rhytides%20(wrinkles)
RHYTIDES (WRINKLES)
Rhytides or wrinkles are visible creases or folds in the skin.
Fine wrinkles is <1 mm in width while coarse wrinkles is >1 mm in width.
The decision to treat wrinkles depends on the degree that they bother the patient, the nature and severity of the wrinkles, and the patient's willingness to accept the risks and costs of treatment.
The patient should understand that protection from the sun at any age will reduce the risk of photoaging (including wrinkles), actinic keratoses and squamous cell cancer.

Pharmacotherapy

Botulinum Toxin

  • Most appropriately used for the dynamic wrinkles of the upper face that are due to muscle hypertonicity
    • Only approved indication is glabellar lines
  • Effects: Available data suggests that at least moderate improvement is shown in 50-75% of patients treated for glabellar lines
    • Peak improvement is seen approx 1 week-1 month after injection & lasts 3-6 months
  • Actions: Neurotoxic effects cause a reduction in the tone of muscles that cause lines in the forehead, glabellar & periocular areas
  • Disadvantages/risks: Headache, bruising, ptosis, paresthesia, frequent re-treatment is needed

Chemical Peels

  • Superficial or medium-depth skin resurfacing are appropriate for patients w/ mild facial wrinkles
  • Coarse wrinkles may respond better to deep peels
  • Patient should be assessed for skin type, complexion, skin texture, skin thickness, degree of photoaging, wrinkle severity & age-related gravitational changes
    • Skin type & complexion will help determine the specific chemical peeling agent that will be used
  • Patient lifestyle needs to be considered because early sun exposure will increase the risk of adverse effects
  • Actions: Chemically destroy the epidermis; depth will depend on agent, concentration & the extent of application
  • Disadvantages/risks: Hyperpigmentation, infection, scarring, pain

Very Superficial (Exfoliation)

  • Removes stratum corneum
  • Agents: Microdermabrasion (Aluminum oxide or Diamond), Retinoic acid, alpha-hydroxy acids (Glycolic acid 30-50% for 1-2 minutes), Jessner’s solution (1-3 coats), Resorcinol 20-30% for 5-10 minutes, Trichloroacetic acid (TCA) 10% (1 coat)

Superficial (Epidermal)

  • Necrosis of part or all of the epidermis anywhere from the stratum granulosum to basal cell layer
  • Agents: Glycolic acid 50-70% for 5-20 minutes, Jessner’s solution (5-10 coats), Resorcinol 50% for 30-60 minutes, TCA 10-35% (1 coat), Phenol 88%

Medium Depth (Papillary Dermal)

  • Necrosis of the epidermis & part or all of the papillary dermis
  • Agents: Glycolic acid 70% for 5-30 minutes, TCA 35% alone or augmented w/ Jessner’s solution, modified Baker-Gordon formula using only 2 drops of croton oil

Deep (Reticular Dermal)

  • Necrosis of the epidermis & papillary dermis that extends into the reticular dermis
  • Agent: Baker-Gordon Phenol formula

Hydroxy Acids

  • Products containing alpha- & beta-hydroxy acids act as exfoliants & moisturizers
  • Low concentrations 4-12% are promoted as assisting in decreasing the aging of the skin
    • High concentrations are used as peels
  • Effects: Overall effects on photoaging are limited
    • Limited studies show mild improvements in fine & periorbital wrinkles
    • Keratolytic & irritant effects are dependent on the specific acid, concentration & pH
  • Disadvantages: Hydroxy acids can increase sun sensitivity by up to 50%
    • Sun protection & sun avoidance are advised to protect against sunburn & further photoaging

Retinoids (Topical)

  • Eg Tazarotene & Tretinoin
  • May be used for palliation of fine wrinkles
  • Effects: Clinical trials generally lasting 6 months have shown some improvement in wrinkling, mottled, roughness & hyperpigmentation in the majority of patients treated w/ these retinoids
  • Continued use seems to be needed to maintain a benefit
  • Disadvantages: Increases penetration of ultraviolet B (UVB) radiation by as much as one third as compared to untreated skin
    • Sun protection & sun avoidance are advised to protect against sunburn & further photoaging
  • Contraindicated in pregnant women

Skin Fillers

  • Eg Bovine collagen, Hyaluronic acid
  • Usually used in coarse (deep) wrinkles that are not due to muscle hypertonicity
  • Actions: Fill wrinkles & furrows
  • Disadvantages/risks: Local allergic reactions & therefore skin testing prior to use is recommended, possible induction of autoimmune disease (w/ Bovine collagen), bruising, pain, frequent re-treatment is needed

Other Drug for Photoaging

  • N6-furfuryladenine
    • Also known as kinetin, is a plant growth hormone w/ antioxidant activities
    • May be useful for patients who cannot tolerate retinoids & alpha-hydroxy acids
    • In a large 6-months study, it has been shown to reduce skin roughness, hyperpigmentation & fine wrinkles; further double-blind studies are warranted

Non-Pharmacological Therapy

Sunscreens

  • Sunscreens that block ultraviolet B (UVB) radiation are readily available
  • Sun protection factor (SPF) corresponds to the ratio of doses of UV radiation (predominantly UVB radiation) that result in erythema (sunburn) w/ protection to the doses that result in erythema w/o protection
    • Eg SPF 2 = 50% block, SPF 45 = 98% block
  • Nonopaque sunscreens that claim to block ultraviolet A (UVA) cannot be consistently quantified
    • Opaque sunscreens may provide good protection from UVA radiation but are cosmetically unacceptable
  • Adequate application is imperative for sunscreen to be effective
    • 2 mg/cm (approx ½-1 tsp) of sunscreen to the face, each arm, exposed shoulders & neck, 2 tsp to the upper body & total of 40 g for the entire body surface
    • Less than recommended application consequently results in lowered SPF

Ablative Resurfacing

  • Laser therapy including carbon dioxide & erbium yttrium-aluminum-garnet (Er:YAG) lasers
  • Indicated for moderate to severe wrinkles
  • Actions: Skin cells are heated resulting in controlled thermal burn
  • Disadvantages/risks: Infection, scarring, pain, pigment changes & prolonged healing

Dermabrasion

  • May be used for all types of wrinkles
  • Actions: Epidermis is removed to various depths by using a “sanding device”
  • Disadvantages/risks: Infection, scarring, pain & pigment changes

Non-ablative Rejuvenation

  • Laser, light & infrared therapy including pulsed-dye, neodymium yttrium-aluminum-garnet (Nd:YAG) diode & erbium glass lasers, intense pulsed light & radio frequency
  • Indicated for mild-moderate wrinkles
  • Disadvantages/risks: Efficacy has not been proven, pigment changes

Rhytidoplasty (Face Lift)

  • May be considered in patients w/ significant laxity & for patients demanding predictably significant change in skin tightening
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