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Common Conditions -
Aging and/or Sun-Damaged Skin
Arlington Center for
Dermatology offers everything from prevention to
reversal of aging and/or sun-damaged skin. First
we will evaluate what are your skin concerns and
goals. Then we will discuss options for
improving your skin health and rejuvenation with
treatment and product methods such as light and
laser treatments, chemical peels, skin-lifting
treatments, BOTOX Cosmetic®, and injectable
fillers. We will also customize a skin care
program made up of professional and/or
prescription products.
What causes aging skin?
Sun damage is the most profound factor in
development of aging of the skin. The most
important other cause in facial aging besides
sun damage is cigarette smoking. Another
possible contributing factor in women is loss of
estrogen. Finally, genetics, nutrition and other
environmental factors probably play important
roles which are yet to be elucidated.
The best approach for prevention of skin aging
are the practice of good sun protection and
avoidance of cigarette smoking. A recent study
of identical twins revealed that factors such as
sun exposure, cigarette smoking, stress and
alcohol ingestion had a dramatic negative effect
on aging changes that were independent of
heredity. Certain topical preparations have been
shown to reverse some signs of photoaging. It
has been assumed that these antiaging
preparations also can prevent skin aging,
although no real studies have been performed
which establish a regimen for this purpose. It
is possible that antioxidant supplementation
and/or nutritional factors could decrease skin
aging. The last 10 years have seen an explosion
of new treatments for prevention and reversal of
skin aging.
What is aging skin?
The appearance of aging skin consists of
wrinkles, brown and red discoloration (photodamage),
laxity and loss of muscle tone. Also associated
with the appearance of the aging face is the
lengthening of the upper lip, loss of volume in
the mid-cheek, at the temple and in the chin,
and a downturn of angle of the lips at the
corner.
Are there different types of aging skin?
There are two types of aging of the skin, “true”
aging due to chronological age and “photo"
aging, due to the toxic effects of cumulative
sun exposure or other environmental toxins, such
as smoking, pollution, and lack of circulating
antioxidants (diet). The two types of aging
manifest themselves in slightly different ways.
True aging results in a downward displacement of
tissues due to the loss of skin resilience in
counteracting the effects of gravity, resulting
in sagging. There is also a loss of subcutaneous
tissue (fat) in the central face resulting in a
hollowed look. There are “lines of expression”
or literal creases in the skin from the constant
use of certain facial expressions such as laugh
lines (crow’s feet, nasolabial folds), frown
lines (lip creases and lines) and worry lines
(forehead lines). If you had a couch in the same
place on your rug for 20 years, you would not
expect the carpet to spring back if you took the
couch away. The same is true when you crease
your face in a certain expression thousands of
times over a lifetime- eventually the line just
stays there.
Finally, the surface of the skin tends to have a
“sallow" appearance- that is, dry, with a slight
yellow tinge, which results from a slow down
from the metabolic process yielding skin that
does not renew frequently and looks "sluggish".
Photoaging, aging caused by ultraviolet light
exposure, tends to act more on the surface of
the skin. There are “sun freckles” (also known
as “liver spots” although they have nothing to
do with the liver) or irregular pigmentation and
dilated blood vessels (often referred to as
“broken” blood vessels) that lead to an overall
uneven tone. Fine textural lines scattered over
the surface are partly due to the loss of
collagen’s integrity. Finally, there is laxity
from the loss of elastic fibers. Excessive sun
damage can yield pre-cancerous or cancerous
growths (see section on skin cancer).
How can I treat aging skin?
The treatment of aging changes of the face is
diverse. Topical treatments consist of vitamin A
derivatives, alpha hydroxy acids, vitamin C
preparations, plant and botanical derivatives,
antioxidants, growth factors and peptides. There
are numerous types of chemical peels and
microdermabrasions. Laser surgery and
radiofrequency devices can be used to correct
“sun freckles”, dilated blood vessels and
wrinkles. BOTOX Cosmetic®, collagen, hyaluronic
acid and fat injections can help with certain
lines of expression and loss of facial fullness.
More major surgical procedures include laser
resurfacing.
Topical treatments
of aging
•Vitamin A
Derivatives (retinoids)- tretinoin (Retin-A,
Renova),tazarotene (Tazorac,Avage), and
adapalene (Differin) and various types of
retinols. Of all the topical agents, the
prescription retinoid creams have the most
scientific evidence demonstrating they can
reverse aging changes. Tretinoin has been shown
to reduce fine lines, mottled hyperpigmentation
(age and liver spots), and sun damage. The main
problem with tretinoin and the other retinoids
is that many people cannot tolerate the side
effects of dryness and irritation that often
accompany their use. There is sometimes a period
of "retinization" that can last as long as two
weeks that causes skin redness, peeling and
discomfort. This is one of the reasons retinol
creams have become popular - they are not as
drying as Retin-A. Although the effects of
retinol creams on human skin have been studied
far less than that of the Rx retinoids, they
hold great promise. A recent study shows that
retinol does increase collagen in human skin.
Vitamin A derivatives retinoids or retinols) are
the cornerstone of any topical antiaging
regimen, although people with rosacea and/or
sensitive skin would be advised to avoid them as
they tend to aggravate the condition by
stimulating blood vessel growth. Reference the
retinol products: Afirm, Dermal Repair.
• Alpha hydroxy and
polyhydroxy acids (AHAs) – glycolic acid, lactic
acid, gluconolactone In the early 1970’s the
team of Van Scott and Yu discovered that alpha-hydroxy
acids could dramatically improve severely dry
skin. In the late 1980’s they formed a company
called Neostrata, making them the first to
develop and manufacture alpha-hydroxy acid
“cosmeceutical” creams. The great thing about
alpha and poly hydroxy acids is that they are
inherently moisturizing. Since people with aging
skin often have dry skin, it is an excellent
choice. The alpha hydroxy acids (glycolic acid
and lactic acid- derived from fruit acid and
milk, respectively), confer a lot of benefits
including smoother, softer skin, a pink “glow”
and more even pigmentation. Their application
results in an increase in collagen deposition,
improved quality of elastic fibers and
thickening of the epidermis (the layer of the
skin that retains water and acts as a barrier to
environmental insults). It is important to know
what strength of free acid is present in the
preparation one is using, because the higher the
strength, the greater the benefits. Many creams
that sport a high percentage on their label have
been “neutralized’- that is, partially
inactivated by a “base” to make the acid have
less of a stinging feeling. This decreases the
effective free acid percentage, and thus, their
effectiveness at producing the desired results,
although they are frequently more tolerable. The
alpha hydroxy acid preparations are available as
creams, lotions, gels, cleansers, and also as
ingredients in chemical peels. Gluconolactones,
or polyhydroxy acid products, appear to have
most of the benefits of alpha hydroxy acids but
are good for people with very sensitive skin.
Furfuryladenine (Kinerase) Kinerase is a plant
extract shown to delay the aging process in
plants, fruitflies and human fibroblast cells
(cells that make collagen). It may also act as a
free radical scavenger, meaning that it has
antioxidant properties and can protect cells
from toxic insults. Its main advantage is that
it is non-irritating. Many people cannot
tolerate either the drying of the vitamin A
derivatives or the stinging induced by the alpha
hydroxy acids. For people with sensitive skin,
Kinerase is a good choice. The jury, however, is
still out regarding its effectiveness – no peer
reviewed journal (articles accepted by an
independent panel of experts in the subject
chosen) has yet published a study. A preliminary
study from the University of California Irvine
has shown it to be effective in reducing fine
wrinkles, coarse texture and blotchy pigment
after 24 weeks of twice a day use. It represent
a good choice for people with very sensitive
skin and/or rosacea. Vitamin C Vitamin C is an
antioxidant which sops up the toxic molecules
that occur in skin cells when they are exposed
to ultraviolet light. It has been shown to
reduce skin damage from ultraviolet light in
animals. It is very difficult to get a Vitamin C
preparation adequately absorbed into the skin
due to its low pH and other molecular factors
and it is also unstable in solution, as the
vitamin becomes easily inactivated when it is
exposed to air or light. Different manufacturers
of vitamin C products have made claims that
their product has the special formula that makes
it absorb into the skin and not lose potency.
Although there is one published study showing
that topical vitamin C reverses aging changes in
humans, their is more evidence it will help to
prevent (as opposed to reverse) aging changes,
especially due to ultraviolet light induced
damage . When Vitamin C “serum” first arrived on
the scene, all my patients were clamoring for
it, despite my warnings that no published data
had emerged on its effectiveness and it was
quite expensive. In the initial two years I
dispensed it to hundreds of people, I was
disappointed with the results. The fact that it
was more expensive than most other antiaging
preparations and didn’t seem as effective made
it lose value in my eyes and I stopped carrying
it in the office. I believe it could have a
place as a preventative to sun damage in a way
that is different from sunscreen, especially if
they could figure out how to formulate it into a
sunscreen. If you are determined to use a
vitamin C product, I recommend the brand
Skinceuticals, which is the original vitamin C
formula developed by the dermatologist who did
all the research on vitamin C’s effects as an
antioxidant in skin (Dr. Sheldon Pinnell). These
formulations appear at least to have shown a
significant concentration of the product
delivered to the skin. Beta-hydroxy acids Beta-hydroxy
acid really is salicylic acid, an ages-old
medicament used for various conditions which
some contend isn’t really a “beta-hydroxy”, but
it took on this popularized name after alpha-hydroxy
acids came into vogue. Salicylic acid is used in
many different types of medications and is
related to aspirin (which is acetylsalicylic
acid). It is used in antiaging products as a
1-2% concentration and can also smooth fine
lines, improve surface texture and tone, in
similar fashion to the alpha-hydroxy products.
But salicylic acid also helps to clear pores,
thus making it superior in this regard for the
treatment of acne and coarse skin pores.
Superficial peels with 20-30% beta-hydroxy
(known as B-lift peels) can be effective if done
repetitively to improve the surface of aged skin
and fine lines, irregular pigment and even acne
scars. (See more information below in the
section on superficial chemical peels).
Intermediate treatments of aging skin Chemical
Peels Chemical peels involve the application of
a liquid, gel or mask to the surface of the
affected area (face, chest, neck, etc.) with the
intention of lifting off some portion of the
skin. The chemical is usually an acid that
essentially “burns” the skin in a controlled
fashion to a certain depth and then either stops
or is neutralized. Afterwards, the layers of
skin are sloughed off and new skin is formed.
There are two important variables in chemical
peeling- the strength or concentration of the
solution and which chemical is chosen. •
Superficial chemical peels Very superficial
chemical peels are popular right now because
there is little to no “down-time” which is why
they are sometimes referred to as “lunchtime
peels”. One can have these performed and go back
to ones daily activities looking a little
flushed: minimal peeling such as what you would
get after a mild sunburn might ensue. These are
done at regular intervals and are used to
“jump-start” the effects of topical antiaging
preparations. Very superficial chemical peels
mainly remove the “dead” layer of skin (stratum
corneum), but this appears to send a signal to
the deeper layers of the skin to make new
collagen. Very superficial chemical peels would
include 20-30% salicylic acid (B-Lift peel),
alpha hydroxy 20-30% glycolic acid peels
(neutralized at the right time). Superficial
chemical peels would include 15%-20 TCA (trichloroacetic
acid) or the 11% TCA mask (Accupeel), and
Jessner’s solution. These may include a few days
of peeling and sloughing skin. Finally, similar
effects and aftercare could be expected from
light (very superficial) or medium (superficial)
microdermabrasion. I find these a truly useful
addition to the anitaging quest. Many of these
peels can be done for a limited expense, very
low risk of an adverse reaction and no time away
from the activities of daily life! However the
effects are gradual and modest, requiring
multiple treatments and the ongoing use of
antiaging topical medications and frequent
maintenance. Another advantage of the very
superficial peels is that they can be used
safely on people with darker skin tones, whereas
higher strength peels can cause
hyperpigmentation (excess pigment) in the
healing stages. My current personal favorite is
the B-Lift peel- it is simple, inexpensive and
I’ve never seen any major problems with it. It
needs to be done at least a few times to have
any lasting effect. Medium depth chemical peels
Medium depth chemical peels are best when the
aging is moderate to severe and one wants to
have one treatment and not many. There is
usually significant sloughing of the top layer
of skin for about a week to 10 days that is
unsightly enough that you wouldn’t want to go
out in public. However, the effect of this one
peel is much more dramatic than with one light
peel . The risks are also proportionately
greater and include possible hyper- or
hypo-pigmentation (skin which is too dark or too
light) , prolonged erythema (redness) and even
scarring . The main chemicals are 35% TCA,
50-70% glycolic acid, 16% TCA mask (Accupeel) or
combination peels (Jessner’s solution plus TCA,
carbon dioxide and TCA, etc.). Although there
are some practitioners who are really skilled
with these peels, lasers have supplanted much of
the use of these peels because of the ability to
more precisely gauge the depth of the wounding
(see below in laser section). However,
practitioners of the new TCA mask claim it makes
up for some of the unpredictability of other
types of peels and peels are usually less
expensive than laser resurfacing.
• Deep chemical
peels: A deep chemical peel is a phenol peel or
a 50% TCA peel . These peels are appropriate for
only the most severe photodamage. Phenol peels
need to be performed with cardiac monitors (if
done on more than just a small area of the face)
because the absorption of the chemical can cause
heart rhythm abnormalities. Although there may
be some evidence that this might get superior
results when compared with carbon dioxide laser
resurfacing, it has become a dying art with the
advent of lasers. Often, people get a kind of
“porcelain” white appearance after this, so it
should not be performed on dark-toned skin.
• Microdermabrasion
This is a machine that looks like a small vacuum
cleaner that has a hand piece on it with suction
which is put against the face or affected area.
The suction then lifts up the skin and bombards
it with tiny aluminum oxide crystals that
lightly abrade the surface in a very uniform
way. The depth of penetration can be increased
by changing the pressure in the machine or the
number of times the skin is passed over. Thus,
one can get a deep abrasion, similar to a
dermabrasion if used this way, with similar
profound changes in the skin. Most practitioners
however, utilize nurses or aestheticians to
provide more superficial treatments weekly or
biweekly for 4-10 sessions to get the desired
results. The aftercare is usually a bland
moisturizer and one typically has a slightly
sunburned appearance with mild peeling for a few
days. Many experienced and trusted
dermatologists are enthusiastic about this
device’s capabilities, although little has been
published in the medical literature. These
appear to offer similar results to a series of
superficial chemical peels, possibly at a
slightly higher cost depending on where you
live. It is better if you get your treatments in
a reputable dermatologist’s office, rather than
at a salon. Even though it may be an
aesthetician performing the treatment in both
places, the dermatologist took the time to train
the aesthetician and oversee her work, as well
as continuing to update her information about
how to perform better treatments and get better
results. In salons the training is performed by
the company manufacturing the equipment, and the
knowledge base is rarely extended. Botox.
Originally used and approved by the FDA for
blepharospasm and strabismus (abnormalities in
eye muscles), injectable botulinum toxin was
“discovered” by Dr. Jean Carruthers, a Canadian
ophthalmologist who noticed it was improving the
wrinkles around the eyes in her patients. She
and her husband Alastair, a dermatologist, went
on to explore its uses and the Botox phenomenon
of was born. It is the number one cosmetic
treatment worldwide. The main uses for Botox
cosmetic are for the frown lines between the
brow, on the forehead and the wrinkles around
the eyes. Botox is made up of botulinum toxin,
one of the most potent poisons known to mankind.
Its principal action is to paralyze muscle. When
used in small dilutions in a controlled fashion
by a skilled physician with extensive knowledge
of the anatomy of the face, it has a
surprisingly good safety record. Many of the
larger wrinkles on the face are really “lines of
expression”. This means that they are creases
formed by the repetitive movement of
characteristic facial expressions. When a person
frowns a certain way and after many years and
many frowns the skin forms a crease where it was
repeatedly bent as a result of the muscular
action. The amazing thing about botox is that
when you relax the muscles involved, you can
actually make the crease go partially or
completely away. The main side effect of Botox
is too much muscle relaxation in muscles that
were not targeted, leading to eyelid or brow
drooping. This is caused by an injection that is
too close to the muscle that lifts up the eyelid
or the solution diffuses to that area, hence
paralyzing its function. Occasionally people get
headaches (although ironically using Botox has
become a new and very effective treatment for
headaches ). Some people don’t like the fact
that they can’t frown as it limits their facial
expressivity. However, with skilled injections,
facial expressivity is maintained. Botox is also
being used for hyperhidrosis (it has recently
been approved for this use by the FDA), a
condition of excess sweating of the hands,
axillae (underarms) or feet. The main limiting
feature of Botox is that its effects are
temporary. While this may be a good thing if you
have a side effect, it becomes quite an expense
to have to get it repeated every 3-4 months, at
somewhere in the range of $3-800 per treatment.
Some people have found that after repeated
injections they don't make the involuntary
expressions leading to the crease, resulting in
a kind of "biofeedback" on the muscles so that
Botox is not needed as frequently to maintain
the effect. Injectable Fillers: Collagen (Zyderm,
Zyplast) and Hyaluronic Acid (Restylane Fine
Lines, Restylane, Perlane, Hyalaform, Hyalaform
Plus) Injectable fillers are materials made from
collagen or hyaluronic acid that are injected
into wrinkles to erase them. It is a very
effective treatment and also affords instant
gratification, in that the results are
immediate. Like botox, the effects are temporary
because eventually the body metabolizes and
reabsorbs the material. Collagen and Hyalaform
injections need to be repeated every 3-6 months
for maintenance and it appears that Restylane
lasts more like 6-9 months, depending on the
area. The advent of Restylane has caused a lot
of excitement in the aesthetic arena. It has
considerably more volume replacement properties
than other fillers, allowing skilled
practitioners to be able to artistically sculpt
the face. One of the most common areas it is
used is the nasolabial folds and in the wrinkles
around the mouth. The biggest problem with
collagen is that it causes allergic reactions in
a small percentage of people. It is very
important to undergo collagen skin testing
twice. The first test area is observed for an
entire month, because the allergy can be delayed
for some time. Then a second test is performed
because there is a small fraction of people who
become allergic to it upon re-exposure. These
two tests screen out more than 99% of people who
would be allergic. Another concern with collagen
that surfaced around the same time as the breast
implant scare was whether or not it could cause
collagen vascular diseases (arthritis and/or
autoimmune types of diseases). Although this has
never been born out in any medical studies, it
still is recommended to avoid collagen
injections if there is a personal history of
lupus, rheumatoid arthritis or scleroderma.
However, many thousands of people have had these
injections for over 20 years and collagen has an
excellent safety record. This is one of my
favorite procedures to perform. It is artistic
and people are always shocked and delighted when
they look in the mirror for the first time
immediately after the procedure. In the last few
years a number of competitors to collagen have
surfaced . There is Dermolagen, a product that
is derived from human cadavers that have been
tissue banked. This is ideal for the collagen
allergic patient, as there are rarely if ever
allergic reactions to this substance. One has to
be concerned also with potential infectious
agents, although the materials are subjected to
the highest possible scrutiny as well as
sanitizing procedures and are approved by the
tissue banking authority. Some have complained
that this material is more painful on injection
than collagen and requires nerve blocks
(anesthetic blocks like the dentist gives you).
There is also Autologen or Isolagen, procedures
which yield collagen grown from a small piece of
skin taken from the same person for whom it will
be used (left over from another surgical
procedure or a small amount removed from behind
the ear). Although in theory this sounds ideal
since it overcomes the problems of allergic
responses and infectious agents, it appears to
be difficult to produce enough material in a
cost-effective manner and appears to require
multiple treatment sessions. This may change,
however, as technology improves. Injectable fat
has many advocates. This is a procedure where a
person’s fat is “harvested” (removed) from one
area (typically the thighs or buttocks) by
liposuction and re-injected into facial creases
. This technique overcomes the problem of
allergy and also addresses the impermanence
issue. It appears that after multiple treatment
sessions the fat settles in and “takes” and it
is possible to get perhaps a 30% permanent
correction . Surgical approaches to aging The
surgical approaches to aging include laser
resurfacing, face-lifting (rhytidectomy),
brow-lifting, eyelid surgery (blepharoplasty)
and liposuction of the face. When the skin is
severely damaged, superficial and moderate
measures may not be enough to really reverse the
damage and significantly alter the appearance.
This is true when the surface wrinkles and
textural and color mottling are severe and/or
the gravitational forces have overwhelmed the
body’s defenses. The jaw sags, the mid-face
sags, the upper lip lengthens and the eyelids
droop. Although superficial peels and antiaging
topical therapy may afford some improvement, a
more aggressive approach is often needed.
• Laser Resurfacing
In the mid-1990’s a revolution took place in
aesthetic surgery with the advent of the
high-intensity pulsed carbon dioxide laser .
These machines were capable of delivering a
predictable depth of penetration into the skin,
so that one could almost “sculpt” away wrinkles
and scars. In addition, studies showed that
there was “collagen shrinkage”, which meant that
for the first time one might be able to actually
tighten the face, or reverse some of the sagging
which heretofore had only been able to be
accomplished via face-lifts. After a period of
time it became apparent that this procedure had
considerable risks as well. Many of the risks
were actually quite similar to medium and deep
chemical peels and could be predicted by the
depth of the tissue wounding. These include
prolonged redness, often lasting up to 6 months
after the procedure , hyperpigmentation (blotchy
dark discoloration) which also resolved with
treatment and time, and most disconcerting, a
white appearance that occurs many months after
the procedure and appears to be irreversible in
a small percentage of those treated . The
introduction of the erbium YAG laser was
heralded as the end of the complications of
laser resurfacing . This laser is more purely
“ablative” meaning that it vaporizes the tissue
but doesn’t heat it. Many researchers had
related the long course of redness and other
complications to the “zone of thermal necrosis”,
that is, a depth of heating that didn’t occur
with the erbium laser. Also, it appeared to be
safer on darker skin types as well as requiring
less anesthesia. More recently, however, it has
been discovered that there is a price to pay for
less risk and that appears to be decreased
effectiveness. Although the erbium procedures
appear to be faster and easier to recover from,
they don’t provide the tissue tightening one can
get with the carbon dioxide lasers, thus are
more useful for those with mild to moderate
aging changes. New “hybrid” models of laser
resurfacing have sprung up to address these
issues. These are “combined” erbium and carbon
dioxide lasers and appear to have some of the
advantages of both, while having less of the
disadvantages of either . The carbon dioxide,
erbium and hybrid lasers are in widespread use
today. When they are used for the appropriate
reasons and their limitations are recognized,
the person undergoing the procedure understands
the risks fully and postoperative care is
maximized , these are excellent treatments for
moderate to severe aging of the face.
• Other laser
procedures The newest laser procedures involve
trying to rejuvenate the skin without actually
removing or burning the top layer, sometimes
called subsurface or noninvasive resurfacing.
One procedure involves another wavelength of YAG
laser at 1320 NM (Cool Touch) which heats up the
upper layer of skin causing a remodeling
process. The other employs an intense pulsed
light source (Photoderm, Multilight or
Vasculight) to focus heat on dilated blood
vessels in the upper layer of skin and achieve
the same remodeling and production of new skin .
Both of these procedures require multiple
treatments but one can return to one’s
activities immediately and they have very low
risk. The procedure utilizing an intense pulsed
light source is called photorejuvenation.
Photorejuvenation procedure works especially
well on sun damaged skin with many dilated blood
vessels and sun freckles. This is a relatively
new procedure and I have been extremely pleased
with the results in my patients thus far.
IWhy treat aging?
Seeking out the best appearance one may attain
is common to the treatment of many skin diseases
including such “medical” diseases as acne and
psoriasis, where it is well-documented that
treatment improves ones self-esteem and quality
of life. We all strive to stave off the loss of
our physical and mental abilities as we age, as
well.
There are some within the field of dermatology
who criticize the new interest in the treatment
of aging as an exercise in greed and an escape
from the rigors of scientific inquiry. These
same people claim that due to the constraints of
managed care, dermatologists are mainly looking
to improve their bottom line and are therefore
preoccupied with cosmetic procedures. This is
far too simplistic. For one thing, the science
of the senescence of cells and tissues is no
less challenging than any other biological
mechanism. For another, real people benefit in
real ways.
Humankind will always struggle against their
limitations, the principal one being their
finite time on earth. Struggling against the
progressive loss of youthful appearance seems
natural as long as it is put into perspective
and does not become the focus of one’s life.
Perhaps through future research we can
understand the biology of aging enough to move
on to a new phase in medicine, one that some
call the paradigm for medical science in the
21st century, when we focus more on wellness and
prevention than on eradication of disease and
abnormal physiology.
What does aging skin look like?
A few examples of sun damaged skin vs non-sundamaged
skin are the arms and the chin area. If you look
at the inside surface of your upper arm you will
see a lighter toned skin where the “sun has
rarely shone”. Compare this to the outside of
the arm, and you can see the “staining” effect
of the sun on the skin. Similarly, you can see
these effects on your neck if you look in a
mirror. Given enough sun exposure to the
surrounding areas, there will be a subtle and
even “v” outlined below your chin, where the
skin has been shielded from the sun by your
chin. The mottled pigmentation of the sides of
the neck is missing here because of your chin “sunbrella”.
Where did this information come from?
Lober CW, Fenske NA. Photoaging and the skin:
differentiation and clinical response.
Geriatrics 1990 Apr;45(4):36-40,42.
Kligman LH.Photoaging. Manifestations,
prevention, and treatment. Dermatol Clin 1986
Jul;4(3):517-28.
Kadunce DP, Burr R, Gress R, Kanner R, Lyon JL,
Zone JJ. Cigarette smoking: risk factor for
premature facial wrinkling. Ann Intern Med 1991
May 15;114(10):840-4.
Antell DE. Ann Plast Surg 1999;43;585-588.
Emerit I. Free radicals and aging of the skin.
EXS 1992;62:328-41.
Weiss JS, Ellis CN, Headington JT, Tincoff T,
Hamilton TA, Voorhees J. Topical tretinoin
improves photoaged skin. A double-blind
vehicle-controlled study. JAMA 1988
Jan22-29;259(4):527-32).
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