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I recommend that my patients avoid exposure to cosmetics ingredients that may be harmful to their skin, such as detergents, chemicals, coloring agents, synthetic fragrances, artificial preservatives, and mineral oil. Furthermore, to help prevent premature aging, I recommend that they follow a basic skin care program of cleansing, exfoliation, moisturization, and sun protection.

A. Cleansing the Skin

Your skin is affected on a daily basis by perspiration, dead cells, secretions, dirt in the environment, and substances that are applied to the skin. Clean skin will obviously look healthier than dirty skin. Cleansing is therefore important, and the removal of dirt, oil, and dead cells can be accomplished by a variety of means.

1. Mechanical Cleansing

Mechanical cleansing involves using a dry cloth or abrasive pad with or without water. Distilled or spring water is preferable to tap water It is now well recognized that excessive scrubbing and cleansing can also have a negative effect on the skin.

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2. Use of Detergents

Because greasy substances in cosmetics and dirt on the skin can be difficult to remove, some kind of cleaning agent is often required. Surface active agents are highly effective for removing dirt and oil. Soaps are the detergents most commo&y used on the skin. All soaps work by dissolving grease and allowing it to be rinsed off with water. Soaps and detergents contain chemicals called emulsifiers, which are able to dissolve grease and oily substances, allowing them to be rinsed away with water. Detergents can be harsh on the skin, removing excessive oil and breaking down the skin’s natural defensive barrier.

Synthetic detergents were produced during World War II when vegetable oils were scarce. Sodium lauryl (sulphate) was one of the first such synthetic detergents to he developed. These detergents are highly effective, but once again, they can be irritating to the skin, especially with excessive use.

“Natural” or Nondetergent Soaps

These are usually made from vegetable oils such as olive oil, coconut oil, or wheat germ oil, treated with sodium or potassium hydroxide.

“Soapless” Cleansers

These substances contain emulsifiers that do not lather or foam. They are available in cream or lotion form.

Washable Creams and Lotions

Washable creams and lotions are basically moisturizers to which soaps or detergents have been added to make them thinner and easily spreadable. Both are intended to be rinsed off with water. Washable creams and lotions should not be confused with cleansing creams or lotions. These are primarily moisturiters used for cleansing purposes. Basically, they are creams that are applied and wiped off with a soft towel rather than washed off with water.

Liquefying Creams

Liquefying creams are cleansing creams that contain waxes which melt upon contact with the skin and have no special properties. These products, however, tend to be greasy and can leave a film on the skin. Furthermore, because they contain little or no detergent, they are generally poor cleansers.

Manufacturers spend millions of dollars trying to persuade you that their cleanser is better than others. All of the exotic sounding additives such as fruit extracts or herbal additives do not add to the soap’s cleansing ability. These exotic soaps clean no better than conventional soaps and provide no additional benefits. The reality is that no matter which soap or cleanser you use, they will all do nothing more than clean your skin, resulting in a fresh feeling. In fact, all soaps and cleansers are actually iri-hating to the skin. The consumer’s final selection of a soap or cleanser is influenced by personal preference of a product color, fragrance, or feel, and by a taste for luxury. For this reason, a large percentage of a soap’s cost is actually related to the packaging and fragrance and has little, if anything, to do with how effective a cleanser is or how nonirritating the substance is to the skin.

Recently, nondetergent cleansers have become available. These may be less irritating to the skin.

Toners and Fresheners

These products do little more than make your skin feel temporarily cool and invigorated. They are essentially alcohol solutions. Witch Hazel (a natural extract) is often added for its cleansing and toning effect. The alcohol does help dissolve some of the dirt and oils, and it causes a cooling and tingling sensation, as well as a drying effect. This effect may be enhanced by adding menthol or other similar ingredient. These products can be irritating to the skin, especially to dry or sensitive skin.

Fruit Acids (Alpha Hydroxy Acids)

Natural fruit acids are excellent water soluble cleansers. Dilute, nonbuffered glycolic acid or Lactic acid, for example, may be used as cleansers. Fruit acids will also loosen the adherence of dead cells, and when combined with the use of a mild abrasive pad such as a cotton gauze pad, they are excellent cleansers. Soap should he used infrequently. Dilute fruit acid used with a cotton gauze pad is recommended.

Salicylic Acid (B Hydroxy Acid)

Salicylic acid is oil soluble. Thus it is able to penetrate the sebum filled follicles and clean the pores. It is also a mild exfoliant and thus an excellent cleanser.

B. Exfoliation of the Skin

The most effective means of rejuvenating the skin is exfoliation. The skin of a child replaces its outer layer approximately every twenty-eight days. This process keeps the skin looking youthful and healthy. As we age, the rate of exfoliation slows down, resulting in a buildup of older, less healthy looking cells on the surface. Eventually, the skin begins to become dry, crusty, and wrinkled. There are several ways to speed up the cell division and shedding rate.

Exfoliation by Mechanical Abrasion

This involves the use of a brisk face cloth, crushed granules, (e.g. crushed walnut shells), or a nonmedicated deep cleansing facial sponge. Although this method is effective, scratching of the skin can occur.

Exfoliation Using Fruit Acids Such as Glycolic and Lactic Acids

Fruit acids are excellent exfoliators. As mentioned earlier, they loosen the adherence of old and dead cells to the underlying healthy cells. When fruit acids are combined with a mild buffing action, these cells will be removed. A longer acting fruit acid gel may be used for deeper penetration and stimulation of the deeper layers.

Exfoliation Using Prescription Medications

Retin-A (trans retinoic acid) stimulates cell division and thus speeds up the exfoliation process. Unfortunately, Retin-A does have some side effects, and if used incorrectly, it can cause problems. Most commonly, Retin-A causes increased sensitivity to the sun and dilatation of blood vessels on the skin. Burning or crusting can occur if it is used too frequently.

C. Moisturization

Moisturizers are most effective if they remain on the surface of the skin, as do petrolatum (Vaseline® or petroleum jelly) and oil. In fact, scientific studies have shown that Vaseline® (petroleum jelly) is the most effective moisturizer available. However, most women do not like the greasy feeling of Vaseline®. In addition, Vaseline® tends to block the pores, as does mineral oil. Cosmetics manufacturers therefore came up with vanishing creams, which “vanish” when placed on the skin. However, when the cream vanishes, where does it go? A vanishing cream is basically an oil emulsified with water. This enables the cream to penetrate into the skin and become absorbed into the blood stream. Therefore, it does not feel oily anymore—it has “vanished”! Women often request this type of moisturizer because they enjoy the light, greaseless feeling of a cream that “goes into” the skin to “nourish” it. Of course, once the cream has vanished, it is no longer an effective moisturizer, for it is not “working” in deeper layers of skin. It is circulating in the bloodstream! No matter what you may have heard or read-no matter how expensive the moisturizer, moisturizers simply do not add moisture to the skin, nor can thcy reverse the skin aging process. Moisturizers only offer temporary relief from dryness and irritation, and help soften and smooth the outer layer of the skin.

1. Oil-free moisturizers

Oil-free moisturizers are water-based gels, such as sea weed gel, aloe vera gel, cellulose (gums), and hyaluronic acid.

2. Oil moisturizers

These include olive oil, sesame oil, squalane, and silicone oil. Creams are made by combining oil-free, water-based components with oils by means of emulsifiers and stabilizers.

Lipids and Essential Fatty Acids

Lipids and essential fatty acids are found within the skin’s own cellular structure. These “barrier lipids” form a protective barrier to prevent water loss. As we age, the level of lipids in the skin decreases, thus weakening the moisture barrier.

All facial skins differ in their oil content, not only from day to day, but also from area to area. Tt therefore does not make sense to use one moisturizer with a fixed percentage of oil. It is far more effective to first apply an oil-free moisturizer which will absorb excess oil from the oily areas, and then apply a specific amount of oil as needed to the dry areas.

It is important to know that synthetic moisturizers, such as mineral oil and its derivatives, inhibit the skin’s own moisture- producing capacity and thereby produce dry skin! These products may also be phototoxic and allergenic and are not at all recommended for any cosmetic product. Natural moisturizers extracted from seaweed and single-celled organisms, plants, and naturally occurring silicas (silicone) are always a superior choice.

D. Bleaching-Skin Lightening Agents

Skin lighteners are used to lighten blemishes, age spots, and irregular pigmentation. Hydroquinone is the most effective skin lightening agent available. It is only available under prescription in the higher concentrations and is most effective if used with Retin-A. A major drawback of Hydroquinone is that prolonged use can lead to rebound hyperpigmentation, that is, a return of the pigmentation problem to a greater degree.

Certain berries, such as Bearberry, are known to have a high concentration of natural Hydroquinone and appear to have ultraviolet ray-blocking properties, thus preventing premature aging. Kojic acid has recently been used as an effective skin lightening agent.

E. Protection against UV Light Sunscreens

Most antiaging or aritiwrinkle creams make their claims based on the fact that they contain sunscreens. Sunscreens fall into two basic groups: ultraviolet ray-absorbing agents such as PABA and the oxy (cinnimates) and ultraviolet ray-blocking agents such as zinc oxide and titanium dioxide. There is concern among physicians regarding the fact that the skin is able to absorb the ultraviolet ray-absorbers, and therefore, it appears that the blocking agents are safer.

It should be noted that a product’s SPF rating is affected by how thick the substance is, how frequently it must be applied, and how waterproof the sunscreen is.

It is recommended that a mild sunscreen be applied every day, even if the skin is not going to be directly exposed to the sun. When the skin is exposed to the sun (as when one is playing tennis or swimming), a stronger, waterproof sunscreen should be used.

Zinc oxide or titanium dioxide sunscreens that are completely free of chemical and synthetic ingredients are recommended. They may be used as liberally as desired without concern for toxic absorption.

The Simpler, the Better

Of the abundance of substances used for skin care, there are very few substances that have truly beneficial or rejuvenating effects on the skin. Basically, a person can clean, exfoliate, moisturize, bleach, and protect the skin. Consumers should avoid the possibly harmful or dangerous ingredients listed in this booklet and seek out cosmetics that have been proven to enhance and not harm.

Because of the many products available, the complexity and confusion surrounding these products, and the paucity of scientific and clinical studies, the best we can do is to seek out simple, basic products. As a general rule, the simpler and more natural a product is, the better and safer it will be. Therefore, seek out: vegetable oils, fruit acids, organic extracts, and natural sun-blocking agents. More expensive and exotic looking products are not necessarily better.

Products with Documented Beneficial Effects on the Skin

1. Retin-A

There have been numerous reports in the media about the rejuvenating effects of Retin-A. Unfortunately, these have caused a great deal of confusion about the benefits of Retin-A. Retin-A was first developed fifteen years ago as a medication to prevent acne. It worked because of its unique ability to unclog facial pores and keep them open, thus preventing the formation of acne lesions. Over the years, physicians have noted the marked anti- aging effects of Retin-A. Results recently published in the Journal of the American Medical Association indicate that it is the first scientifically proven product to have any significant effect on the appeanmce and aging process of the skin.

Retin-A opens and cleans out the pores and helps smooth the skin. It tightens the skin, thereby removing superficial wrinkles. It compacts the top layer of the skin (the stratum corneum), thus producing a much smoother and glowing appearance. It also increases the amount of blood flow under the skin, making the skin look rosier and more youthful.

Retin-A is beneficial to collagen, which is the underlying supportive structure of the skin that is damaged over a lifetime due to the cumulative effect of exposure to the sun’s direct and indirect rays. It increases the collagen supply in the skin and increases the rate of skin healing. It also reverses some sun damage caused by ultraviolet ray exposure.

Retin-A repairs sun-damaged cells and restores the cells to their undamaged state. These findings strongly suggest that Re- tin-A plays an important role in the prevention of skin cancer.

If used properly Retin-A can benefit all types of skin (black to very fair), but one has to select the proper concentration for the right skin problem.

Retin-A can also be irritating to the skin and increases the skin’s sensitivity to the sun. It may also increase the skin’s susceptibility to skin cancer, contact dermatitis, and other forms of skin damage if the appropriate precautions are not taken. Without proper supervision, some individuals have had a severe reaction in and around the eyes after using Retin-A on the eyelids in an attempt to remove wrinkles.

2. Fruit Acid (Glycolic Acid)

Fruit acids, also known as alpha hydroxy acids, are nontoxic, naturally occurring substances found in milk and a variety of fruits such as grapes, apples, sugar beets, and citrus. These acids are commonly known as glycolic, citric, malic, lactic, and pyruvic acids. Over two hundred years ago, French women knew about the beneficial effect that aged wine has on the skin. Old wine contains alpha hydroxy acids, which are now known to have a rejuvenating effect on the skin. Glycolic acid is a deep cleanser and exfoliator that stimulates collagen formation. Exfoliation removes the dead cell buildup and pore-clogging oil to produce smoother skin. Superficial residue is removed and skin is prepared for further therapeutic applications. With prolonged use, fruit acid decreases fine wrinkles and age spots. It also improves oily and acne-prone skin.

3. Lactic Acid

Lactic acid is an aipha-hydroxy acid derived from milk. When applied to the skin, lactic acid causes exfoliation by loosening the adhesion of the outer layer of cells. As those cells break away, new cell growth is stinmlated.

4. Hyaluronic Acid

Hyaluronic acid is a naturally occurring carbohydrate (polysaccharide) found in the space between the cells of the skin. Because it holds more water than any other natural substance, hyaluronic acid plays an important role in tissue hydration, lubrication, and cellular function.

The aging of human skin is accompanied by a decline in the hyaluronic acid content, resulting in a loss of elasticity that appears in the form of wrinkles (the most dramatic decline being observed after age fifty). Therefore, the healthy appearance of younger looking skin has a direct relationship to the hyaluronic acid content. Hyaluronic acid is used in some of the top-selling commercial products such as Estee Lauder’s Night Repair Lotion and Lancome’s Activating Serum. However, due to its high cost, it is only used in very small concentrations in these products. Hyaluronic acid has been shown to reduce dryness, itching, and burning of the skin. Its unmatched hydrating properties result in smoother, softer skin.

5. Salicylic Acid

Salicylic acid is a beta hydroxy acid and helps eliminate the signs of aging. Salicylic acid is more effective than many alpha hydroxy acid preparations, and is also less irritating and thus more conducive to daily use. Salicylic acid is water-soluble and lipophilic, thus it is able to penetrate sebum filled follicles and clean out clogged pores. Regular use of salicylic acid plus periodic salicylic acid office peels will result in a decrease in fine lines, a smoother skin, more even pigmentation and a reduction in pore size.

6. Natural Seaweed Extract

Seaweeds are especially rich in cosmetically active compounds. Seaweed extracts combine with the proteins of the outer layer of the skin and hair to form protective moisturizing complexes. Chemical compounds in seaweed help retain water and act as hydrating agents, so that seaweed extracts hydrate and soften the skin. Efficient hydration enhances the skin’s natural ability to repair itself. Irritation caused by shaving and depilation (chemical removal of hair) is decreased by application of seaweed extracts.

7. Squalane

Squalane is a remarkable extract from the liver of the Aizame shark. It is also found in olive oil. Squalane is the main constituent of sebum, which is the skin’s own natural moisturizer. It was initially discovered in Japan, where it was used successfully to treat tuberculosis. Squalane is an unsaturated oil having a molecular structure similar to that of vitamin A. It has been shown to have beneficial effects for the management of dermatitis and skin cancer. Japanese scientists believe that squalane has a tumor-blocking potential. Studies have shown that it has a stimulatory effect on the healing process. Squalane is used in some of the world’s most expensive beauty formulas. Beneficial effects on the skin include decrease in dryness (it is one of the most effective moisturizers available) and smoothing of wrinkles and scaly skin.

8. Essential Fatty Acids (Lipids)

Essential fatty acids are the main components of sebum, which is naturally manufactured by the skin as a protective agent.

Sphingolipids are secreted by the deeper layer of the skin to function as a lipid barrier.

A lipid harrier is necessary for optimal cell function and for preventing damaging agents from penetrating the skin. Vitamin E Linoleate and Linoleic are the main essential fatty acids found in the skin.

9. Topical Vitamin C

Vitamin C, also called ascorbic acid, is essential for life in humans. In the l930s it was discovered that a deficiency of vitamin C causes scurvy. Since this discovery, much research has been done concerning vitamin C’s metabolic roles and its uses in pharmacologic doses, but only a small body of literature has focused on topical applications of vitamin C for protection from sun damage and resultant aging.

In small clinical trials, a few researchers have concluded that there is an implication that supplemental topical vitamin C may slow cutaneous aging and may improve wound healing. Based on in vitro studies of human skin cells, vitamin C has also been shown to replenish vitamin E in the skin and to stimulate the skin’s collagen synthesis.

Although dietary vitamin C has been shown to possibly delay the incidence of skin cancer in animals, there is no indication of this effect in humans.

10. Sunscreen

Most antiaging creams that claim to reduce wrinkles contain sunscreens. Sunscreens do prevent premature aging by decreasing the harmful effects of ultraviolet rays on the skin. They are the single most effective means of preventing skin damage. (See pages 35 and 49.)

11. Hydroquinone

This agent is indicated in the treatment of pigment problems such as chloasma, melasma, freckles, and senile lentigines. Hydroquinone decreases melanin production and acts as a depigmenting agent. When pigmentation is superficially located, depigmentation can be expected in two to four weeks time. Deeper pigmentation may require up to three months, and then the effect still may be incomplete. Hydroquinones are not approved for children under twelve years of age and should be avoided during pregnancy. Prolonged use over six months may produce an irreversible effect. Rarely reported after prolonged use is a brown to yellow discoloration of the skin, called ochronosis. Kojic acid has a similar effect to hydroquinone.

12. Alpha Lipoic Acid

Recent research has shown that alpha lipoic acid preserves and elevates Vitamin C and Vitamin E levels in the skin. This antioxidant effect is believed to protect the skin from free radical effects. Early research has shown that fine lines are reduced with the use of Lipoic acid.

Facial Peels

The most effective way to rejuvenate the skin is to stimulate the skin cells to divide more rapidly. Cell division slows down with age, resulting in a buildup of damaged cells at the surface. Cell division can be increased by a variety of solutions that are applied to the skin. More rapid cell division is evidenced by exfoliation or peeling. Retin-A and glycolic acid are the most commonly used exfoliating agents, while glycolic acid, trichloracetic acid (TCA), and phenol are used for deep skin peeling.

A. Exfoliating Washes

Tn order to enhance the action of Retin-A and glycolic acid, biweekly or monthly “acid washes” are helpful. A more concentrated solution of glycolic acid is applied to the facial skin. A mild peeling is experienced during the following week, with little or no inconvenience. When deeper washes are performed, redness and mild scabbing may prevent the application of makeup for a few days.

B. Light Peels

Light peels are usually performed using tricloracetic acid (TCA). The lighter the peel, the less the likelihood of complications such as scarring and pigmentation changes. By the same token, lighter peels are less effective in removing deep wrinkles. Light peels can be effective in improving blotchy pigmentation, freckles, sun damage, fine wrinkles, and mild acne scarring.

The peel is performed in the doctor’s office without sedation. There are normally a few minutes of stinging and burning after which there is no further discomfort during the peeling process. The face has the appearance of a mild to moderate sunburn.The patient can apply makeup, leave the office, and even go back to work. The light peel takes takes approximately five to seven days to heal. Light peels are usually repeated every few months for optimal results. Repetitive peels have an accumulative effect, especially if they are combined with glycolic acid home peeling and Retin-A.

C. Medium peels

Medium peels are performed in a similar way to light peels; however, intravenous sedation is used. Peeling usually persists for seven to ten days. The skin scabs and becomes darker in color. It is usually necessary to take several days off work while healing takes place. Medium peels are usually performed with

TCA.

D. Deep peels

This type of peel is most effective in treating deeper wrinkles, especially around the mouth and eyes. Peeling is done under anesthesia, most commonly using a phenol solution.

E. Laser Peels

Recently the CO; laser has been used very effectively to perform deep facial peeling with fewer of the problems associated with the traditional phenol peel. The skin becomes quite red and swollen, taking approximately two weeks to heal. Redness can persist for several weeks. The best candidates are healthy patients with fair complexions.

It is important to prepare the skin with Retin-A and a bleaching agent for several weeks prior to the peel.

Following the peel, exposure to the sun should be avoided for several months to maintain good results. A good skin care program should be adhered to (see page 43). Recently we have been performing lighter laser peels in two stages. The complications have decreased while the results improve with each treatment.

Power Peel

One of the newer derrnabrasion techniques is known as the Power Peel, Paris Peel, or Micro dermabrasion.

It basically consists of an air driven device that blows fine granules over the surface of the skin. It removes the outer layers of the skin effectively with very little pain or down time—the effect being similar to a light TCA peel.