Restoring Your Youthful Appearance

Facial rejuvenation is the term used to encompass all forms of restoring a youthful appearance to the face. It includes the broad categories of:

* Injectables (Botox® & fillers) (See BotoxFacts.ca for additional uses of Botox®);
* Resurfacing procedures (laser treatment, microdermabrasion & chemical peels);
* Surgical rejuvenation (brow lifts, eyelid surgery; facelifts, nose jobs, face and chin augmentation, and neck lifts);
* Topical tretinoin and tazarotene which reverse sun damage and enhance collagen production. The normal changes associated with facial aging are the result of both:

* intrinsic (age related fat and bone loss known as atrophy, and skin laxity for example) and
* extrinsic factors (like ultraviolet light / sunlight, chemicals, and smoking).

These factors contribute to biological changes associated with age and create predictable patterns of facial change. An over-simplistic analogy is mimicked by the changes in the helium balloon your child wouldn’t let you throw away. With time there is loss of internal volume (gas in this example) and as a result the covering loses its taught shape, luster, and becomes wrinkled. Moreover, there is a marked change in shape of the entire structure. Naturally, similar changes on your face can be highly distressing especially since many available treatments are being promoted.

Physicians can treat facial aging three ways: through reduction (making the skin “fit”), augmentation (“stretching” the skin back to normal) or a combination of the two.

When it comes to choosing a rejuvenation procedure, the severity of the facial aging must be considered. Here’s a review:

* Wrinkles (individual fine or deep rhytids) are managed well by Botox® or injectable fillers. Although other agents are touted to produce similar results, Botox® is currently unsurpassed in its ability to soften or eliminate wrinkles caused directly by the action of underlying muscles of facial animation. (Botox Facts has more information for you)

* For wrinkles that may not be contributed to directly by facial movement or for depressed scars; superficial or deep fillers (ranging from collagen, hyaluronic acid and poly-L-lactic acid to silicone particles and bone cement and even your own injected fat). These can also be used for wrinkles, scars, and soft tissue augmentation (most commnly lip augmentation).

* When you have wrinkles involving larger areas or if it’s related to sun-damage, the underlying problem commonly lies in the biological changes in the skin itself. Here rejuvenation methods such as laser resurfacing, microdermabrasion, and chemical peels act to restore some of the lost intrinsic biologic properties of the skin and can provide a significant restorative change over these large areas. These treatments use light associated heat, physical sanding, or chemicals, respectively, to remove the surface layers of the skin and hence stimulate a regenerative-like process. Many common skin creams advertised to improve facial wrinkles contain glycolic or other acids used in light chemical peels to help improve the taughtness of your treated skin.

* As the severity of skin aging increases, injection and resurfacing procedures may be combined themselves or with surgical rejuvenation (possibly in a staged fashion).
* Surgical management of more severe forms of facial aging can be through an additive (implants), reductive (excisions or tucks), or combined approach. Modern rhinoplasties (“nosejobs”) are a good example where combined approaches of reduction by excision and

augmentation through cartilage grafting are employed. As these procedures typically address changes in the three-dimensional volume (deep structures) and in the skin (envelope or cover) they obviously provide the greatest extent of rejuvenation and can address the greatest degrees of facial change. That said, they do come with a limited amount of scaring and the possibly some temporary numbness. Often these scars, created in lines of election, are fine and highly acceptable with some rare exceptions.

* Topical tretinoin and tazarotene can improve fine lines and the general appearance of the skin. The down-side is that you need to continue to use these topical treatments in order to maintain its effect. Sometimes, tretinoin and tazarotene can be combined with the procedures listed above to enhance the effects.

Although you may hear more and more about treating aging skin with the procedures and products mentioned above, we all know that the best form of care is through modification of your exposure to the extrinsic “modifiable” risk factors, like sun exposure (See Skin Cancer Guide for more information).

By: Dr Bryce J Cowan BSc MSc MD PhD FRCS(C)

Acne Treatments and Topical Drugs

TREATMENT

Acne treatment consists of reducing sebum production, removing dead skin cells, and killing bacteria. Treatment methods differ depending on how serious the acne is.

Topical Drugs

Topical drugs are applied directly to the affected areas of the skin. They are available in the form of creams, gels, lotions, or pads. They are used primarily to treat mild forms of acne in which there is little or no inflammation.

One group of topical drugs used for acne includes antibiotics. These drugs kill the bacteria that contribute to the disease. Another group of drugs is called comedolytics (pronounced KO-mee-do-LIE-tiks). These drugs loosen hard plugs and open pores. Still another group of drugs works by increasing the rate at which new skin cells form. These drugs prevent the formation of new comedos.

Topical drugs are applied once or twice a day after washing with mild soap. Treatment may have to continue anywhere from a few weeks to a few months to a few years. Side effects such as mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight may occur.

Oral Drugs

Oral drugs are taken by mouth. Doctors sometimes prescribe oral antibiotics for moderate cases of acne. These antibiotics prevent the formation of new comedos and reduce inflammation. They are usually taken once a day
for two to four months. Side effects may include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.

A drug that is used for severe cases of acne is isotretinoin (pronounced i-so-TRET-uh-no-un, trade name Accutane). This drug reduces the production of sebum and the stickiness of skin cells. It is used when cysts and nodules are present. The drug may be used alone or with other topical or oral antibiotics.
Isotretinoin treatment usually lasts for four or five months. It is effective in about 60 percent of all patients. If the acne reappears, another course of treatments may be necessary. Some side effects that may accompany the use of isotretinoin include nosebleeds, dry skin, a temporary worsening of the acne, vision disorders, and increased production of liver enzymes, blood fats, and cholesterol. It may also cause birth defects and cannot, therefore, be used by pregnant women.

Women who do not respond to any of these treatments may be given another type of oral drug, an anti-androgen. Anti-androgens reduce the production of androgen and therefore reduce the formation of comedos. Certain types of oral contraceptives are also effective as anti-androgens.

The most serious forms of acne require other types of drugs, including oral corticosteroids, or anti-inflammatory drugs. These drugs are often used for the treatment of a form of acne known as acne fulminans, which occurs mostly among adolescent males. They are also used with acne that produces numerous deep, inflamed nodules that heal with scarring.

Benzoyl Peroxide and Tretinoin

Benzoyl Peroxide and Tretinoin

When applying antiacne drugs to the skin, people should be careful not to get the medicine in the eyes, mouth, or inside the nose. They should not put the medicine on skin that is wind burned, sunburned, or irritated, and not apply it to open wounds.

Because antiacne drugs such as benzoyl peroxide and tretinoin irritate the skin slightly, users should avoid doing anything that might cause further irritation. They should wash the face with mild soap and water only two or three times a day, unless the physician says to wash it more often. They should also avoid using abrasive soaps or cleansers and products that might dry the skin or make it peel, such as medicated cosmetics, cleansers that contain alcohol, or other acne products that contain resorcinol, sulfur, or salicylic acid.

If benzoyl peroxide or tretinoin make the skin too red or too dry or cause too much peeling, the user should check with a physician. Using the medicine less often or using a weaker strength may be necessary. Benzoyl peroxide can irritate the skin of people with skin of color and cause darkened spots called hyperpigmentation on the skin. Benzoyl peroxide may discolor hair or colored fabrics.

ORAL DRUGS. Oral antibiotics are taken daily for two to four months. The drugs used include tetracycline, erythromycin, minocycline (Minocin), doxycycline, clindamycin (Cleocin), and trimethoprim-sulfamethoxazole (Bactrim, Septra). Possible side effects include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.

The goal of treating moderate acne is to decrease inflammation and prevent new comedones from forming. One effective treatment is topical tretinoin, used along with a topical or oral antibiotic. A combination of topical benzoyl peroxide and erythromycin is also very effective. Improvement is normally seen within four to six weeks, but treatment is maintained for at least two to four months.

Special Conditions

People who have certain medical conditions or who are taking certain other medicines may have problems if they use antiacne drugs. Before using these products, the physician should be informed about any of the following conditions.

ALLERGIES. Anyone who has had unusual reactions to etretinate, isotretinoin, tretinoin, vitamin A preparations, or benzoyl peroxide in the past should let the physician know before using an antiacne drug. The physician should also be told about any allergies to foods, dyes, preservatives, or other substances.

PREGNANCY. Teens who are pregnant or who may become pregnant should check with a physician before using tretinoin or benzoyl peroxide. Isotretinoin causes birth defects in humans and must not be used during pregnancy.

OTHER MEDICAL CONDITIONS. Before using antiacne drugs applied to the skin, people with any of these medical problems should make sure their physicians are aware of their conditions:
•    Eczema. Antiacne drugs that are applied to the skin may make this condition worse.
•    Sunburn or raw skin. Antiacne drugs that are applied to the skin may increase the pain and irritation of these conditions.

In people with certain medical conditions, isotretinoin may increase the amount of triglyceride (a fatty-substance) in the blood. This may lead to heart or blood vessel problems. Before using isotretinoin, adolescents with any of the following medical problems should make sure their physicians are aware of their conditions:

•    alcoholism or heavy drinking, currently or in the past
•    diabetes or family history of diabetes (Isotretinoin may change blood sugar levels.)
•    family history of high triglyceride levels in the blood
•    severe weight problems

Using antiacne drugs with certain other drugs may affect the way the drugs work or may increase the chance of side effects.

Anti Acne Drugs for Severe Acne

Anti-acne drugs are medicines that help clear up pimples, blackheads, whiteheads, and more severe forms of acne.

Benzoyl peroxide is found in many over-the-counter acne products that are applied to the skin, such as Benoxyl, Clear By Design, Neutrogena Acne, PanOxyl, and some formulations of Clean & Clear, Clearasil, and Oxy. Some benzoyl peroxide products are available without a physician’s prescription; others require a prescription. Tretinoin (Retin-A) is available only with a physician’s prescription and comes in liquid, cream, and gel forms, which are applied to the skin. Isotretinoin (Accutane), which is taken by mouth in capsule form, is available only with a physician’s prescription. Only physicians who have experience in diagnosing and treating severe acne, such as dermatologists, should prescribe isotretinoin.

Acne is a skin disorder that leads to an outbreak of lesions called pimples or “zits.” The most common form of the disease in adolescents is called acne vulgaris. Antiacne drugs are the medicines that help clear up the pimples, blackheads, whiteheads, and more severe forms of lesions that occur when a teen has acne.
Different types of antiacne drugs are used for different treatment purposes, depending on the severity of the condition. For example, lotions, soaps, gels, and creams containing substances called benzoyl peroxide or tretinoin may be used to clear up mild to moderately severe acne. Isotretinoin (Accutane) is an oral drug that is prescribed only for very severe, disfiguring acne.

Acne is caused by the overproduction of sebum during puberty when high levels of the male hormone androgen cause excess sebum to form. Sebum is an oily substance that forms in glands just under the surface of the skin called sebaceous glands. Sebum normally flows out hair follicles onto the skin to act as a natural skin moisturizer. The glands are connected to hair follicles that allow the sebum, or oil, to empty onto the skin through a pore.

Sometimes the sebum combines with dead, sticky skin cells and bacteria called Propionibacterium acnes (P. acnes) that normally live on the skin. The mixture of oil and cells allows the bacteria to grow in the follicles. When this happens, a hard plug called a comedo can form. A comedo is an enlarged hair follicle. It can appear on the skin as a blackhead, which is a comedo that reaches the skin’s surface and looks black, or as a whitehead, which is a comedo that is sealed by keratin, the fibrous protein produced by the skin cells and looks like a white bump.

In addition, pimples can form on the skin. Types of pimples include:
•    papules, which are small, red bumps that may be tender to touch
•    pustules, which are pus-filled lesions that are often red at the base
•    nodules, which are large, painful lesions deep in the skin
•    cysts, which are painful pus-filled lesions deep in the skin that can cause scarring

Pimples form when the follicle is invaded by the P. acnes bacteria. The damaged follicle weakens and bursts open, releasing sebum, bacteria, skin cells, and white blood cells into surrounding tissues. Scarring happens when new skin cells are created to replace the damaged cells. The most severe type of acne includes both nodules and cysts.

Acne cannot be cured, but antiacne drugs can help clear the skin and reduce the chance of scarring. The goal of treating moderate acne is to decrease inflammation and prevent new comedones from forming. Benzoyl peroxide and tretinoin work by mildly irritating the skin. This encourages skin cells to slough off, which helps open blocked pores. Benzoyl peroxide also kills bacteria, which helps prevent whiteheads and blackheads from turning into pimples. Isotretinoin shrinks the glands that produce sebum. It is used for severe acne lesions and must be carefully monitored because of its side effects. Antibiotics also may be prescribed to kill bacteria and reduce inflammation.