Saturday, May 06, 2006

Anti-Aging Skincare FAQ v. 2.0

lkl ANTI-AGING SKINCARE FAQ v. 2.0

revised 5/2003

------------------------------------------------- Contents:

1. Introduction 2. What is the anatomy of the skin? 3. What factors effect skin health? 4. What is Retin-A or tretinoin? 5. What is retinol? 6. What is copper peptide? 7. What other topical treatments are available? 8. What is skin resurfacing? 9. What are alpha-hydroxy acids and skin exfoliation? 10. How can I treat oily skin? 11. How can I treat scars? 12. How can I treat visible capillaries?

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1. INTRODUCTION

Most people start seeing aging effects in the skin by their late 30s.  Over the years you may also accumulate scars from injuries or burns.  This FAQ answers common questions about how to improve the appearance of aged or injured skin, short of plastic surgery.  It does not cover cosmetics, cleansers, o! r moisturizers, but rather products and procedures that can improve skin structure.  It is based on a review of medical research, books on skincare, and consumer reviews.  This information applies to both men and women.  The pharmaceutical information is for customers in the U.S.A.

2. WHAT IS THE ANATOMY OF THE SKIN?

The outer layer of the skin is the epidermis, and the next layer is the dermis. The epidermis, which is generally less than a millimeter thick on the face, is constantly being regenerated as surface cells are shed.  As epidermal cells are pushed to the skin surface, they become flattened and a hard protein   called keratin is formed in them.  The thicker dermis under the epidermis contains collagen and elastin fibers that give skin its elasticity.  The pores contain fine hairs and secrete sebum (skin oil) to keep your skin moist. The appearance of your skin is governed by both the condition of the dermis and! the epidermis.

Wrinkles and fine lines are caused mostly by damag e to the collagen and elastin in the dermis.  Some of this damage in the dermis is caused by "intrinsic" cellular aging, but most is caused by "extrinsic" damage from sun exposure (called photoaging).  Solar ultraviolet (UV) radiation also causes most skin discolorations and cancers.  The best-looking skin most people have is in areas without much sun exposure - under the arms, on the breasts, or the rear.  

The dermis can also be damaged by injuries.  If a wound penetrates deeply into the dermis, thick, uneven scar collagen can form as the wound heals.  This produces a raised scar.  If there is significant tissue loss in the dermis, a pit or depressed scar may form.   Burn scars can have an irregular appearance with both raised and depressed areas.

While the condition of the dermis in reflected in wrinkles, lines and scars, the condition of the epidermis effects the surface texture of your skin. &! nbsp; Generally, the best appearance is produced by a thick epidermis.  A thicker epidermis also tends to minimize the appearance of pores and depressed scars.   However, if the epidermis grows abnormally or is excessively dry, the skin can appear rough or scaly.  At the other extreme, stripping off the upper epidermal layers with excessive scrubbing or over-use of cosmetic acids can temporarily produce an uneven surface texture and increase the size of the pore openings.   Injured or burned areas sometimes have a thinner epidermis, even after complete healing.

Based on skin anatomy, we can say that a true anti-aging skincare treatment   will produce one or more of the following effects: 1. prevent or repair damaged collagen and elastin in the dermis, 2. promote the growth of new collagen and elastin, 3. promote epidermal growth to thicken the epidermis, or 4. smooth the epidermal surface.

There are scientific methods to determi! ne if a substance or procedure has any of these effects, and research in this field is ongoing.  However, despite advertising claims, most skincare products sold today don't have any effect on collagen or elastin, and only temporarily change the appearance of the upper epidermis.  For example, moisturizers only temporarily smooth fine lines by trapping moisture in the skin.  

3. WHAT FACTORS EFFECT SKIN HEALTH?

Obviously, if you want healthy skin, you need to stay out of the sun or cover up with clothes, a hat, and a broad-spectrum UVA/UVB sunblock.  (Sunblock is a true anti-aging product because it prevents damage to collagen and elastin.)   Don't use tanning beds.  Avoiding sun damage is the most effective thing you can do to protect your skin.  This is important for children too, since sun damage is cumulative.  If a person were able to avoid sun exposure their whole life, their skin would have few wrinkles, even in old age.

If you smoke, quit.  Doctors say smokers have muc! h worse skin than non-smokers because the toxins in smoke damage the skin.  A medical study showed that smoking was correlated with a higher incidence of facial wrinkles.  

Limit your consumption of alcohol.  A medical study showed that heavy alcohol consumption was correlated with a variety of skin diseases and blood vessel abnormalities.  Alcohol consumption has adverse effects on nutrition and immune functions, which also effect the skin.

While some doctors believe that diet influences intrinsic skin aging, there is no conclusive evidence about what that diet should be.  However, healthy immune and cardiovascular systems may help prevent skin abnormalities.  A diet rich in fruits and vegetables and low in saturated fat will improve both these systems.

Moderate exercise also helps the cardiovascular system.  If your diet is less than ideal, vitamin and mineral supplements that contain the recommended daily allowanc! es (RDA) can provide necessary nutrients for skin growth.  (Howev er, "megadoses" of supplements above the RDA may be dangerous, particularly for people with certain diseases or pregnant women.)  

Check your skin all over with a hand mirror every few months.  If you see any odd discolorations, bumps, or changes in a mole, see your doctor or a dermatologist immediately.  Most growths are benign, but some are skin cancer.  Skin cancer can often be inexpensively cured if it is caught early.   If you wait even a few months, some types of skin cancer can kill you.  Even with a benign growth, waiting until it gets larger can result in a scar when it is removed.  If you have it removed early, usually there will be only a tiny scar after healing.

4. WHAT IS RETIN-A OR TRETINOIN?

Currently, the best available topical anti-aging treatment is prescription tretinoin (Retin-A, Retin-A Micro, Renova, Avita, or generic).  Tretinoin is also called "vitamin A acid" or "! retinoic acid"; but it is a different chemical from regular vitamin A - which is called "retinol."  A prescription is required for tretinoin because it produces significant changes in the structure of the skin.  Tretinoin is the only topical treatment so far that has been conclusively shown in many medical studies to promote growth of new collagen in the dermis and improve the condition of the epidermis.  As was written a few years ago in the Journal of the American Academy of Dermatology, "to date, tretinoin remains the only therapeutic agent proved to repair photodamage."  Tretinoin and related chemicals (called "retinoids") are some of the most important discoveries in dermatology.  Other retinoids prescribed for acne and various skin conditions may also have some anti-aging effects similar to tretinoin, but they have not been studied for this use as extensively as tretinoin.

Tretinoin was develo! ped about 40 years ago and is often prescribed for acne because it re duces sebum build-up in pores.  But in addition, dozens of peer-reviewed medical studies done since the early 1980s showed that tretinoin can improve fine lines, epidermal skin texture, and uneven pigmentation.  Over time, tretinoin may also improve the appearance of large pores, tiny depressed scars and burn scars by thickening the lower epidermis.  The effects are modest with most people, but a few people achieve significant improvement.  

Initially, there was some controversy about tretinoin.  It's effects were wildly exaggerated in the media, sometimes with help from doctors.  Then the initial manufacturer got into serious legal trouble with the FDA for promoting tretinoin as a prescription wrinkle treatment before it had been approved for that use.  Also, many people experienced irritation with some forms of tretinoin.  Because of all this, you don't read nearly as much in the media today about tretinoin.  Anot! her problem is that now only one brand of tretinoin cream called Renova can legally be advertised as a treatment for photoaging, though all forms contain the same active chemical.  (This is an unfortunate consequence of the current FDA regulations.)  Doctors can legally prescribe any other brand of tretinoin for general skin improvement, though this is called an "off-label" use if you don't have acne.

Ortho Pharmaceuticals has published before and after photos from the tretinoin medical studies that show significant improvement in fine lines and discoloration for some of the test subjects.  In a number of studies lasting from six months to one year, approximately 65% of the test subjects had some noticeable improvement in their skin appearance (though most had modest improvement).  Nearly all subjects showed improvement to their skin under microscopic examination.  Net reviews of tretinoin are almost all positive, though pe! ople with sensitive skin often complain of some irritation.

With a prescription, you can buy a 45 gram tube of generic tretinoin (.025% gel or .025%, .05%, .1% cream) at pharmacies for between $50 and $75.  This is obviously very expensive, but a 45 gram tube will last for many months if used sparingly.  (Only a pea-sized amount is used for the whole face).  20 gram tubes cost between $25 and $40.  Prices vary widely at pharmacies, so call around for quotes when you get your prescription.  Mail-order pharmacies may be less expensive.  The Avita brand and generics cost less, but some pharmacies may only carry one concentration in a generic.  The Ortho Retin-A/Renova/Retin-A Micro brands are more expensive.

It is possible to buy tretinoin over the Net or by mail from foreign sources at much lower cost, but beware that you could get product of dubious quality.   There are some reputable Canadian and British mail-order pharmacies which have low prices and quality brands - you can check var! ious consumer websites for recommendations.  With any mail-order pharmacy it is best to use a credit card on your first order, rather than a check or money order, to protect against fraud.  (You can contest the charges on your credit card if your order is not sent.)  

Some pharmacies in Mexico also sell various brands of tretinoin without a prescription.  Under U.S. law, it is legal to bring a "90 day personal supply" of tretinoin or other non-controlled-substance medication across any border if you declare it, and it is clearly labeled with the generic medication name. Two or three large tubes would probably be O.K.  More than this could be confiscated at the border, but border inspectors may not care much about illicit skin cream.  Under the rules you may also be required to have in your possession a simple, signed written statement (that is, signed by you) saying that the tretinoin you are bringing in is for your ow! n personal use.   You should also write on the statement the nam e and address of your personal doctor who knows you are using tretinoin.  If you have a U.S. doctor's prescription it is also a good idea to have a photocopy of it with you, though this is not required by the rules (be sure to write "copy" on it so they know you are not trying to use it as an original).  However, you should know that on rare occasions Mexican police have illegally stopped U.S. citizens leaving Mexican pharmacies with various medications and asked for cash "fines".  (Any trip to Mexico carries some risk.)  

All tretinoin made by major pharmaceutical companies should have a potency expiration date stamped on the box or tube.  Be sure the expiration date is at least six months away since one large tube may last you this long.  Keep the tube capped, since exposure to air and light can inactivate tretinoin.  Also keep the tube away from high temperatures (like inside a hot car).

Unless you ! have tretinoin prescribed for acne, insurance companies will not usually pay for a doctor's visit or a prescription.  You can obviously pay for a skincare consultation with your doctor or a dermatologist, but you can save money by simply having your doctor give you a prescription at your next insurance-covered visit.  If you go to a dermatologist, be sure to also ask for tretinoin samples; they often have small tubes to give away to patients.  Since tretinoin is now considered a routine skincare product, your regular doctor may also be willing to call in a prescription to your pharmacy without an exam.   Some clinics can also schedule a lower-cost consultation with a nurse practitioner or physician assistant who can give you a prescription for tretinoin.  Always be sure to ask that the prescription specify a number of refills.  When you run out of refills, often you can get the doctor's office to call the pharmacy to authorize more ! without having to pay for another visit.

Most of the studies showi ng skin improvement with tretinoin have been done with a .05%-concentration formula.  However, many people find that regular .05% tretinoin cream initially causes peeling and redness.  They often give up on tretinoin because of this.  To avoid this irritation, it is best to start out with a small tube of .025% cream.  Also, many people who complain of irritation apply too much tretinoin.  Initially, apply only a tiny amount to your face on alternate nights.  You can also dilute the cream versions by wetting your face first with water if necessary.  Work your way up very gradually to no more than a pea-size amount nightly for the whole face.  Do not use it during the day, since it may cause sun-sensitivity.  Don't apply other products at the same time, since they could inactivate the tretinoin.  If you still find the .025% cream too irritating, you can try Ortho's .02% Renova brand, which is an emollient cream for ! sensitive skin.  If you have no problems with .025% cream, your doctor can next prescribe the regular .05% cream or .05% Renova.  People with oily skin may be able to  use the .1% cream or .1% Retin-A Micro, which is a time release formula with less irritation.  Some people with oily skin may prefer the .025% gel form since it feels less greasy. A very potent .05% liquid is also available, but most people find it too irritating (and it is easy to accidently spill it).  

Remember, you must be patient with tretinoin.  While microscopic changes start immediately, it takes about six months before you will see any visible improvement in the mirror.  After about one year of nightly use, maximum results are achieved, and you need only apply it two or three days per week for maintenance.  If you stop using tretinoin, the skin will gradually regress. You may want to take before-and-after, close-up photographs of your face to ch! eck your progress.  People who don't do this often greatly undere stimate their results, because the effect of tretinoin is gradual and generally modest.  The gradual nature of its effect may be one reason why tretinoin is not used by more people.

Safety and side effects: Animal skin tests suggest that topical tretinoin application is safe, and it has been widely used without significant short- term problems by acne patients.  However, there are no long-term human safety tests, so the risks of using it for many years are unknown.  (This is another good reason for decreasing application frequency after one year.)  Because of its effect on pigment cells, tretinoin will lighten your skin slightly.  You should not use tretinoin if you are pregnant or trying to become pregnant. (An excess of vitamin A and related compounds in the body may cause birth defects.)  Don't apply any other medications or moisturizers to your skin over tretinoin.  Tretinoin should be applied only at night because UV ra! diation decreases its action, and it may cause sun-sensitivity (particularly during the first few months).  When using tretinoin, you must use a sunscreen during the day when outside.  

5. WHAT IS RETINOL?

Retinol is another name for vitamin A.  This can be confusing because the word "retinol" sounds like the tretinoin brand, Retin-A.  Retinol is not nearly as effective as tretinoin, but medical studies have shown that stabilized forms of retinol do have some positive effects when applied to the skin. Before-and-after photographs of retinol users show a slight reduction in the depth of fine lines and a somewhat smoother skin surface.  Retinol skincare products are also relatively inexpensive, so you can experiment with them without spending a lot of money.

Many drugstores and grocery stores have non-prescription retinol products like Neutrogena Anti-Wrinkle (regular and SPF15), Alpha-Hydrox Night ResQ, and St. Ives ! Anti-Wrinkle.  These are non-greasy, light creams that are usuall y applied at night.  They cost about $11 for 30 to 40 grams.  They claim to have stabilized retinol formulas that effectively penetrate into the epidermis.  A few medical studies indicate that if the retinol penetrates, some may be converted by enzymes in the skin to small amounts of tretinoin, thereby producing similar effects such as improved collagen and a thickened epidermis. Unfortunately, the products do not list the percentage concentration of retinol, so you can't compare them directly to the studies.  The directions on most of these products say they should be used only at night, but Neutrogena's SPF 15 version can presumably be used outside during the day.

The regular Neutrogena product is the most widely available, and Wal-Mart also has a less-expensive store-brand called "Equate Anti-Wrinkle" for about $7 with similar ingredients.  Net reviews of Neutrogena Anti-Wrinkle are generally positive, but reported result! s are usually slight.  

All the vitamin A products are inexpensive compared to prescription tretinoin, and the medical studies indicate they can potentially improve your skin appearance.  However, they are much less effective than tretinoin.  One dermatologist has said that currently-available retinol products are 5-10 times weaker in effect that .05% tretinoin.  The instructions included with retinol products say you can see results in a matter of weeks, but since tretinoin takes months for visible results, this seems highly optimistic.  In fact, you might have to use a retinol product for years to get the same noticeable effect as with only six month's use of tretinoin.  Given this, there may not be any long-term cost savings over tretinoin.

You can roughly compare retinol concentrations in different products by looking at the ingredients list.  Ingredients are listed in order of highest to lowest concentration in the ! product.  Obviously, you want to buy products that list retinol near the top of the list.  Some retinol products with retinol near the end of the ingredients list don't contain enough to have any noticeable effect. Some brands may also be irritating, so start by using only a small amount on alternate nights.

Retinol products do degrade over time and lose potency after about 3 years.   Unfortunately, most products do not have expiration dates stamped on the tubes. Since products can sometimes sit in warehouses and on store shelves for up to two years, it is best to only buy one tube at a time.

6. WHAT IS COPPER PEPTIDE?

Copper peptide has been shown in a few medical studies to increase collagen production and promote healing of the skin.  It may have some value as an antiaging skin treatment. There are some positive Net reviews of copper peptide, with some people reporting smoother skin texture.  Others report only a slight effect.  Currently, the positive medical evidence for copper peptide ! is not nearly as extensive as for tretinoin.

Copper peptide products are available without a prescription.  However, some copper peptide products are very expensive and some may not contain the correct form of the chemical.  The scientist who originally developed copper peptide skin treatments has technical and product information at skinbiology.com and skinbio.com.  His mail-order products are generally a better value than those in stores, because they have a higher concentration of copper peptide.  Neutrogena makes a low-concentration copper peptide product called "Visibly Firm Night Cream" that costs about $17 for 50 grams.  It is available at many drug stores.  You can check www.neutrogena.com for more information on this product.  (Note that some Neutrogena boxes have a stamped expiration date that indicates a shelf life of about three year! s for this product, but other boxes have no date.)

7. WHAT OTHER TOPICAL TREATMENTS ARE AVAILABLE?

There are many other non-prescription topicals that claim to improve the health and appearance of the skin.  These include special vitamin formulations, furfuryladenine (Kinerase and Kinetin), and alpha-lipoic acid.  Some claim to deliver anti-oxidants into the dermis to prevent intrinsic aging.  Others claim to have a chemical that improves collagen or elastin.  These  products are generally more expensive than retinol and copper peptide products, and some are even more expensive than tretinoin.  Some are sold at department stores for very high prices.

Obviously, you don't want to spend a lot of money trying all of these products. Remember, when you pay more than $25 for a 40 gram tube of anything, it is costing you more than gold, so you should expect definitive proof that it actually improves the skin.  The problem is that there are only a few published medical studies on the anti-agin! g effects of these products, so it is hard to determine if they work.  Unlike tretinoin, dermatologists do not yet agree on their effectiveness, biochemical action, or safety.  Like moisturizers, some of these products may temporarily improve the appearance of the epidermis without effecting the skin's structure.  It is significant that most of the companies making these products do not publish any before-and-after photographs from clinical studies on their websites.  Unlike tretinoin, Net reviews from users of these products vary, with some people reporting improvement and others reporting no effect at all.  Some of these products may work, but unless you have money to spend experimenting, it is better to use tretinoin until there is more scientific proof of their effectiveness.  

There are a couple of other topical treatments that should be mentioned, if only because they are so inexpensive.  There are a variety of chemica! ls that have been found to improve epidermal growth after skin abrasi ons.  Two of these cost only a few dollars and available at most drug stores.  Both cod liver oil (which is rich in vitamin A) and zinc oxide ointment have been found in many medical studies to significantly improve epidermal healing when compared to other unmedicated ointments like plain petroleum jelly.  One study also found them to be synergistic when applied together.  They won't do anything for wrinkles, but they may help smooth the epidermis if used regularly.   (Note that since these products contain oil, they are not appropriate if you have oily or acne-prone skin.)

There are some special skin ointments available from pharmacists that contain both cod liver oil and zinc oxide, but you can find the separate products on the shelf in many drug stores for under $10.  Cod liver oil is an ingredient in "Vitamin A and D Ointment" and other scented diaper-rash ointments, but you can simply buy liquid cod liver oil in bu! lk or in capsules for a higher concentration of the oil.  (You should refrigerate bulk cod liver oil after opening.)  Zinc oxide is also used in scented diaper rash ointments, but you can often find plain un-scented zinc oxide ointment in the first-aid section of stores.

Cod liver oil and zinc oxide are only suited for application while at home or before sleeping.  Both products leave a noticeable tacky film on the face.   Cod liver oil has a very slight odor, but most people can't smell it on their skin.  Zinc oxide will leave a white film on your face until it is absorbed or washed off.  You may get some minor flaking of the skin with both products due to increased epidermal growth.  They may also stain fabrics, so if you apply them before sleeping, use old sheets and pillowcases.

8. WHAT IS SKIN RESURFACING

Skin resurfacing is the removal of skin layers by chemical acid peeling, abrasive dermabrasion or laser. &nb! sp;When the skin regrows, the skin may appear smoother.  Resurfa cing can potentially reduce the appearance of wrinkles, remove benign discolorations, improve skin texture, and improve some scars. Light resurfacing removes only part of the epidermis.  Medium-depth resurfacing penetrates through the epidermis to the upper dermis, and may stimulate new collagen growth in the upper dermis.  Deep resurfacing extends further into the dermis and is rarely done due to the high risk of scarring.

Light resurfacing is generally safe, but medium-depth resurfacing has risk of scarring, pigmentation changes, and pore enlargement.  Net reviews of light resurfacing are generally positive, but the effects are modest.  Net reviews of medium-depth resurfacing vary widely with results ranging from great improvement to permanent disfigurement.  There have been a number of news reports about lawsuits against doctors for causing permanent facial scarring from resurfacing that penetrated too far into the skin.  (As ! in any profession, most doctors are skilled, but some are incompetent.)   Though the potential effect is not nearly as great, it is far safer to have one or more light resurfacing procedures rather than one medium-depth procedure.  

To understand the risks of medium-depth resurfacing, you should think of the procedure as a controlled wound.  For it to be successful, penetration must be carefully controlled, and then the skin must heal well.  Excessive penetration into the dermis to remove wrinkles can cause uneven, scarred skin.  If this happens, the resulting scars are similar to those caused by second-degree thermal burns.  Infection following the procedure can also cause scarring. Pigment cells can be effected by medium-depth resurfacing, producing uneven skin color or permanent lightening.  Complications of medium-depth resurfacing are routinely reported in medical journals and mentioned in patient consent forms, but ar! e often minimized in consumer information.  

There is another little-publicized, but significant risk with medium-depth resurfacing.  Even if penetration is not excessive, in some people the epidermis may not regenerate well, resulting in a worse surface texture than before the procedure.  This is due to variations in the way new edpidermal cells grow from around the pore openings.  Even though wrinkles may be reduced, up close the resulting skin may have an uneven "orange peel" appearance.  The pore openings may appear larger than before with tiny fissures around them, particularly in the center of the face.  If you have had abrasions or minor burns on other parts of your body, you may see a similar difference in texture compared to your normal skin.  Long-term use of tretinoin may help this problem, but the skin texture may never look smooth up close.  This risk of rough texture and enlarged pores is mentioned in some patient consent forms and journal articles on resurfacing, ! but it is not often covered in consumer information.  This is a significant risk of medium-depth resurfacing, and is another reason why single or multiple light-resurfacing procedures are much safer.  With light resurfacing, any problems with epidermal healing will be much less noticeable.

If you decide to have medium-depth resurfacing despite the risks, you should ask the doctor to resurface a small test area first to see how your skin responds.  Allow the area to heal for at least two months.  This test procedure is advised in medical texts on resurfacing, particularly for those with darker skin, since medium-depth resurfacing can destroy some pigment cells.  If a doctor will not do this, go to another doctor.  Don't risk permanent scarring of your face.  Some doctors will assure you that using the electronic power settings on a laser eliminates the need for test areas. This is simply wrong, because there is wide variatio! n in skin thickness and healing ability.

With medium-depth resurf acing, you can minimize risk and cost by resurfacing only the areas where you have wrinkles or benign skin discolorations.  For wrinkles, the areas with the best results seem to be the sides of the eyes (i.e. "crows feet"), forehead, rear cheek area, and around the mouth. Results seem to be variable directly under the eyes, on the front cheeks, and around the nose, so these should be only lightly resurfaced.  The neck is usually only very lightly resurfaced because it does not heal as well as the face.  You can see many before and after pictures of resurfacing at dermatology and plastic surgery websites.  (Remember though, that they don't post pictures of the complications.)  

If you do get medium-depth resurfacing, be prepared to look awful for at least 10 days (with red skin, crusts forming, peeling, etc.).  Doctors are sometimes too optimistic about healing time when selling the procedure.  You will need to stay! home from work and keep the skin moist with antibiotic ointment. While you are usually presentable within two weeks, the complete healing process can be slow.  In light-skinned people, the skin will be pink for a few months.  In dark-skinned people, pigmentation may be uneven for a few months.  You must stay out of the bright sun until your skin is fully healed. Ask your doctor when you can resume outdoor activities and what kind of sunscreen you should use since some may irritate the new skin (e.g. those with alcohol).  In the future you will need to always use sunscreen when outside during mid-day because the new skin may be more easily damaged by solar UV radiation.  

Due to the risks of medium-depth resurfacing, it is important to select a board-certified dermatologist or plastic surgeon (see www.certifieddoctor.com or the American Board of Medical Specia! lties {ABMS} directory at your library.)  These doctors have pas sed rigorous exams in their specialty beyond what is required for state licensure.  Check with your state medical licensing department to see if the doctor has had any disciplinary actions.   You can also check with the state or local court clerk if any malpractice lawsuits have been filed against the doctor in your state.  (Note that some suits filed against doctors are frivolous, so you can ask to read the court file if there is only one case.)  Consult a few doctors before you make a choice.  Try to find a doctor who will explain everything to you personally and is cautious about infection and scarring.  The doctor should offer to show you before and after pictures of other patients.  If you are over age 50 and have creases, folds, or sagging skin, a plastic surgeon can also suggest other procedures which will give greater improvement than resurfacing alone.

Full-face, medium-depth resurfacing is expensive, generally abou! t $1000 to $3000.  Resurfacing on smaller areas of the face will be less.  Usually, laser resurfacing is most expensive, due to the cost of the laser equipment.  Many doctors prefer laser resurfacing due to the ability to closely control penetration depth.  However, a skilled doctor can also get good results with chemical peeling or dermabrasion.  Plastic surgeons will often give you a free initial consultation and price quote on resurfacing; this may be less common with dermatologists, so be sure to ask first.  

Light resurfacing is far less traumatic and has fewer risks since it only removes part of the epidermis.  It is usually done with a low-concentration chemical acid peel or with low-abrasive dermabrasion.  While a single light resurfacing has little effect on wrinkles, after the upper epidermis regenerates, it is often smoother in texture than before.  Some studies have shown that a few light resurfacing p! rocedures spaced a few months apart are more beneficial than a single procedure and may reduce fine lines. Light resurfacing is much less expensive than medium-depth resurfacing.   There is usually no anesthetic used and less complex infection control.  The price is usually about $100-$150 per procedure.  Total healing time is only a few weeks, and usually you only look like you have a sunburn for about a week. You should stay out of the bright sun for a few weeks, and use sunscreen in the future.  Depending on the type of chemical used, you may have to stay home from work for a few days because the upper skin layers may harden slightly and peel off after about two days.  The pores will often appear slightly larger until the skin completely heals.  Light resurfacing is often done by nurses or physician-assistants working under the supervision of a dermatologist or plastic surgeon.  If you work with a nurse or physician- assistant, you can ask them for a business card and check the status of their! state license and any disciplinary actions with the state medical licensing department.  Aestheticians also do light resurfacing.  If you use an aesthetician, be sure to check their private certification or state licensure.

If you want to save money on light resurfacing, you can get nearly the same effect with temporary nightly use of an inexpensive over-the-counter alpha hydroxy acid product (see next section).

9. WHAT ARE ALPHA-HYDROXY ACIDS AND SKIN EXFOLIATION?

Low-concentration alpha hydroxy acids (AHAs) and salicylic acid are chemicals promoted to improve signs of photoaging such as rough skin surface texture, fine lines, and uneven pigmentation.  Salicylic acid is sometimes called a "beta hydroxy acid" and is also contained in some acne medications.   Acid concentrations are typically 2% to 15%, though concentrations are calculated differently among different manufacturers.  These cosmetic acids are available ! as creams, lotions, and gels on the shelf at most drugstores for less than $15. Note that these acids are not moisturizers, but some vendors classify them with moisturizers because they have a similar appearance effect on the skin. One popular, reasonably-priced AHA brand is Alpha Hydrox, in the red boxes (www.alpha-hydrox.com for information).  

Just like light resurfacing by a doctor or aesthetician, low-concentration AHAs applied over a few weeks or months remove or "exfoliate" only part of the epidermis.  After the epidermis regrows, it may be smoother than before.  The most common acids in AHA products are glycolic acid, malic acid, and lactic acid.  One medical study indicated that lactic acid produced better results than glycolic acid, but most products contain glycolic acid.  Unlike AHAs, salicylic acid is mildly toxic and more caustic at a given concentration, so most salicylic acid products contain concentration! s below 10%.  (By the way, salicylic acid is not aspirin, that's acetlysalicylic acid.)  

Home use of AHAs originally became popular because they provide quick results on areas of rough skin by peeling off the upper layers of the epidermis. Initial medical studies indicated that use of low-concentration AHAs resulted in improvements in both the lower epidermis and the upper dermis.   However, the FDA and some doctors raised concerns that long-term AHA use could cause permanent cellular damage.  The issue is being studied, and the FDA has already confirmed that AHAs make the skin more sensitive to solar UV radiation damage (though the effect is reversible when use is discontinued).

You should also know that there are Net reports of AHA use preceding the development of rosacea, which is sometimes triggered by skin irritation.  If true, this is a significant risk.

Net reviews on AHAs are generally positive with skin texture and fi! ne lines improved slightly.  However, just like light resurfacin g, most people also experience some irritation, peeling, and redness corresponding to removal of the top epidermal layers.  As with light resurfacing, your skin may look like you have a mild sunburn until you stop using the AHA and the epidermis fully regenerates.  Some people with sensitive skin complain of serious irritation when using the higher concentration products.

Cosmetic acids can be used regularly if you have abnormally rough skin due to overgrowth of the top epidermal layers.  However, despite what some advertising says, acids should only be used temporarily on normal skin.  Even if you have chronic rough skin, it is better to try various moisturizers first, including special urea-based moisturizers like Carmol 20, available from pharmacists (a higher strength, Carmol 40 is also available by prescription).  For normal skin, continuous exfoliation (either with cosmetic acids or abrasive scrubs) is unnecessary and can be har! mful.  The upper epidermis provides an important environmental barrier, and burning it off continuously with acid for the rest of your life doesn't make sense.  One reasonable strategy would be to use an AHA nightly for a few months, and then switch to long-term use of tretinoin.

As with tretinoin, you should only use cosmetic acids at night, since they may cause sun sensitivity.  Don't apply them with any other products since the acids can react with other chemicals.  Don't apply them right next to your eyes.  Also, stand next to a sink when you apply them so you can flush your eyes and face with water if you get any in your eyes or if your face starts to sting badly.

Another reason not to use AHAs continuously is that peeling off the upper epidermis can temporarily make your pores look larger.  Contrary to some advertising, AHAs are not a treatment for large pores and do little to disolve sebum-keratin plugs in the pores. &! nbsp;Pore appearance is influenced by how the upper epidermis forms t he pore opening.  Stripping off the upper layers and thinning the epidermis increases the size of the pore opening.  When you stop using the acid, the pore opening will usually return to normal as the epidermis regenerates, but this can take weeks.  Remember, if you have large pores, a thinned epidermis makes your pores look larger, not smaller.  

Unlike AHAs, low-concentration salicylic acid acne medications can help disolve impacted sebum-keratin plugs inside pores.  So even though it thins the upper epidermis, it may have a positive effect on pore appearance if they are dialated by sebum and keratin.  However, tretinoin is a better long-term treatment for plugged pores than salicylic acid, since it does not require continuous peeling of the upper epidermis and also helps to thicken the epidermis.  Higher concentrations salicylic acid solutions will also cause light crusting and peeling which may be unsightly.

There are! some non-prescription sources for high-concentration AHA and salicylic acid solutions, but they are not safe for general home use.  Using high-concentration acid solutions without specialized knowledge is very dangerous.  As with light and medium-depth chemical peels, such higher- concentration solutions can only be left on the skin for a short time and then must be quickly washed off or neutralized with a base solution to prevent burns, scarring, and possible infection.  It only takes minutes for a high-concentration solution to penetrate into the dermis and cause permanent scars.  High-concentration solutions can also cause permanent damage if they get into your eyes.  It is much safer to use low- concentration AHAs for a few months than to try to do one deeper peel with a higher-concentration solution.  Don't risk scarring your face.

Most AHA products are not stamped with expiration dates, but manufacturers say they start to! degrade after about 3 years.  It is best to only buy one tube a t a time to assure potency.

10. HOW CAN I TREAT OILY SKIN?

Skin oil, or sebum, is produced by sebaceous glands attached to your skin pores and prevents your skin from drying out and flaking.  However, excess sebum can become impacted in the pores leading to "blackheads", "whiteheads" or inflammatory acne.  Pores can appear larger due to impacted sebum.  Even if you have otherwise smooth skin, this can obviously detract from your appearance.  

Most people get some acne as teenagers.  Some adults continue to have low-level acne throughout life due to excess sebum.  Usually, this can be effectively treated with topical prescription retinoids like tretinoin (Retin-A or generic), adapalene (Differin), and tazarotene (Tazorac).  These allow sebum to be shed more easily from the pores.  Sebum on the surface of the skin can be removed by simply washing with a mild cleanser, but avoid excessive use of ! alcohol-based astringents, which can damage the skin. Cleansers usually will not remove sebum that is impacted in pores, that is why you need to use a prescription retinoid.  

If absolutely necessary, blackheads and whiteheads can be removed manually with a wire-type remover tool.  A good brand is the "Tweezerman" skin care tool, which is sold at drugstores (see www.tweezerman.com).  However, it is easy to damage your skin with these tools, so follow the directions carefully.  If you can't remove the sebum with a light pressure, wait a few days for the retinoid medication to loosen it.  Medical studies have found that even careful use of such tools can produce scarring and permanent pore enlargement, so many doctors say it is better simply to let the medication resolve the lesions rather than squeeze them out.

For some people, retinoids alone are insuf! ficient to treat excessive sebum.   There are effective prescrip tion treatments available that act directly to reduce sebum production by the sebaceous glands.  However, these oral medications can have side effects, so dermatologists will usually want you to try the various retinoids for at least a year before prescribing them.  

Sebum production is partially controlled by androgens (hormones).  In women, a doctor can reduce sebum production with medications such as anti-androgens or oral contraceptives (e.g. Tri-Cyclen) that affect androgen production.   You can discuss this option with your dermatologist or your regular doctor. These medications should not be used by men because they can have feminizing effects, such as growth of breast tissue.  

Pharmaceutical companies are currently working on medications that can be taken by both men and women which block the effect of androgens on the sebaceous glands.  These experimental medications are similar to prescription finasteride (Propecia ! and Proscar) which blocks the harmful actions of the hormone dihydrotestosterone (DHT).  (DHT causes hair-loss and prostate enlargement in men.)  You can ask your dermatologist to see if these medications have been approved, or check the newsgroup alt.skincare.acne and websites that discuss acne treatment.

The most potent medication available to reduce sebum production is oral Accutane (isotretinoin), a chemical related to vitamin A.  It acts directly to reduce sebum production and shrink the sebaceous glands.  Sebum production is usually permanently reduced after Accutane is taken for a number of months.   It can be taken by both men and women, however, it can have significant side effects similar to those of vitamin A toxicity.  The possible side effects include birth defects in pregnant women, ocular effects, effects on bones, severe headache and fluid pressure in the head, depression, and increased blood triglycerides or cho! lesterol.  Because of these possible side effects, dermatologist s are generally reluctant to prescribe Accutane except for severe acne.  However, some physicians now believe Accutane is appropriate for persistent mild to moderate adult acne.  See for example "Treatment of Acne With Intermittent Isotretinoin," British Journal of Dermatology 1997 Jul;137(1):106-8; "Roaccutane Treatment Guidelines: Results of an International Survey," Dermatology 1997; 194(4):351-7; and "Acne Vulgaris in the Elderly: the Response to Low-Dose Isotretinoin," British Journal of Dermatology 1998 Jul;139(1):99-101.  You can download abstracts of these papers from the Internet medical index "Medline" and discuss them with your dermatologist.  Be aware however, that Accutane is very serious business, and while most people do not develop serious side effects, you must be willing to accept their risk.  Women who are pregnant or who may become pregnant during treatment must never use Accutan! e because of the high probability of serious birth defects.

Many insurance companies will not pay for Accutane unless it is prescribed for severe acne that does not respond to retinoids.  So you may have to pay for it yourself if your dermatologist is treating you for excess sebum and mild acne.   Accutane is very expensive, but it is now available as a generic, so have your doctor prescribe generic isotretinoin.  An Accutane course will cost at least $150 per month, and you will need to take it for at least 4 months to prevent relapse.  So compare prices at various pharmacies.  Prices for isotretinoin are usually lower at British and Canadian mail-order pharmacies than at U.S. pharmacies.  Your doctor will also usually want you to have blood tests while you are on Accutane to check for certain side effects.  

11. HOW CAN I TREAT SCARS?

After an injury, it can take a year or more for scarred skin to fully heal.  ! Most of the treatments to minimize scars are best performed early in this process, soon after initial healing.

As a wound heals, you can minimize scar formation by keeping it moist and free of infection.  After the wound is cleaned and closed (if necessary), apply non-prescription Neosporin, Polysporin, or a similar antibiotic ointment under a bandage.  For burns, you can also ask your doctor for prescription Silvadene ointment.  Applying cod liver oil or zinc oxide ointment after the skin has healed over may also help the epidermis regrow.  Large burned areas must obviously be treated by a doctor; there are many new specialized techniques and wound dressings that can minimize scar formation from burns.

After a raised scar has formed, daily massage of the scar using a moisturizer or oil can help soften the stiff scar collagen.  Vitamin E oil is sometimes recommended for massaging into scars, but other moisturizers may work just as well.  Medical studies have generally found that vitamin E oil ! has no special effect on scars, but many Net posters say it has improved their scars when rubbed in daily.  

Some Net reviewers have reported success using non-prescription "Mederma" gel on new raised scars (www.mederma.com, available at pharmacy counters).   However, others have reported little effect.  The active ingredient in Mederma is onion extract, which has been shown to inhibit the growth of collagen in test tubes (possibly resulting in a flatter scar).  Mederma costs $15 or $25 (depending on tube size).  You have to use it for many months to see any effect.  Mederma may inhibit epidermal healing when used on new wounds, so it should only be used after the skin has healed over the wound and a raised scar seems to be forming.  Mederma doesn't work on depressed or pitted scars.

If you have very shallow depressed scars, tretinoin may improv! e their appearance slightly because it increases collagen production and epidermal thickness, slightly filling in the depression.  However, tretinoin will not fill in deep pitted scars.  (There are surgical techniques that can be used for these scars.)

You can buy medical-grade silicone sheets for scar treatment that are taped over raised scars.  There are a few brands available at pharmacy counters or in the first-aid section.  There are many medical studies that show this works to flatten new raised scars, though the mechanism is unknown.  It doesn't seem to work as well on old scars.  The sheets are expensive, about $20 to $45 for a 1.5" x 4" piece, but it doesn't wear out.  Curad sells disposable pads called "Curad Scar Therapy" which work on the same principle (see curadusa.com).   Band-Aid also has a similar product.  There is also some evidence that simply keeping a new raised scar completely covered with tight-fitting first-aid tape for many weeks reduces! the thickness of the scar.

If you have prominent scars, dermatologists and plastic surgeons have many other techniques available for treating both raised and depressed scars.  For example, both raised and depressed or pitted scars can be cut out and stitched closed or replaced with a small skin graft.  The thin raised scar this produces is usually much less noticeable than the original scar.  Various materials can be injected under depressed scars to elevate them.  Some doctors also use medium-depth resurfacing on some types of scars, but results seem to vary widely with this method.  There are more options available for new scars, so it is best to see a doctor soon after the scar has formed.

12. HOW CAN I TREAT VISIBLE CAPILLARIES?

Dilated capillaries (telangiectasia) in the face or legs are a common, benign hereditary condition that usually becomes noticeable in the late thirties or early forties.  Temporary thinning of! the epidermis following resurfacing or AHA use can also make capilla ries more noticeable on the face.  A doctor can treat these with a laser, an electrocautery needle, or by injection of a clotting (sclerosing) agent.  Injections are the most effective method for the legs, but are usually not used on the face due to possible temporary discoloration and risk of migration of the sclerosing agent.  For the face, laser is most effective, but is much more expensive than electrocautery.  Some net reviewers have said that the electrocautery did not work well for them and left a small scar, so it might be prudent to try it on one small capillary first.  Often repeat treatments are required with all of these methods. ------------------ END

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