40 2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050

Master Case Presentation

Blackwell Publishing Inc
Elderly skin and its rejuvenation: products and procedures for
the aging skin
Marcia Ramos-e-Silva, MD, PhD
1
& Sueli Coelho da Silva Carneiro, MD, PhD
1,2
1
Sector of Dermatology and Post-Graduation Course, HUCFF-UFRJ and School of Medicine, Federal University of Rio de Janeiro
2
Sector of Dermatology, HUPE-UERJ, and School of Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil
Summary In the last few decades, there has been a substantial increase in the population of people
over 60 years of age. Most of them maintain a good general health and physical activity
and tness. For these individuals there is a good number of dermatologic procedures,
medications, and cosmetics that can be prescribed to improve the aspect of skin aging,
providing an improvement in their self-esteem and quality of life as a result of their better
look. We will discuss the mechanisms of skin aging, and the procedures and substances
used to minimize its deleterious effects, such as sunscreens, estrogens, chemical peels,
toxin botulinum, llers and surgical procedures, among others. The use of makeup and
the adverse reactions to cosmetics will also be mentioned.
Keywords: aged, cosmetics, elderly, photoaging of the skin, skin aging
Introduction
Skin aging is a continuous time-dependent and
multifactorial phenomenon of reduction in size and
number of cells and reduction in the rate of many organic
functions, both at the cellular and molecular levels. Many
skin functions decline with age, such as cell replace-
ment, injury response, barrier function, chemical clearance,
sensory perception, immune and vascular responsiveness,
thermoregulation, sweat production, sebum produc-
tion, and vitamin D production.
1,2,3,4
Successful aging
is characterized by good mental health and adaptative
psychosocial functioning, resulting in life satisfaction.
5
Obviously no one can remain young forever, but
cosmetic innovations through scientic research are
progressing very rapidly. Patients are able to signicantly
delay the visible aging process by practicing a preventive
skin care and taking advantage of the many chemical
treatments available for facial rejuvenation.
6
People over
65 years of age represented 13% of population in the year
2000, but will be 20% by 2030. This preponderance of
aged people over young people will transform the shape of
the age distribution graph into a rectangle rather than
the pyramid observed nowadays.
7
Cutaneous aging provides a visible model of the inter-
action between endogenous and exogenous (ultraviolet
or UV light) factors. Clinically detectable, age-associated
cutaneous changes result from two independent pro-
cesses: chronologic aging and actinic irradiation. Several
lines of evidence suggest that these two processes have
different biologic, biochemical, and molecular mecha-
nisms.
8
Tables 1 and 2
9
summarizes the differences
between photoexposed (Fig. 1) and photoprotected
(Fig. 2) skin in the clinical and also epidermal and dermal
histologic features.
Chronologic aging
The physiologic changes observed in chronologic aging
skin are barrier function impairment, slower turnover of
epidermal cells, and a poor vascular network around hair
bulbs and glands, leading to atrophy. The most affected
Correspondence: Marcia Ramos-e-Silva, MD, PhD, Rua Dona Mariana 143/
C-32, 22280-020 Rio de Janeiro, Brazil. E-mail:
ramos.e.silva@dermato.med.br
Accepted for publication July 15, 2006
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050 41
Table 1 Clinical changes seen in sun-exposed and sun-protected skin.
Clinical changes
Exposed skin Unexposed skin
Thickened and nodular Thinned and smooth
Yellow and sallow Clear, almost transparent
Coarse wrinkling Fine wrinkling
Rough Smooth
Frequent telangiectasia and ecchymoses Less frequent telangiectasias and ecchymoses
Multiple lentigines Minimal lentigines
Mottled pigmentation Even pigmentation
Elastotic, lax skin Inelastic, saggy, redundant skin
Comedones Milia
Decreased sweating Decreased sweating
Marked dryness and scaliness Dryness and some scaling
Easy tearing and shearing of skin Fragile skin
Increased numbers of seborrheic and other keratoses Few seborrheic and other keratoses
Increased numbers of premalignant lesions Ocasional premalignant lesions
Increased numbers of malignant lesions Ocasional malignant lesions
Reprinted from Benedetto, with permission from Elsevier Science.
9
Table 2 Histopathologic changes observed in the epidermis and dermis of sun-exposed and sun-protected skin.
Exposed skin Unexposed skin
Epidermal histopathologic changes
Reactive thickening, with eventual marked epidermal atrophy Slight decrease in thickness
Slight elongation of rete ridges Rete ridges effacement
Cellular atypia Flattening of dermalepidermal junction
Loss of polarity Decreased dermal and epidermal contact
Variability in basal cell morphology with cytoplasmic microfootlets present Nearly normal basal cells with loss of cytoplasmic microfootlets
Increased melanogenesis Decrease in the number and function of melanocytes
Marked decrease in the number and function of Langerhans cells Moderate decrease in the number and function of
Langerhans cells
Dermal histopathologic changes
Grenz zone present Grenz zone absent
Thick, degraded nonfunctional elastic fibers Decrease in total volume
Increase in amorphous elastotic material Decrease in cellularity
Increase in collagenogenesis Degenerated elastin
Increase in soluble collagen Decrease in soluble collagen
Activated fibroblasts Less prominent fibroblasts
Decrease in mature collagen (insoluble) Increase in mature collagen (insoluble)
Increase in collagenase activity Loss of oxytalan fibers
Fragmented collagen Haphazard, rope-like collagen bundles
Increase in glysosaminoglycans and proteoglycans Increase in glysosaminoglycans and proteoglicans
Marked regression and disorganization of small blood vessels Less prominent regression and disorganization of
small blood vessels
Marked thickening of post capillary venular walls, increased number
of veil cells
Less prominent and even thickening of small vessel
walls, decreased number of veil cells
Perivenular chronic inflammation No evidence of inflammation
Marked decrease in sweat-gland number and function Reduced sweat-gland number and function
Marked increase in sebaceous-gland size, but decrease in function Increase in sebaceous-gland size, but decrease in function
Reprinted from Benedetto, with permission from Elsevier Science.
9
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
42 2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050
cells in the senescence process are keratinocytes and
broblasts, which are reduced in numbers. Hair and nail
growth are retarded. Synthesis of vitamin D decreases as
time goes by, and last but not least, the immune response
is also impaired.
1013
All these situations lead to alteration
of skin functions, such as protection, excretion, secretion,
absorption, thermoregulation, and sensory perception.
Besides the reduction in the number of keratinocytes,
epidermal changes associated with aging involve the at-
tening of its underside, a reduction in the number of
Langerhans cells, and also in the number of melanocytes
and synthesized melanosomes, leading to reduced
pigmentation.
11,12,1418
Dermal changes are represented by a reduction of
broblasts, collagen and elastic bers, mast cells and
macrophages, and also dilation of the lymphatic channels.
The dermalepidermal junction is attened and the
number of hair follicles decreases with age, although
their structure remains unchanged.
11,12,1418
There is a progressive reduction in sebum production.
Water-binding capacity of the stratum corneum is
decreased. Loss of fat and redistribution of the existing fat
in the subcutaneous layer of the skin result in changes in
facial contour. Function of both Meissner and Pacinian
corpuscles are decreased. There are changes in cutaneous
permeability to chemical substances and increased pro-
duction of free radicals is also observed.
8,1921
Colorimetric measurements show that elderly skin is
darker than young skin even in areas not exposed to
the sun. Epidermal atrophy and increase transparency
may contribute to this, leading to increased visibility
of dermal components. Some pigmented cells, however,
particularly in sun-damaged areas, become over-
active, producing blotches of hyperpigmentation.
22
Hair on
the face and in the ears and nose may become coarser,
more bristly, and more obvious, while scalp and body
hair turns white because of loss of functioning pigmented
cells.
17,18,23
Computerized images showed that intrinsic aged skin
have the same density of veins and arteries, but reduced
caliber, while the actinic aged skin progressively looses
the dermal vasculature and their vessel caliber.
24
Other
problems may appear as years go by, like pruritus, xerosis,
and others.
Interleukin-1 (IL-1) alpha family of cytokines/recep-
tors are present in normal murine epidermis and they
increase or decrease after barrier disruption in young
murine epidermis. IL-1 alpha is capable of initiating
the cytokine cascade, which triggers homeostatic and
pathophysiologic changes in the skin. This cytokine
predominates in keratinocytes and is normally expressed
in all epidermal cell layers, and barrier disruption mark-
edly enhances both IL-1 alpha mRNA and protein levels.
Aged epidermis, on the contrary, expresses subnormal
mRNA and protein level of certain members of this
cytokine family.
2527
Figure 1 Sun-exposed area (dorsum of hand): 85-year-old woman
photoaging.
Figure 2 Nonexposed area (buttock): same 85-year-old woman of
Fig. 1, not intensively sun exposed during her life intrinsic or
chronologic aging.
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050 43
Actinic radiation
Photoaging, heliodermatosis, actinosenescence, or actinic
dermatosis is an accelerated aging of chronically sun-
exposed skin, with distinct clinical, histologic, and
functional features, and an evident relation to skin
cancer. Photoaged skin, as on the neck, dcollet, face,
forearms, and hands, overlaps and superimposes the
alterations seen in the normally aged skin. Those changes
caused by sun exposure can occur even before signs of
chronic skin aging. The clinical features depend on factors
such as skin type, nature of sun exposure (occupational
and/or recreational), hairstyle, dress, and individual repair
capacity. A leathery appearance with wrinkle formation,
increased fragility of the skin, and impaired wound
healing are seen and there are also some dermal changes.
28,29
Many different types of lesions begin to appear as the
skin ages, including actinic and seborrheic keratoses,
cutaneous horns, and skin cancer; most of them in sun-
exposed areas (Figs 3 and 4).
17,18,23
The clinical features
of actinosenescence may be classied according to
Glogau in four types, as observed in Table 3.
13
Epidermal changes are characterized by pigmentary
alterations, such as lentigines and hyperpigmentation,
associated with hypertrophic or atrophic epidermis, and
deposition of fragmented elastic bers on histopathology.
The horny layer shows hyperkeratosis, but the most
prominent histologic feature is elastosis, which begins
at the junction of papillary and reticular dermis.
30,31
Another prominent feature is basophilic degeneration,
representing the replacement of mature collagen bers
by a basophilic appearance collagen.
32,33
Ultraviolet light interacts with various cells located
at different depths depending on its wavelength. The
shorter wavelengths (280320 nm) are absorbed in the
epidermis and affect keratinocytes, whereas longer wave-
lengths (320400 nm) interact with keratinocytes and
dermal broblasts.
30
The induction of matrix metallopro-
teinases (MMP) plays a major role in the pathogenesis of
photoaging. They are a group of enzymes subfamily of
proteinases responsible for the degradation of collagen.
34
UV light affects the post-translational modication of der-
mal matrix proteins and induces a wide variety of an ever
increasing family of MMPs with proteolytic activity to
degrade matrix proteins. Each one MMP degrades different
components of the dermal matrix proteins, for example,
MMP-1 cleaves collagen types I, II, and III and MMP-9
degrades collagen types IV and V and gelatin. There are
also tissue-specic inhibitors of MMPs (TIMP) to inacti-
vate certain MMPs.
29
Mitochondria are cell organelles whose main function
is to generate energy for the cell, by a multistep process
called oxidative phosphorylation or electron transport
Figure 3 Heavily sun-exposed area (pre-esternal region): 78-year-
old woman wrinkles, keratoses, and mottled pigmentation.
Figure 4 Moderately sun-exposed area (face): 79-year-old woman
wrinkles, keratoses, and pigmentation.
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
44 2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050
chain. The human mitochondrial DNA (mtDNA) shows a
mutation frequency 50-fold higher than nuclear DNA
and may be involved in the process of photoaging.
35,36
Located in the inner mitochondrial membrane are ve
multiprotein complexes that generate an electrochemical
proton gradient used in the last step of the process to turn
ADP and organophosphate into ATP. This process may
lead to the generation of reactive oxygen species (ROS),
making the mitochondrion the site of the highest ROS
turnover in the cell. Close to this site is the mtDNA with
its great mutation frequency. ROS can exert a multitude
of effects as lipid peroxidation, activation of transcription
factors, and generation of DNA-strand breaks. Assess-
ment of the underlying photobiologic mechanism has
revealed that, similar to UVA-induced MMP induction,
the generation of mtDNA mutations is due to production
of singlet oxygen. This indicates that substances with
ROS-quenching potential may be employed to prevent
photoaging of human skin. By inhibiting the translation
of transiently damaging ROS effects into genetically
imprinted mutations, quenchers may not only protect
from short-term damage of UV but also prevent hazard
caused by long-term UV exposure.
28
Ultraviolet radiation is closely related to the formation
of d--aspartyl in the elastic bers of skin. Those biologi-
cally uncommon d-aspartyl residues have been reported
in proteins of various elderly tissues.
37
A basic knowledge of collagen formation and break-
down is necessary to fully appreciate the results of a few
key studies and their signicance in photoaging patho-
genesis. Mature collagen in skin undergoes continuous
turnover, which is required for optimal connective tissue
formation. Collagen is the most abundant component of
the extracellular matrix.
34
Skin aging in smokers
Smokers look older than nonsmokers of the same age,
because smoking has an aging effect on human skin,
especially in the facial region.
38
The molecular basis of
smoking-induced facial aging is not known, but in vitro
studies have shown that tobacco smoke extract induces
MMP-1 and MMP-3 mRNA in skin broblasts in vitro.
39
However, tobacco smoke extract has no effect on tissue
inhibitor of metalloproteinases (TIMP-1) and TIMP-3
mRNA. Lahmann et al.
40
demonstrated that smoking
induces MMP-1 mRNA in skin in vivo, but has no effect on
TIMP-1 mRNA. They suggested the multiplicative effects
of sunlight and smoking on facial aging occurred by
induction of MMP-1.
Pharmaceutical products and procedures for
the elderly
The cutaneous stigmata of aging may affect an
individuals mental well-being, body image, and quality
of life.
41
Aging, unfortunately, is a fact of life and the older
population is increasing in number. That is why it is
worth to keep researching cosmetic products and procedures
for the elderly because as said by Irene Ravache, a famous
Brazilian actress, only those who die early dont age,
and by Mario Quintana, one of the most well-known
Brazilian poets, aging is wonderful because the other
option is worse
4
According to Earle Brauer, cosmetics may be broadly
dened as topical agents to effect personal grooming,
inuence appearance, and improve self-image. There
are four kinds of cosmetics: toiletries, skin-care products,
camouage products, and fragrance products. The great
Table 3 Glogaus types of actinosenescence.
Type I No wrinkles Type II Wrinkles in Motion
early photoaging early to moderate photoaging
mild pigmentary changes 0 early senile lentigines visible
no keratoses keratoses palpable but not visible
minimal wrinkles parallel smile lines beginning to appear lateral to mouth
minimal or no makeup usually wears some foundation
younger patient: 20s or 30s patient age: late 30s or 40s
Type III Wrinkles at Rest Type IV Only Wrinkles
advanced photoaging severe photoaging
obvious dyschromia, telangiectasia yellow-gray color of skin
visible keratoses prior skin malignancies
wrinkles even when not moving wrinkled throughout, no normal skin
always wears heavy foundation cannot wear makeup cakes and cracks
patient age: 50s or older patient age: sixth or seventh decade
Adapted from Glogau, with permission from HMP Communications.
13
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050 45
changes in elderly skin allow the dermatologist to recom-
mend specic products that might be better than others.
Multiple factors affect the way skin ages: heredity, sun
exposure, chronologic age, emotional stress, repeated
weight gain and loss, diet/nutritional supplements, and
exercise.
17,42,43
Sunscreens and sunblocks
The sunscreen agent is thought to prevent cellular
damage and thus prevent dehydration. It may be
chemical, physical, or a combination of both.
The best cosmetic a person can wear for preservation of
his or her youthful appearance is a sunscreen. It can
cause an apparent reversal of some photoaging and keep
the skin youthful looking. Physical sunblocks are impor-
tant for individuals who must be absolutely protected
from the sun. They also are important to protect the most
vulnerable parts of the body, such as the ears, nose tips,
shoulders, and cheeks. There are several types of UVB and
UVA chemical sunscreens.
17
Patients should avoid the sun during the peak hours of
sunshine, wear protective clothing, and use sunscreens
while outdoors.
4446
The constant use of a photoprotec-
tor can promote an apparent reversion of photoaging
giving skin a younger aspect. A great improvement may
occur with suppression of exposure or photoprotection,
even when started late in life. There is formation of
neocollagen and new elastic bers, giving the same aspect
as seen in nonexposed skin.
17
Moisturizers and keratolytic agents
The continuous loss of water content of the stratum
corneum through evaporation on the surface to the
environment leads to xerosis. The cells accumulate, giving
the skin a white and scaling aspect. However, xerotic
skin is due to more than simply low water content, and
electron micrographic studies demonstrate a thicker,
ssured, and disorganized horny layer. This characteristic
tends to increase with age due to a decrease in the
inherent water content of the stratum corneum, and
probably an abnormal desquamatory process is also
present. Moisturizers decelerate the loss of humidity from
the surface of skin by deposition of an oil lm, avoiding
evaporation; help minimize the aspect of ne wrinkles;
and maintain appropriate level of skin humidity. Fine
wrinkles more visible when skin is too dry so hydration
makes wrinkles less obvious. Rehydration can be achieved
with the use of occlusives, humectants, hydrophilic
matrices, and sunscreens.
47,48
There are many moisturizing
agents, such as hydrocarbon oils, silicone oils, vegetable
and animal fats, fatty acids, fatty alcohol, polyhydric
alcohols, phospholipids, and sterols, among others.
Keratolytic agents act in the xerosis of the elderly by
preventing accumulation of excessive stratum corneum
and removing the cohesive attachment of the cornied
cells. The oldest keratolytic agent is salicylic acid, a beta-
hydroxy acid. Others are propylene glycol, retinoic and
glycolic acids, propylenoglicol in water, and lactic acid,
which also act as moisturizers.
47,49,50
Topical application
of retinoids and analogs are used for aging skin and the
ones currently available are retinol, retinaldehyde, retinoic
acid, isotretinoin, adapalene, and tazarotene.
5158
Antioxidants
Ultraviolet A light acts indirectly through generation of
ROS, as well as UVB light, which also generate ROS by
induction of DNA damage. The induction of MMP also
plays a role in the pathogenesis of photoaging. UV light
induces a wide variety of an ever increasing family of
MMPs.
28
If the generation of ROS is an important
proximal step in the UV signaling, which mediates
photoaging, then the appropriate use of antioxidants
may be an effective prevention strategy. Although
countless commercial products containing one or more
of alleged antioxidant exist, no data have proven that any
of them really affects the UV response.
Antioxidants include vitamins A (retinol), C (ascorbic
acid), and E (tocopherols); -carotene; and bioavonoid.
Antioxidants act as oxygen scavengers, and seem to affect
primarily the number of sunburn cells, the apoptotic
keratinocytes, which appear after UV radiation.
59
Topical
applications of -tocopherol or ascorbic acid decrease
UVB-induced erythema and edema and decrease the
number of sunburn cells. Carotenoid preparations and
synthetic phenolic antioxidants similarly are reported to
reduce UV-induced erythema and retard development of
squamous cell carcinomas in the hairless mouse model.
Intervention modalities that would enhance cellular
DNA damage repair would be of utmost importance for
maintaining health in the elderly.
59,60
Caloric restriction
Caloric restrictions have a benecial effect on some
cutaneous functions, but do not seem to affect all
functions. Pendergrass et al.
61
showed that caloric
restriction increased the proliferative potential of
cutaneous murine broblasts; however, no difference in
cellular proliferation between caloric restricted animals
vs. ad libitum-fed animals was found in a study using
rhesus monkeys (Macaca mulatta).
62
It is possible that
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
46 2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050
decreasing energy metabolism by restricting calories
would reduce the rate of ROS generation and increase
lifespan. Caloric restriction or undernutrition without
malnutrition is well documented to affect longevity.
Estrogens
Skin aging process increases rapidly in postmenopausal
women after the age of 50. The external symptoms of skin
aging observed in this period are connected with a
decrease in collagen content, which is conditioned by the
same mechanisms that regulate its contents in bone
tissue.
6366
Estrogens inuence the amount of collagen synthe-
sized by broblasts, increase the synthesis of hyaluronic
acid, and promote water retention. Skin broblasts have
receptors for both androgens and estrogens. Most estro-
gen receptors are found on facial skin. They also increase
synthesis of the extracellular matrix and inhibit sebum
secretion, so their regular use should prevent dry skin
and skin wrinkling.
67
Hormone replacement therapy
contains two main ingredients: estrogens and progesta-
gens. Most of the postmenopausal symptoms depend on
decreased concentration of the estrogens. Hormone
therapy was shown to signicantly improve parameters
involved in skin aging such as hydration, elasticity, and
skin thickness. These ndings support the clinical
impression that an early hormone substitution therapy
may restore the initial features of hormonally induced
skin aging.
68
The evaluation of skin condition of post-
menopausal women after topical treatment with creams
containing estrogens (estriol and estradiol) showed a
signicant reduction of wrinkles as well as increased
elasticity and better vasculature of the skin.
69
Chemical peels
Destruction of epidermis and, in some cases, supercial
dermis does produce edema and, hence, appreciable
improvement in appearance. There is documented
evidence that some of these substances and procedures
can induce formation of new collagen with normal
staining properties.
50,70,71
Trichloroacetic acid 1035% is used to accomplish
supercial chemical peelings on facial and nonfacial
areas and may be repeated every 7 to 28 days.
Jessners solution is a combination of resorcinol, sali-
cylic acid, and lactic acid in ethanol. Its application
can be light or intense and may be repeated after
34 min. Jessners solution amplies the effect of 5-
uorouracil and this association is called the uor-
hydroxy pulse peel.
Salicylic acid is a -hydroxy acid and can be used as a
50% ointment on the dorsa of hands and forearms or as
a 35% solution in ethanol for the face. Erythema and
edema are minimal and the peel can be repeated every 2
4 weeks.
Peels of glycolic acid are excellent facial rejuvenating
therapies. Although the irritant power of glycolic acid
is often directly related to its low pH, irritancy of the
vehicle must also be considered.
7275
Other -hydroxy
acids include lactic, malic, citric, and tartaric acids; the
most commonly used in dermatology are glycolic and
lactic acids.
A new era in dermatologic treatment began with the
introduction of retinoids two decades ago.
76
They may be
used orally or topically for a wide variety of skin disorders.
Topically and in higher concentrations than the ones
used for the keratolytic effect, some retinoids may be used
as peelings agents with very good results.
5158
The traditional deep chemical peels formula with fenol
was described in 1961 by Baker and Gordon.
52
Toxin botulinum
Toxin botulinum, just to mention, is a sterile, vacuum-
dried puried form of botulinum toxin type A indicated
for the treatment of strabismus, blepharospasm, and
other related condition. It acts by inhibition of acetylcholine
release of the motor endplates. It temporarily denervates
specic muscles responsible for certain facial rhytids
including the glabelar furrow, horizontal forehead lines,
horizontal neck lines, and crows feet.
77
Fillers
Every substance used for soft tissue augmentation
presents features that make it, case by case, the best
choice,
78
or not indicated for a certain patient. A variety
and countless lling substances are in the market and
some of the defects susceptible to improvement by
cutaneous lling presented by the aging patient are
cutaneous aging, as furrows and wrinkles, expression
wrinkles, depressed scars, prole defects of the face, lip
atrophy, and skin roughness.
Substances successfully employed in soft tissue aug-
mentation are bovine collagen, autologous fat, silicone,
hyaluronic acid, Goretex, Fibrel, and SoftForm, among
others, and all need skilled physicians to apply them.
Large wrinkles can improve with injection of bovine
collagen, silicone, hyaluronic acid, or fat extracted from
the abdomen or thigh of the patient. Each method is
highly effective when used for its correct indications and
by skilled physicians.
79
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050 47
Plastic surgery
There are many surgical procedures for different areas
and objectives. Plastic surgery techniques, including
blepharoplasty and rhitidectomy, and dermabrasion,
have been a part of the medical scenario and conceivably
will remain. Full face cryopeeling can eliminate precan-
cerous lesions and also improve texture, wrinkles, and
pigmentary problems associated with photoaging.
80
Dermabrasion or surgical skin planning is used to
improve the skins contour as new collagen and
epidermis replace the abraded skin. The new skin
generally has a smoother appearance. It is indicated in
selected patients for ne wrinkles, scar correction,
melasma, and perioral wrinkles.
81
Makeup
The skin, as a most important presentation of a person to
its counterparts, is essentially the visual calendar by
which the years are measured.
82
Cosmetics of the skin,
hair, and nails represent an area of great importance for
the practicing dermatologist. Cosmetics aspects of aging
skin are of intense interest in most societies and the
products now available can actually improve the appearance
of the skin.
Lips, mainly the inferior, show alterations due to sun
exposure, dryness, scaling, loss of the limits between
semimucosa and skin, and atrophy are characteristics of
photoaging (Fig. 5). The careful use of a lip liner can avoid
the vertical bleeding of lipstick onto the wrinkles of the
borders of the lips. It can also enlarge the appearance of
thin, atrophic lips and correct the lip line if there is an
irregularity due to the removal of a skin cancer or other
type of lesion along the vermilion border.
42
The use of
specic products for photoprotection of the lips is essential.
If the upper lid has sagged too much, a thin line of color
applied just above the lash line may be the best way to
enhance the beauty of the eye.
83
Mascara in soft brown or
brown-black may be better than midnight blue or jet
black. This should be applied carefully. Water-washable
mascara is easier on the eyelids and may result in less loss
of eyelashes. Careful use of eyeliner may be desirable. It is
important to avoid harsh lines; softness is the key. Pencils
may be preferable to the straight brown eyeliner. If the
upper lids hang heavily, the use of an eyelash curler to lift
the lashes up and around the sagging lids may help. The
curler must be used before the mascara is applied so that
the eyelashes do not stick to the curler.
17,83
Nail cosmetics, in the form of nail polish, repair kits,
tips, and sculptures, may not only camouage a nail dis-
ease, but also be the cause of a problem due to the prod-
ucts use. Skin-care products, in the form of cleansers,
toners, exfoliation agents, masks, moisturizers, specialty
creams, and antiperspirants/deodorants, may conict with
the treatment or worsen a nail disease. The elderly shows
many types of onychodistrophies, as opacication, longitu-
dinal striation (Fig. 6), fungal and/or bacterial infections,
onychogryphosis, splinter hemorrhage, subungual
Figure 5 Actinic cheilitis: 73-year-old man dryness, scaling,
atrophy, and loss of the limits between the skin and the vermillion of
the inferior lip.
Figure 6 Longitudinal striae on nail: 62-year-old man.
Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro
48 2007 Blackwell Publishing Journal of Cosmetic Dermatology, 6, 4050
hematoma, and others, which are usually facilitated
by circulation alteration, repeated microtrauma during
life, and postural alterations. These nail lesions must
be treated, if possible. The dermatologist must be aware
that certain medical and cosmetic products may even
be the cause of skin problems besides being hazardous
to the nail, as for instance nail polish being the major
cause of skin allergy to the eyelids. Care of nails has many
benets, which include improving self-esteem of the
patient.
43,8486
The aged individual has difculty to efciently wash
hair, thus seborrheic dermatitis and bacterial folliculitis
are frequent in this age group. Since most shampoos may
dry and irritate scalp of elderly, the best ones for them
should not be very efcient in removing oil and should also
be nonirritating to the eyes, as the nonionic shampoos.
87
Elderly patients, especially women, use dyes, perma-
nent wave, and other hair products very often, because of
the graying and loss of their hair. All these methods may,
at the same time they make the hair look better, be
hazardous to it with constant use.
4
Hair permanent waves: a permanent wave is designed
to last 34 months. When hair is permanently waved
with a strong waving lotion, the result is hair loss by frac-
turing at the exit point from the scalp.
88,89
Hair dyes: hair-dyeing products with the ability to
lighten, darken, or alter the hair color for various lengths
of time have been developed and can be divided into
several types: gradual, temporary, semipermanent, and
permanent.
Hair additions: it is a semipermanent method of
camouaging partial and localized hair loss. Failure to
cleanse the scalp regularly because of the hair addition can
result in seborrheic dermatitis and bacterial folliculitis.
Hair integration: another method of supplementing
localized hair loss is through the use of hair integration.
This technique does not cause traction alopecia and does
not use attachment methods. This is an excellent but
expensive alternative for alopecia.
88,89
Adverse reactions to cosmetics
The stratum corneum of the elderly is less capable to act
as a barrier; thus, it is frequent to see allergic and irritant
reactions to cosmetics. They are caused by endogenous
and environmental factors and, besides an irritative
dermatitis, cosmetics can produce allergic reactions also
in elderly patients. They may be acute reaction, irritant
dermatitis, mechanical irritation, acneiform eruption,
phototoxic reaction, subjective irritation, such as burning,
stinging, or itching, contact urticaria syndrome, and
delayed hypersensitivity reactions.
48
Conclusion
The cosmetic aging changes of the skin are not a direct
threat to the physical well-being of the patient, but their
psychological impact, particularly in regard to self-
perception, self-esteem, and quality of life, can be
signicant and even profound.
90,91
As the population of
elderly people increases, patients dissatisfaction with
their aging skin changes will attract more and more the
attention of physicians and merit a response for their
caring. There are already many ways to attenuate skin
aging by the use of topical, injectable, oral, and/or
surgical therapies, and the dermatologist is the best
specialist to prescribe them to the aging patient. The
limitation of sun exposure by avoiding the sun during the
peak tanning hours (between 10:00 a.m. and 2:00 p.m.),
the use of a sunscreen with a high sun-protection factor,
and the use of protective clothing when exposed to the
sun are the most important advice physicians can offer to
their patients at any age.
82
Even when its use begins at
an older age, the constant use of a photoprotector can
promote an apparent reversion of photoaging, giving a
younger aspect to the skin.
Physicians, especially dermatologists, geriatricians,
gerontologists, and plastic surgeons, must know how to
use to prescribe cosmetics and toilet articles to this age
group because they constitute an important part in the
life of the elderly.
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