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CHAPTER 5 HORMONES AND AGING SKIN 33
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CHAPTER 6 Photoaging
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Leslie Baumann, MD Sogol Saghari, MD
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As life expectancy has increased and baby boomers have begun to enter middle age, interest has increased in slowing the aging process Implied in this escalating interest is the confidence that greater scientific knowledge and advancements in technology may allow us to control the physical manifestations of aging In the meantime, more and more people are becoming aware of the external factors implicated in premature aging Although dermatologists have discussed, since the end of the 19th century,1 the notion that sunlight contributes to premature aging, there remains a great need for education to convince people of the hazards posed by sun exposure The consequences to the skin of chronic sun exposure are readily apparent when one compares the exposed skin of the face, hands, or neck to the unexposed skin of the buttocks, inner thigh, or inner arm (Fig 6-1) This sun damage can be highlighted by using a Wood s lamp, blue light, or an ultraviolet camera system, rendering the epidermal pigment component more noticeable (Figs 6-2, 6-3, and 6-4) Showing such results to sun-seeking patients can prove useful in convincing them of the havoc that the sun has wreaked on their skin The sun is not the sole source or cause of skin aging It is the major external cause among several components, both endogenous and exogenous This chapter will concentrate, though, on the role of the sun on the extrinsic aging process of the skin, also known as photoaging aging reflects the genetic background of an individual and results from the passage of time It is inevitable and, thus, beyond voluntary control Extrinsic aging is engendered by external factors such as smoking, excessive use of alcohol, poor nutrition, and sun exposure, which in many cases can be reduced with effort This process, then, is not inevitable and, by definition, refers to premature skin aging It is believed that as much as 80% of facial aging can be ascribed to sun exposure2
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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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INTRINSIC VERSUS EXTRINSIC AGING
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Intrinsically aged skin is smooth and unblemished, with exaggerated expression lines but preservation of the normal geometric patterns of the skin Under the microscope, such skin demonstrates epidermal atrophy, flattening of the epidermal rete ridges, and dermal atrophy3 Collagen fibrils are not thickened but are elevated in number with an increase in the collagen III to collagen I ratio4 Extrinsically aged skin appears predominantly in exposed areas such as the face, chest, and extensor surfaces of the arms It is a result of the total effects of a lifetime of exposure to ultraviolet radiation (UVR) Clinical findings of photoaged skin include wrinkles and pigmented lesions such as freckles, lentigines, and patchy hyperpigmentation, and depigmented lesions such as guttate hypomelanosis (Fig 6-5) Interestingly, a study in the Journal of the American Medical Association reported that children with the tendency to freckle developed 30% to 40% fewer freckles when treated with an SPF 30 sunscreen daily as compared to children not treated with a sunscreen5 This study illustrates the importance of sun protection in the prevention of these pigmented lesions that not only make the skin appear older, but also are known to be associated with an increased risk of melanoma Other signs of skin aging include a loss of tone and elasticity, increased skin fragility, areas of purpura owing to blood vessel weakness, and benign lesions such as keratoses, telangiectasias, and skin tags (Fig 6-6) Glogau developed a photoaging scale that is used to classify the extent of clinical photodamage (Table 6-1) Patients with a significant history
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SKIN AGING
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There are two main processes of skin aging, intrinsic and extrinsic Intrinsic
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FIGURE 6-1 Comparing the sun-exposed surface of the forearm to the non-sun-exposed surface demonstrates the sun s ability to cause skin changes
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of sun exposure may score higher on this scale than expected for their age, just as patients with a history of minimal sun exposure may achieve a score lower than expected for their age The histopathologic alterations in photoaged skin are easily distinguished and characterized by elastosis (Fig 6-7) Photoaged skin is also marked by epidermal atrophy and discrete changes in collagen and elastic fibers In severely photoaged skin, the collagen fibers are fragmented, thickened, and more soluble6 Elastic fibers also appear fragmented and may exhibit progressive cross-linkage and calcification7 These alterations in collagen and elastic fibers have been demonstrated to worsen with continued UV exposure
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