results.24
Mineral makeup can enhance the healing phase of skin restoration. True mineral makeup is made from micronized minerals with properties that resist bacteria growth, allow the skin to breathe and block harmful sun rays.29 Mineral cosmetic products are nontoxic and incorporate vitamins and potent antioxidants that can reduce the body's internal toxin load.
The effectiveness of botanicals or herbs in cosmetics is not supported by research. To promote skin health, several resources recommend avoiding talc, mineral oil, petroleum and waxes, formaldehyde, butylated hydroxytoluene and fragrances. These substances can be toxic to other organs, cause skin irritation and alter skin functioning.9,14
Lasers for Photoaging
A complete discussion of laser therapies for aging skin is beyond the scope of this article. Key points about this therapy include the following:
Laser therapy is a popular nonsurgical option for tightening and toning sagging skin in the facial area, neck, abdomen, thighs, buttocks and arms. When used to stimulate collagen growth in these ways, radiofrequency and infrared lasers are known for efficacy and safety.
Laser therapy has the ability to deliver heat through preset pulsed lighting that penetrates deep into the skin to target melanin, oxyhemoglobin and water. This allows providers to treat a broad range of skin types and issues, including pigmentation disorders, vascular lesions and unwanted hair. It also permits rejuvenation of inner and outer skin structures.
Laser technologies are now available to treat skin conditions including psoriasis, actinic keratosis and nonmelanoma skin cancers. These treatments are delivered with a combination of light and light-activated medication called photodynamic therapy. Although traditional methods of cryosurgery, electrocautery and excision are still used, light therapy has become popular because patients are likely to comply with treatment and it is time efficient and effective.16
Dermal Fillers and Botox
Hyperdynamic wrinkles (wrinkles in motion) result from repetitive movements of the facial muscles that facilitate facial expressions. Static wrinkles (wrinkles at rest) develop as a result of sun exposure and the progressive loss of skin elasticity. Wrinkles are classified according to expectations about the ability of treatment options to correct or enhance their appearance.
Botulinum toxin (Botox) injection is the most commonly performed cosmetic procedure to treat hyperdynamic wrinkles. The select chemical denervation action of Botox can paralyze or slow the muscles underneath the wrinkles. Advanced techniques work synergistically with other treatments, including fillers and resurfacing, to improve the appearance of aging facial skin.30
Dermal fillers, which are also delivered via injection, are suitable for soft tissue augmentation, for diminishing the appearance of wrinkles, for restoring fat loss in the face, and for diminishing the appearance of superficial or deep lines and wrinkles.31 These fillers are derived from bovine, hyaluronic acid, water, glycerine-based gel, nonallergic substances and fat. When injected into the dermis, these substances replenish the collagen layer, smoothing lines and deep wrinkles and adding definition to the lips and cheeks.
Several FDA-approved dermal fillers are on the market (Cosmoplast, Radiesse, Restylane, Juvederm, Perlane, Captique, Prefill HA, etc.). The effects of any filler are dependent on the properties of the agent, the area to be injected, the administration technique used, the age of the patient, and the body's collagen response to the treated area. The results of collagen products typically last 2 to 3 months, while the effects of hyaluronic acid usually last 6 to 12 months.30 Longer-lasting results are achievable with poly-L-lactic acid (Sculptra; 12 to 18 months) and calcium hydroxylapatite (Radiesse; 1 to 2 years).30
Fat transfer, once a common procedure, is the focus of new interest among women who want to achieve longer-lasting restoration of volume in the lower face and in the hands using a more natural method.32,33
With any wrinkle correction procedure, understanding of the following are essential: the anatomy of the patient's face, her medical history, the ingredients and properties of the filler, and the volume required.
Skin Rejuvenation
Skin rejuvenation is a term that encompasses procedures designed to improve skin tone and texture. Chemical peels alone or in combination with other treatments are popular choices for skin rejuvenation. Chemical peels are classified according to penetration of the chemical agent as very light, light, medium and deep.
Very light chemical peels are safe and appropriate for all skin types. A series of these peels may include mild concentrations of alpha hydroxy acids, beta hydroxy acids, tretinoin and 10% to 20% trichloroacetic acid. These agents penetrate the stratum corneum to improve skin texture, reduce pigmentation and increase thickness at the granular level.34 These peels are often a component of an acne treatment plan. They are also used to reduce postinflammatory treatment complications in patients with darker skin.
Light chemical peels penetrate the epidermis and consist of higher concentrations of alpha hydroxy and beta hydroxy acids. Light peels treat actinic keratosis, solar lentigines and seborrheic keratosis. They should be avoided in patients with darker skin because of risk for scarring and hypopigmentation. Erythema and scaling typically occur, but after the 7-day healing time, the improvement in skin texture is dramatic.
Medium and deep chemical peels are effective for treating actinic keratosis, wrinkles, melasma, seborrheic keratosis, solar lentigines and advanced photodamage. These peels usually produce brief discomfort, and patients experience erythema and significant skin flaking for 7 to 10 days. The effectiveness of a medium-depth peel can be enhanced with pretreatment protocols and combination with other resurfacing treatments (such as Fraxel laser technology). The deepest chemical peel delivers a phenol solution that causes significant discomfort and requires anesthesia in a surgical setting. Up to 14 days of healing time is required. This peel is typically recommended for women with lighter skin, acne scarring, deep wrinkles and severe photodamage.
Microdermabrasion
Microdermabrasion is a popular treatment for photodamaged skin, acne and hyperpigmentation. The procedure is safe, nonaggressive and requires no down time. Microdermabrasion projects particles of aluminum oxide crystals onto the skin in a uniform manner and removes the superficial layer of dead cells via a dual closed system to leave the skin smooth and draw oxygen and nutrients to the surface to repair and feed new cells. Recent research has demonstrated that the use of sodium bicarbonate crystals is as effective as aluminum oxide — without the same level of irritation.35
Crystal-free systems that use ultrasonic vibrations in a liquid medium are now available (SilkPeel, DermaSweep, Vibraderm). JetPeel and EpiInfused are customized treatment options that use oxygen and various solutions to treat acne and pigmentation disorders. These particle-free systems create a cleaner surface for laser treatment and provide greater safety for the patient, provider and laser equipment.
Putting It Into Practice
As you add aesthetics services, do not give training and knowledge short shrift. Obtain adequate education and preparation, and check state practice laws regulating dermatologic procedures by NPs. Remember that while many of the latest aesthetic equipment choices and procedures appear promising, limited research has been conducted thus far.
References
1. McCance KL, Huether S. Structure, function, and disorders of the integument. In: Pathophysiology: The Biologic Basis for Disease in Adults and Children. St. Louis, Mo.: Mosby; 1990:1390-1401.
2. Murad H, Lange DP. Skin 101. In: Wrinkle Free Forever: The 5-Minute, 5-Week Dermatologist's Program. New York, N.Y.: St. Martin's Griffen; 2003: 21-40.
3. Shalita A, et al. Treating dry-skin conditions: recommendations for hand and body. Patient Care. 2007;(suppl):2-8.
4. Federman D, et al. The primary care provider and the care of skin disease. Arch Derm. 2001;137(1):25-29.
5. Gold MH. Enhancing cosmetic surgical dermatologic procedures: the patient's perspective. Skin & Aging. 2006;14(10):52-53.
6. Bauman L. The Skin Type Solution: A Revolutionary Guide To Your Best Skin Ever. New York, N.Y.: Bantam; 2006.
7. Bauman L. Cosmetic Dermatology: Principles and Practice. New York, N.Y.: McGraw-Hill; 2002:3-19.
8. Hall G, Phillips TJ. Estrogen and skin: the effects of estrogen, menopause and hormone replacement therapy on the skin. J Am Acad Dermatol. 2005;53(4):555-572.
9. Smith PW. Hormones and your skin. In: HRT: The Answers. A Concise Guide for Solving the Hormone Replacement Therapy Puzzle. Traverse City, Mich.: Healthy Living Books Inc.; 2006:76-77.
10. Stulberg D, et al. Common hyperpigmentation disorders in adults. Part I: diagnostic approach, café au lait macules, diffuse hyperpigmentation, sun exposure, and phototoxic reactions. Am Fam Physician. 2003;68(10):1955-1960.
11. Winnington P. Get better results from topical rosacea management. Practical Dermatology. 2006;3(1):27-30.
12. Scheinfeld N. When rosacea resists standard therapies: four medication groups to consider. Skin & Aging, 2006;8(14):46-48.
13. Thiboutot D. Advances in rosacea therapy: a review of available therapies. Skin & Aging. 2007;(5 suppl):7-9.
14. Klingman A. Cosmeceuticals and the practice of dermatology. In: Procedures in Cosmetic Dermatology: Cosmeceuticals. Philadelphia, Pa.: Elsevier Saunders; 2005;1:5-10.
15. Keri J. Vitamins and acne. Skin & Aging. 2006;12(14):18-19.
16. Dierickx C, Grossman M. Procedures In Cosmetic Dermatology: Laser and Lights Volume 2. Philadelphia, Pa.: Elsevier-Saunders; 2005:61-75.
17. Taylor S, Wu J. Natural ingredients in dermatology. Skin & Aging. 2005;13(7):56-62.
18. Mitts T, et al. Skin biopsy analysis reveals predisposition to stretch mark formation. Aesth Surg J. 2005;25(6):593-600.
19. Elson M. Understanding cellulite. Healthy Aging. 2006;1(6):13-16.
20. Katz M. Comparative advantage and disadvantage of body shaping technology. Aesthetics Buyers Guide. 2006;3(9):64-70.
21. Lucky AW. Quantifiable documentation of a premenstrual flare of facial acne in adult women. Arch Derm. 2004:140(4):423-424.
22. Klingman A. Postadolescent acne in women. Cutis. 1991;48(1):75-77.
23. Aebesman H. Milk: it does a body good, but what about the skin. Practical Dermatology. 2006;3(2):17.
24. DelRosso J. Highlights from the latest acne treatment guidelines. Skin & Aging. 2007;15(2):84-88.
25. Taubman A. High-tech acne treatments light the way for long-term solution to common skin conditions. American Academy of Dermatology. Press release issued Feb. 2, 2007. Available at: http://www.aad.org/aad/Newsroom/Treating+Acne.htm. Accessed July 23, 2007.
26. Rubin M. Procedures in Cosmetic Dermatology: Chemical Peels. Philadelphia, Pa.: Elsevier Saunders; 2005:13-15.
27. Dahiya A, Romano J. Cosmeceuticals: a review of their use for aging and photoaged skin. Cosmetic Dermatology. 2006;19:7:479-484.
28. Lewis W. Cosmeceuticals: maximizing science in skin care. Medesthetics. 2006;6:55-58.
29. Ranger D. Mineral makeup enhances skin rejuvenation. Aesthetics Buyers Guide. 2007;1:50-51.
30. Beer K. Using Botox in an area once deemed 'off limits.' Skin & Aging. 2007;2:53-54.
31. Bauman L, et al. Dermal filling agents: evaluating more choices for your patients. Part 1. Skin & Aging. 2007;3:38-44.
32. Bauman L, et al. Dermal filling agents: evaluationg more choices for your patients. Part 2. Skin & Aging. 2007;6:50-55.
33. Sundaram H. Autologous fat transfer. Medesthetics. 2007;3:12-14.
34. Rubin M. Procedures in Cosmetic Dermatology Series: Chemical Peels. Philadelphia, Pa.: Elsevier Saunders; 2005: 13-15.
35. Hansen I. Evolution of microdermabrasion. Medesthetics. 2006;4:36-45.
Donna Rinker is a family nurse practitioner who specializes in aesthetics, health and wellness within a family practice setting. In addition, she owns and manages Bella Skin Care, with three locations in Michigan. She is a member of the adjunct clinical nursing faculty at Michigan State University in Lansing and a preceptor for family nurse practitioner students. She also provides consultant services on incorporating skin care into primary care settings. Reach her at donna.rinker@worldnet.att.net. The author reports no affiliations with any manufacturer of products or equipment mentioned in this article.
Table 1: Components of the Skin History
Past and current medical conditions
Previous skin disorders
Medications and treatments used to treat previous skin disorders
Allergies or sensitivity to topical medications or skin products
Current medications (prescription and over the counter)
Herbs and supplements
Alcohol, smoking and caffeine intake
Exercise and sleep patterns
Work environment (past and present)
Sun tanning and outdoor sun exposure (past and present)
Skin response to the sun
Current skin care regimen and sunscreen use
Nutrition and water intake
Ethnicity
Natural eye, hair and skin color
Menstrual cycle or age at menopause
Use of oral contraceptives or hormone therapy
The Fitzpatrick Scale and Glogau's Aging Classification can be used as subjective and objective assessment tools to classify pigmentation and photoaging stage.
Table 2: Cosmeceuticals With Antioxidant Properties
Many of these ingredients are used alone or in combination with a daily skin routine. They are also used as adjuncts to skin procedures such as chemical peels, microdermabrasion and laser treatments.
Vitamin A (retinoids)
Vitamin C (l-ascorbic acid)
Vitamins B and E
Coenzyme Q10
Idebenone
Superoxide dismutase
Kinetin
Green tea
Grape seed extract
Pomegranate extract
Grapefruit extract
Coffee berry extract
Pycnogenol
DMAE (dimethylaminoethanol)
Alpha hydroxy acids:
lactic acid
mandelic acid
glycolic acid
beta hydroxy acids
alpha lipoic acid
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