Cosmetic Dermatology in Primary Care

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Cosmetic Dermatology inPrimary Care

• Jenifer Hammond MD
• Anita Wolfe FNP
• Park Meadows Center for Cosmetic Procedures

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What is Skin?

• A protective, yet permeable barrier for the human
  body
• Bodys largest organ
• Most essential source of sensory stimulation

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Three layers of skin

• Epidermis
• Dermis
• Subcutaneous fat (hypodermis)

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

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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

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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.

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Intrinsic Aging

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

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Extrinsic Aging

• Photodamage - 80
• Smoking
• Stress
• Poor nutrition
• Pollution
• Excess alcohol

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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

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Clinical Signs of Aging Skin

• Mild dryness
• Fine lines and wrinkles
• Freckles
• Moles

• Spider veins
• Skin tags
• Red spots

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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

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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)

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Photodamaged Skin
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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

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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

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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

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Exfoliate

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

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Microdermabrasion

• 2nd 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

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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

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Protect
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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

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Topical C

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

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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

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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

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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

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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

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UVA protection Whats 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

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Summer Solstice

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

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Sunscreen
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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)

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Rejuvenation Procedures

• Chemical Peels
• Botox
• Facial Fillers
• Laser treatments

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Peels
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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.

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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.

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Types of Peels
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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

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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

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Jessnars 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

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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

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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, crows feet, forehead and around mouth
  lasting approximately 3 months
• Used for cosmetic purposes since 1981

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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

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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

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Collagen Lip Augmentation
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Hyaluronic Acids

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

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Juvederm
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Juvederm before
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Juvederm after
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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

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Marionette before
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After 3 months
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Nasolabial before
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After 3 months
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Cheeks before
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After 3 months
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Sculptra

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

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Before Sculptra
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Sculptra after 3 treatments
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Lasers
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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

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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

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Before
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After 2 months
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Laser Hair Removal

• Takes 6-8 treatments
• Permanent hair reduction
• Fast
• Convenient

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Before After 8 treatments
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Whats New

• Tissue tightening
• Ablative fractional resurfacing
• Non-ablative fractional resurfacing
• Ablative erbium resurfacing
• Profractional resurfacing

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Ablative Non-Ablative Skin Resurfacing
CONFIDENTIAL Palomar Medical Technologies, Inc.
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Mechanism of Light-induced Skin Rejuvenation
Light absorption by tissue water
Limited thermal damage
Inflammatory response
Release of inflammatory mediators into dermal
interstitium
Stimulation of fibroblast activity
Increase of collagen production and proliferation
of keratynocytes
CONFIDENTIAL Palomar Medical Technologies, Inc.
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Non-ablative skin resurfacingLux 1540 and Fraxyl

• Produces microthermal treatment zones
• Improves texture and pore size
• Removes skin discolorations
• Improves acne scarring
• Treats hands, neck decollete
• Reduces crows feet around eyes
• Does not remove epidermis

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Lux1540 Fractional Laser for Texture, Wrinkles
and Acne Scars
CONFIDENTIAL Palomar Medical Technologies, Inc.
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Lux 1540 Fractional
Pre Tx 1 Immediately After Tx 1
1 Week after Tx 1 8 Weeks after Tx 1
Photos courtesy of Dr. Dwight Scarborough
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Lux1540 Fractional
6 weeks post tx 2 _at_50 MJ
Pre-TX
Aesthetica Cosmetic Laser Center David B.
Vasily, M.D.
CONFIDENTIAL Palomar Medical Technologies, Inc.
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Lux 1540 Fractional
PreTx 1 PostTx 2
Tiffani Hamilton, MD
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Lux 1540 Fractional
3 WeeksPost 2 tx
PreTx 1
CONFIDENTIAL Palomar Medical Technologies, Inc
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Lux 1540 Fractional
Stan Kovak MD-2 Weeks Post 4 TXs
Post 4 Treatments w/o Botox
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Lux 1540 Fractional2 weeks Post 1st Treatment
Post-Treatment
Pre-Treatment
CONFIDENTIAL Palomar Medical Technologies, Inc.
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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

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Thermage before After 3 months
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Titan before after
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Titan before after
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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.

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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

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Stop Smoking!
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• NOT ALL WRINKLES ARE CREATED EQUAL