Treatment Guideline Chart
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.

Rhytides%20(wrinkles) Treatment


Botulinum Toxin

  • Most appropriately used for dynamic wrinkles of the upper face that are due to muscle hypertonicity
    • Approved indications are glabellar lines, lateral canthal lines (crow’s feet) and forehead 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 approximately 1 week to 1 month after injection and lasts 3-4 months
  • Actions: Neurotoxic effects cause a reduction in the tone of muscles that cause lines in the forehead, glabellar and periocular areas
    • Causes localized muscle relaxation into specific overactive muscles that results in smooth overlying skin and reduction of wrinkles
  • Disadvantages/risks: Headache, bruising, ptosis, paresthesia, frequent re-treatment is needed
  • Contraindicated in patients with keloidal scarring, neuromuscular disorders eg myasthenia gravis, body dysmorphic disorder

Chemical Peels

  • Superficial or medium-depth skin resurfacing are appropriate for patients with mild facial wrinkles
  • Coarse wrinkles may respond better to deep peels
  • Contraindicated in patients with:
    • Telangiectasias
    • Confirmed malignant lesions
    • Nevoid or nevus lesions
    • Hepatorenal or cardiac disease
  • Patient should be assessed for skin type, complexion, skin texture, skin thickness, degree of photoaging, wrinkle severity and age-related gravitational changes
    • Skin type and 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 and the extent of application
  • Disadvantages/risks: Hyperpigmentation, infection, scarring, pain

Superficial (Exfoliation-Epidermal)

  • Removes stratum granulosum and papillary dermis
  • Usually requires multiple peels that range from 6-8 peels per week or every other week
  • Agents: Glycolic acid (low concentration), Jessner’s solution, Pyruvic acid, Tricloroacetic acid (TCA) 10-20%,Tretinoin, 5-Fluorouracil, Salicylic acid

Medium Depth (Papillary Dermal)

  • Necrosis of the epidermis to the upper reticular dermis
  • Agents: Glycolic acid 70%, TCA 35% alone or augmented with Jessner’s solution, Phenol 88%

Deep (Reticular Dermal)

  • Necrosis that extends into the midreticular dermis
  • Agent: Baker-Gordon Phenol formula, TCA 50%

Hydroxy Acids

  • Products containing alpha- and beta-hydroxy acids
  • Alpha-hydroxy acid acts by thinning the stratum corneum, promoting epidermolysis, dispersing basal layer melanin and increasing collagen synthesis within the dermis
  • Beta-hydroxy acid has similar antiinflammatory action as alpha-hydroxy and are often less irritating

Retinoids (Topical)

  • Eg Tazarotene and Tretinoin
  • Effects: Clinical trials generally lasting 6 months have shown some improvement in wrinkling, mottled, roughness and hyperpigmentation in the majority of patients treated with these retinoids
  • Continued use seems to be needed to maintain a benefit
  • Actions: Shown to increase collagen production, upregulate fibroblast proliferation and block dermal matrix degradation following sun exposure
  • Disadvantages: Increases penetration of ultraviolet B (UVB) radiation by as much as one third as compared to untreated skin
    • Sun protection and sun avoidance are advised to protect against sunburn and further photoaging
  • Contraindicated in pregnant women

Tretinoin (Topical)

  • When applied daily may improve fine wrinkles in patients with mild to severe photodamage
  • May cause itching, burning, erythema and skin peeling


  • When applied daily may improve fine wrinkles however it can cause burning of the skin

Skin Fillers

  • Temporary fillers (eg Collagen, Hyaluronic acid); permanent fillers (Hydroxyethylmethacrylate, Polymethylmethacrylate, Silicone)
  • Usually used in coarse (deep) wrinkles that are not due to muscle hypertonicity
  • Actions: Fill wrinkles and furrows; replace lost tissue volume and fill and efface coarse wrinkles
  • Disadvantages/risks: Bruising, pain, frequent re-treatment is needed

Other Drug for Photoaging


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

Non-Pharmacological Therapy

Ablative Resurfacing

  • Laser therapy that includes carbon dioxide and erbium yttrium-aluminum-garnet (Er:YAG) lasers
  • Indicated for mild to moderate wrinkles
  • Carbon dioxide laser is used for treatment of perioral vertical furrows, periocular crow’s feet and glabellar rhytides
  • Actions: Skin cells are heated resulting in controlled thermal burn
  • Disadvantages/risks: Infection, scarring, pain, pigment changes and prolonged healing
  • Requires destruction of the dermis and thus requires a substantial period of healing and regrowth

Non-ablative Rejuvenation

  • Laser, light and infrared therapy including intense pulsed-dye, fractional photolysis, neodymium yttrium-aluminum-garnet (Nd:YAG) diode and erbium glass lasers, photodynamic therapy, intense pulsed light and radiofrequency
  • Refers to techniques that avoid damage to the epidermis while treating the dermis to produce the desired resurfacing effect
  • Indicated for mild to moderate wrinkles
  • Disadvantages/risks: Needs multiple treatments to obtain desired effect, pigment changes
  • May be used for all types of wrinkles especially in the difficult-to-treat perioral and vermillion regions
  • Actions: Epidermis is removed to various depths by using a “sanding device” or abrasive surfaces to remove the epidermis and create a wound in the papillary or reticular dermis
  • Disadvantages/risks: Infection, acne outbreaks, scarring, pain and pigment changes
  • May be used in fine rhytides
  • Actions: Small-particle microcrystals (ie aluminum dioxide, sodium chloride or sodium bicarbonate) abrasive action are used to wound the epidermis, coupled with suction to remove any skin debris
    • Stimulates an inflammatory response within the epidermis which prompts new stratum corneum formation within 3-5 days
  • Disadvantages/risks: Erythema, requiring increased moisturization and sun protection

Rhytidoplasty (Face Lift)

  • May be considered in patients with significant laxity, for patients demanding predictably significant change in skin tightening and to reconstruct the anatomic changes that occur with aging
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