Cosmetic Dermatology in Primary Care

What is Skin? A protective, yet permeable barrier for the human body Body’s largest organ Most essential source of sensory stimulation

A protective, yet permeable barrier for the human body

Body’s largest organ

Most essential source of sensory stimulation

Three layers of skin Epidermis Dermis Subcutaneous fat (hypodermis)

Epidermis

Dermis

Subcutaneous fat (hypodermis)

Epidermis (outer layer) 1. Stratum corneum - “dead outermost layer” consists of 15 - 40 layers 2. Granular layer 3. Spinous layer- is the matrix Melanocytes produce the pigment, melanin Langerhans’ immune cells Merkel’s sensory stimulation cells 4. Basal layer- basal cells divide to make new skin about every 30 days

1. Stratum corneum - “dead outermost layer” consists of 15 - 40 layers

2. Granular layer

3. Spinous layer- is the matrix

Melanocytes produce the pigment, melanin

Langerhans’ immune cells

Merkel’s sensory stimulation cells

4. Basal layer- basal cells divide to make new skin about every 30 days

Dermis (middle layer) 1. Papillary layer haphazardly arranged thin collagen 2. Reticular layer thick collagen arranged parallel for structure elastin fibers sebaceous glands, hair follicle, blood vessels

1. Papillary layer

haphazardly arranged thin collagen

2. Reticular layer

thick collagen arranged parallel for structure

elastin fibers

sebaceous glands, hair follicle, blood vessels

Free Radical Theory of Aging Dehnam Harman, 1956 First proposed theory of aging Free radicals occur naturally with human metabolism and aging Free radicals cause damage to DNA/RNA leading to decreased cell function and disease.

First proposed theory of aging

Free radicals occur naturally with human metabolism and aging

Free radicals cause damage to DNA/RNA leading to decreased cell function and disease.

Intrinsic Aging Genetics set the internal clock of human metabolism Decreased estrogens during menopause contribute to collagen loss in women

Genetics set the internal clock of human metabolism

Decreased estrogens during menopause contribute to collagen loss in women

Extrinsic Aging Photodamage - 80% Smoking Stress Poor nutrition Pollution Excess alcohol

Photodamage - 80%

Smoking

Stress

Poor nutrition

Pollution

Excess alcohol

Facts of Aging Skin Signs begin about age 30 Texture changes Decreased cellular turnover in epidermis causing fine lines and wrinkles Collagen decreases by 1% yearly after age 30 causing thinner skin Decreased elastic fibers, fat, and blood vessels causing decreased elasticity Decreased hair follicles, sweat ducts, and sebaceous glands Decreased water binding capability causing dryer skin

Signs begin about age 30

Texture changes

Decreased cellular turnover in epidermis causing fine lines and wrinkles

Collagen decreases by 1% yearly after age 30 causing thinner skin

Decreased elastic fibers, fat, and blood vessels causing decreased elasticity

Decreased hair follicles, sweat ducts, and sebaceous glands

Decreased water binding capability causing dryer skin

Clinical Signs of Aging Skin Mild dryness Fine lines and wrinkles Freckles Moles Spider veins Skin tags Red spots

Mild dryness

Fine lines and wrinkles

Freckles

Moles

Spider veins

Skin tags

Red spots

Clinical Signs of Photoaging Skin Texture changes dryness, enlarged pores, wrinkles pigment changes- sun spots, freckles, melasma Vascular changes spider veins, red spots, rosacea Degenerative changes Benign- seborrheic keratosis, skin tags, moles Precancerous- actinic keratosis Cancerous- melanoma, basal cell, squamous cell

Texture changes

dryness, enlarged pores, wrinkles

pigment changes- sun spots, freckles, melasma

Vascular changes

spider veins, red spots, rosacea

Degenerative changes

Benign- seborrheic keratosis, skin tags, moles

Precancerous- actinic keratosis

Cancerous- melanoma, basal cell, squamous cell

FACTS about PhotoAging 20 minutes of sun exposure is enough to cause damage to the skin. Sunburn and sun-tanning causes wrinkles and thinning skin. Number one risk factor for all skin cancers is SUN EXPOSURE! (one blistering sunburn doubles the risk of skin cancer)

20 minutes of sun exposure is enough to cause damage to the skin.

Sunburn and sun-tanning causes wrinkles and thinning skin.

Number one risk factor for all skin cancers is SUN EXPOSURE! (one blistering sunburn doubles the risk of skin cancer)

Photodamaged Skin

What is the treatment for Photoaging Skin? Diet high in fruits and vegetables Adequate oral hydration ( 64 oz + daily) Good daily skin care regimen No Smoking Rejuvenation procedures Protection/Prevention

Diet high in fruits and vegetables

Adequate oral hydration ( 64 oz + daily)

Good daily skin care regimen

No Smoking

Rejuvenation procedures

Protection/Prevention

You Are What You Eat! 64 oz water per day to hydrate 6 servings of fruits 6 servings of vegetables Omega 3 fatty acid or fresh fish 3x week Less than 2 servings of caffeine/day

64 oz water per day to hydrate

6 servings of fruits

6 servings of vegetables

Omega 3 fatty acid or fresh fish 3x week

Less than 2 servings of caffeine/day

What is Good Skin Care? Cleanse-PH balanced wash 2x/day Exfoliate-chemical and physical Hydrate-topically and orally Protect UVA/UVB Sunscreen Topical antioxidants Rejuvenate Retinoid 3 – 5x weekly Optional Rejuvenation Procedures readily available

Cleanse-PH balanced wash 2x/day

Exfoliate-chemical and physical

Hydrate-topically and orally

Protect

UVA/UVB Sunscreen

Topical antioxidants

Rejuvenate

Retinoid 3 – 5x weekly

Optional Rejuvenation Procedures readily available

Exfoliate 1. Chemical exfoliation Glycolic or Salicylic Acid daily skin care Chemical peels Retinoids 2. Physical exfoliation Fine granular scrubs Microdermabrasion

1. Chemical exfoliation

Glycolic or Salicylic Acid daily skin care

Chemical peels

Retinoids

2. Physical exfoliation

Fine granular scrubs

Microdermabrasion

Microdermabrasion 2 nd most common non-surgical cosmetic procedure in the United States Mechanical removal of the outer 1-2 dead layers of skin with a “sand blasting” technique No down time Works well with chemical peels

2 nd most common non-surgical cosmetic procedure in the United States

Mechanical removal of the outer 1-2 dead layers of skin with a “sand blasting” technique

No down time

Works well with chemical peels

Hydrate 1. Drink 64 oz water daily 2. Topical moisturizers Barriers- block water loss Petroleum, lanolin, paraffin, beeswax Emollients- smooth edges Petroleum Humectants- draw water into skin Glycerin, urea, hyaluronic acid, glycolic and lactic acid

1. Drink 64 oz water daily

2. Topical moisturizers

Barriers- block water loss

Petroleum, lanolin, paraffin, beeswax

Emollients- smooth edges

Petroleum

Humectants- draw water into skin

Glycerin, urea, hyaluronic acid, glycolic and lactic acid

Protect

Skin Cancer Facts 2007 3% increase in all skin cancers 1 million new cases of non-melanoma 60,000 new cases of melanoma 8,000 deaths last year from melanoma

3% increase in all skin cancers

1 million new cases of non-melanoma

60,000 new cases of melanoma

8,000 deaths last year from melanoma

Topical C L-ascorbic Acid Lasts 72 hours Increases collagen synthesis Decreases cell damage from sun 58% 10% minimum concentration to be effective

L-ascorbic Acid

Lasts 72 hours

Increases collagen synthesis

Decreases cell damage from sun 58%

10% minimum concentration to be effective

Prevage MD Topical antioxidant Idebenone 0.5% available over the counter 1% is prescription strength Protects from sun, air pollution, smoke, and ozone 95% Use twice daily; titrate up

Topical antioxidant Idebenone

0.5% available over the counter

1% is prescription strength

Protects from sun, air pollution, smoke, and ozone 95%

Use twice daily; titrate up

UVB Protection SPF (Sun Protection factor) is a measurement of UVB protection only. Refers to the ability of a sunscreen to delay sun-induced redness in epidermis SPF 30 blocks 97% for 2 hours; SPF 15 blocks 93%, 50 blocks 97%, 70 blocks 97%

SPF (Sun Protection factor) is a measurement of UVB protection only.

Refers to the ability of a sunscreen to delay sun-induced redness in epidermis

SPF 30 blocks 97% for 2 hours;

SPF 15 blocks 93%,

50 blocks 97%,

70 blocks 97%

UVA Protection Measured by PFA (protection factor) Present sunrise to sunset Present cloudy days, even in winter Passes through windows Penetrates deep into dermis Cause up to 80% of skin damage

Measured by PFA (protection factor)

Present sunrise to sunset

Present cloudy days, even in winter

Passes through windows

Penetrates deep into dermis

Cause up to 80% of skin damage

Sun Protection Tips Apply 30 minutes prior and every 2 hours Apply generously Choose Total UVB/UVA protection Titanium dioxide, zinc oxide – Sunblock Blue Lizard sensitive skin SPF 30+ Helioplex – avobenzone w/oxybenzone Neutragena Ultra Sheer Dry Touch SPF 55 Mexoryl SX – avobenzone w/Octocrylene Lancome UV Expert 20 La Roche-Posay Anthelios SX Ombrelle Sunscreen Lotion

Apply 30 minutes prior and every 2 hours

Apply generously

Choose Total UVB/UVA protection

Titanium dioxide, zinc oxide – Sunblock

Blue Lizard sensitive skin SPF 30+

Helioplex – avobenzone w/oxybenzone

Neutragena Ultra Sheer Dry Touch SPF 55

Mexoryl SX – avobenzone w/Octocrylene

Lancome UV Expert 20

La Roche-Posay Anthelios SX

Ombrelle Sunscreen Lotion

UVA protection “What’s New” Zinc Oxide or Titanium Dioxide Physical barrier to block all sun rays Parsol 1789 (Avobenzone) Developed in 1992 to protect against UVA Recently found unstable and loses effectiveness in 2 hours of exposure to sun. Helioplex Avobenzone stabilized with Oxybenzone to protect against UVA for 6 hours Neutragena Ultra Sheer Dry touch Mexoryl Avobenzone stabilized with Mexoryl SX or Tinosorb to protect against UVA for 4 hours Lancome UV Expert 20 and LaRoche-Posey Anthelios SX

Zinc Oxide or Titanium Dioxide

Physical barrier to block all sun rays

Parsol 1789 (Avobenzone)

Developed in 1992 to protect against UVA

Recently found unstable and loses effectiveness in 2 hours of exposure to sun.

Helioplex

Avobenzone stabilized with Oxybenzone to protect against UVA for 6 hours

Neutragena Ultra Sheer Dry touch

Mexoryl

Avobenzone stabilized with Mexoryl SX or Tinosorb to protect against UVA for 4 hours

Lancome UV Expert 20 and LaRoche-Posey Anthelios SX

Summer Solstice June 21 st is the day of highest sun intensity. On a clear day, intensity April 21 st equals that of August 21 st .

June 21 st is the day of highest sun intensity.

On a clear day, intensity April 21 st equals that of August 21 st .

Sunscreen

Retinoids Stimulates collagen production Decreases cell damage from sun exposure Increases skin cell turnover Helps prevent skin cancer Tretinoin (Retin-A, Renova) Terazatane (Tazorac) Differin (Adapalene )

Stimulates collagen production

Decreases cell damage from sun exposure

Increases skin cell turnover

Helps prevent skin cancer

Tretinoin (Retin-A, Renova)

Terazatane (Tazorac)

Differin (Adapalene )

Rejuvenation Procedures Chemical Peels Botox Facial Fillers Laser treatments

Chemical Peels

Botox

Facial Fillers

Laser treatments

Peels

What are Chemical Peels? Application of a chemical solution to produce a controlled peel. Purpose: To allow peeling of the sun-damaged layers resulting in rejuvenation of the skin. Newer healthier cells and more even skin tones.

Application of a chemical solution to produce a controlled peel.

Purpose: To allow peeling of the sun-damaged layers resulting in rejuvenation of the skin. Newer healthier cells and more even skin tones.

Benefits of Chemical Peels Benefits: Stimulates collagen and reduces the appearance of wrinkles. Diminishes pigmentation associated with sun damage, acne, and melasma. Treats pre cancerous changes of the skin. Improves texture and pore size.

Benefits:

Stimulates collagen and reduces the appearance of wrinkles.

Diminishes pigmentation associated with sun damage, acne, and melasma.

Treats pre cancerous changes of the skin.

Improves texture and pore size.

Types of Peels

Glycolic Acid (AHA) Promotes exfoliation Increase the density of collagen Functions as moisturizer Good for regular skin types Causes superficial flaking and redness for 1 – 4 days

Promotes exfoliation

Increase the density of collagen

Functions as moisturizer

Good for regular skin types

Causes superficial flaking and redness for 1 – 4 days

Salicylic Acid 17% Lipophilic : Penetrates the oil filled follicles in acne Good for oily skin types Anti-inflammatory properties are good for rosacea and acne

Lipophilic : Penetrates the oil filled follicles in acne

Good for oily skin types

Anti-inflammatory properties are good for rosacea and acne

Jessnar’s Peel Medium depth peel Lactic acid, Salicylic acid and Resorcinol Causes minimal inflammation Good for acne, rosacea and most sensitive skin Good on all skin types

Medium depth peel

Lactic acid, Salicylic acid and Resorcinol

Causes minimal inflammation

Good for acne, rosacea and most sensitive skin

Good on all skin types

TCA Peel Medium depth “Wounding Peel” Controlled peel of entire epidermal layer or down to papillary dermis 5 – 10 days “down time” Builds collagen, decreases pore size, evens out skin tone, decreases pigment Not for use on darker skin types

Medium depth “Wounding Peel”

Controlled peel of entire epidermal layer or down to papillary dermis

5 – 10 days “down time”

Builds collagen, decreases pore size, evens out skin tone, decreases pigment

Not for use on darker skin types

Botox Injection of botulinum toxin A FDA approved for cosmetic use in Glabella Works by causing temporary block in nerve signals preventing contraction of muscles Glabella, crow’s feet, forehead and around mouth lasting approximately 3 months Used for cosmetic purposes since 1981

Injection of botulinum toxin A

FDA approved for cosmetic use in Glabella

Works by causing temporary block in nerve signals preventing contraction of muscles

Glabella, crow’s feet, forehead and around mouth lasting approximately 3 months

Used for cosmetic purposes since 1981

Facial Fillers Collagen Human – no skin testing required Cosmoderm, Cosmoplast Bovine – rarely used due to skin testing Is gold standard Hyaluronic Acid Restylane, Hylaform, Juvaderm Radiesse – injectable facial contouring agent Sculptra – injectable volumizing agent

Collagen

Human – no skin testing required

Cosmoderm, Cosmoplast

Bovine – rarely used due to skin testing

Is gold standard

Hyaluronic Acid

Restylane, Hylaform, Juvaderm

Radiesse – injectable facial contouring agent

Sculptra – injectable volumizing agent

Collagen Human vs Bovine Cosmoplast is thicker than Cosmoderm Last 3 – 4 months Great for lip border, peri-oral lines, fine lines and wrinkles No down time

Human vs Bovine

Cosmoplast is thicker than Cosmoderm

Last 3 – 4 months

Great for lip border, peri-oral lines, fine lines and wrinkles

No down time

Collagen Lip Augmentation

Hyaluronic Acids Hydrophilic in nature Lasts 6 – 9 months Great for nasolabial folds and deeper lines and wrinkles No testing needed Hylaform, Restylane & Juvederm

Hydrophilic in nature

Lasts 6 – 9 months

Great for nasolabial folds and deeper lines and wrinkles

No testing needed

Hylaform, Restylane & Juvederm

Juvederm

Juvederm before

Juvederm after

Radiesse Injectable implant Nasolabial folds, marionette lines, cheek implants Calcium Hydroxylapatie Injected deeper into skin Lasts 12 – 18 months Shown to promote collagen after 3 months

Injectable implant

Nasolabial folds, marionette lines, cheek implants

Calcium Hydroxylapatie

Injected deeper into skin

Lasts 12 – 18 months

Shown to promote collagen after 3 months

Marionette before

After 3 months

Nasolabial before

After 3 months

Cheeks before

After 3 months

Sculptra Synthetic Poly-L-lactic acid Injected into subcutaneous tissue Increases skin thickness

Synthetic Poly-L-lactic acid

Injected into subcutaneous tissue

Increases skin thickness

Before Sculptra

Sculptra after 3 treatments

Lasers

IPL Photo-Facial Multiple wavelengths of light penetrate to different depths in the skin treating various conditions Minimal down-time Lightens age spots, decreases redness and red veins, and evens the skin tones Stimulates collagen Excellent for rosacea

Multiple wavelengths of light penetrate to different depths in the skin treating various conditions

Minimal down-time

Lightens age spots, decreases redness and red veins, and evens the skin tones

Stimulates collagen

Excellent for rosacea

IPL with Levulan Therapy Combination IPL with the chemical Levulan to provide a more aggressive rejuvenation of epidermis Treats photoaging, precancerous skin lesions, hyperpigmentation, acne, and rosacea Causes temporary photosensitivity Light peeling for 5 – 7 days

Combination IPL with the chemical Levulan to provide a more aggressive rejuvenation of epidermis

Treats photoaging, precancerous skin lesions, hyperpigmentation, acne, and rosacea

Causes temporary photosensitivity

Light peeling for 5 – 7 days

Before

After 2 months

Laser Hair Removal Takes 6-8 treatments Permanent hair reduction Fast Convenient

Takes 6-8 treatments

Permanent hair reduction

Fast

Convenient

Before After 8 treatments

“ What’s New” Tissue tightening Ablative fractional resurfacing Non-ablative fractional resurfacing Ablative erbium resurfacing Profractional resurfacing

Tissue tightening

Ablative fractional resurfacing

Non-ablative fractional resurfacing

Ablative erbium resurfacing

Profractional resurfacing

Ablative & Non-Ablative Skin Resurfacing CONFIDENTIAL Palomar Medical Technologies, Inc.

Mechanism of Light-induced Skin Rejuvenation Light absorption by tissue water Inflammatory response Release of inflammatory mediators into dermal interstitium Stimulation of fibroblast activity Increase of collagen production and proliferation of keratynocytes Limited thermal damage CONFIDENTIAL Palomar Medical Technologies, Inc.

Non-ablative skin resurfacing Lux 1540 and Fraxyl Produces microthermal treatment zones Improves texture and pore size Removes skin discolorations Improves acne scarring Treats hands, neck & de’collete’ Reduces crows feet around eyes Does not remove epidermis

Produces microthermal treatment zones

Improves texture and pore size

Removes skin discolorations

Improves acne scarring

Treats hands, neck & de’collete’

Reduces crows feet around eyes

Does not remove epidermis

Lux1540 Fractional ™ Laser for Texture, Wrinkles and Acne Scars CONFIDENTIAL Palomar Medical Technologies, Inc.

Lux 1540 Fractional Photos courtesy of Dr. Dwight Scarborough Pre Tx 1 Immediately After Tx 1 1 Week after Tx 1 8 Weeks after Tx 1

6 weeks post tx #2 @50 MJ Pre-TX Aesthetica Cosmetic & Laser Center David B. Vasily, M.D. Lux1540 Fractional™ CONFIDENTIAL Palomar Medical Technologies, Inc.

Tiffani Hamilton, MD Lux 1540 Fractional ™ PreTx 1 PostTx 2

Lux 1540 Fractional™ PreTx 1 3 WeeksPost 2 tx CONFIDENTIAL Palomar Medical Technologies, Inc

Lux 1540 Fractional™ Stan Kovak MD-2 Weeks Post 4 TXs Post 4 Treatments w/o Botox

Lux 1540 Fractional™ 2 weeks Post 1 st Treatment Pre-Treatment CONFIDENTIAL Palomar Medical Technologies, Inc. Post-Treatment

Non-ablative tissue tightening Causes dermal and subcutaneous heating, without damaging the surface of the skin. Thermage-radiofrequency heating Polaris – combined technology Titan- infrared broadband Starlux IR - infrared

Causes dermal and subcutaneous heating, without damaging the surface of the skin.

Thermage-radiofrequency heating

Polaris – combined technology

Titan- infrared broadband

Starlux IR - infrared

Thermage before After 3 months

Titan before & after

Titan before & after

Other New Treatments in 2007 Cellulite laser therapy Portrait laser technology Longer lasting fillers Ablative lasers We live a time of changing technology. There is something new every couple of months.

Cellulite laser therapy

Portrait laser technology

Longer lasting fillers

Ablative lasers

We live a time of changing technology. There is something new every couple of months.

Provider Role in Skin Care Educate yourself Evaluate patient risk Do skin checks yearly Discuss good skin care Recommend sunscreen Encourage smoking cessation Provide education about services available http://generalhealthinformation.co.cc

Educate yourself

Evaluate patient risk

Do skin checks yearly

Discuss good skin care

Recommend sunscreen

Encourage smoking cessation

Provide education about services available

http://generalhealthinformation.co.cc

Stop Smoking!

NOT ALL WRINKLES ARE CREATED EQUAL

NOT ALL WRINKLES ARE CREATED EQUAL

Thank You Source http://generalhealthinformation.co.cc

Source

http://generalhealthinformation.co.cc