John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442

Aging of the Skin: What Can Be Done

Patient Information Sheet

The funny thing about aging of the skin is that it's not really due to growing older. The overwhelming majority of what we call aging of the skin is due to sun damage not to age. The only correlation it has to age is that the older you are, the more chances you have had to be in the sun. My main concern is that those same ultraviolet light rays that cause aging also cause cancer.

What Is Aged Skin

What is aging of the skin? There are specific features we collectively refer to as aging of the skin. They are essentially the features of sun damage. With sun damage, the outer layer of growing skin, the epidermis, becomes thin. There tends to be a spotty thickening of the outermost dead layer of skin. This is noticeable as a feeling of rough spots. There is a decrease in the number of small blood vessels in the skin. Thus, aged areas (sun damage areas) appear pale or sallow. This is why so many people try to add color by using rouge. Pigment is unevenly distributed causing splotches of dark and light. There are areas with decreased numbers of pigment making cells, melanocytes.

Ultraviolet light chops up the elastic and collagen fibers that comprise the lower portion of the skin, the dermis. Thus the skin becomes wrinkled and loses its elasticity. When stretched, it does not snap back as younger skin does.

Another common sign of sun damage to the skin is the formation of little stubborn blackheads around the eyes, periorbital solar comedos.

Invisible, hidden damage to the chromosomes of the cells in the basal layer of the epidermis sets some of the sun damaged skin cells on a path to forming precancerous spots, actinic keratoses, and skin cancers.

Treatment of Aged Skin

Can anything be done to reverse aging of the skin? I used to think not. But after I had been in practice in Bozeman for seven years, I noticed than many of the ladies coming back to see me for precancerous lesions, actinic keratoses, who used sunscreen faithfully, had younger feeling and looking skin. I asked a leading authority about this. He told me that there is now evidence that fibroblast cells in the dermis slowly repair the damaged collagen. It takes about five to seven years of faithful use of sunscreen before the results can be seen.

Avoid Sun

The mainstay of keeping your skin looking young is to avoid exposure to ultraviolet light. This really is no surprise. That is the origin of the use of the parasol, an umbrella-like shade from the sun and a secret know as far back as the ancient Chinese and probably farther. Today we are lucky to have excellent sunscreens such as Neutrogena Ultra-Sheer Dry Touch SPF 100. Suntan parlors are certain to age the skin and increase the risk of skin cancer. The American Academy of Dermatology has been officially opposed to their use for many years. The people who run such businesses will tell you that their special lights do not cause skin damage and that by getting a gradual tan, you avoid the damage. Don't believe it. Those are just outright lies that are contradicted by an extensive body of scientific literature. There is some evidence that excessive sun exposure during the teen years causes a disproportionately greater risk of getting skin cancer later, especially the dreaded melanoma.

Avoid Dry Skin

Another cause of wrinkles is dryness. When people vacation in Hawaii, they frequently start looking 15 years younger in a few days. Is it the magic of the is lands? The Hawaii Traveler's Bureau would like you to think so, but no. Hawaii has a higher humidity-- 75% to 80%. Wetting the skin makes small wrinkles disappear, and thus the skin looks younger and more beautiful.

There is a type of cosmetic called vanishing cream. You apply it at bedtime. When you wake up, your wrinkles vanish. The active ingredient is water. For vanishing cream, you are paying $20 or more/oz. for water. Now there is a new improved super vanishing cream. It's more expensive. Guess what it has more of in it. Yep, water.

You can accomplish the same thing with water and a dry skin lotion. Just wet the skin and then rub in the dry skin lotion. A high society trick used by the Madison Avenue crowd was to wet the skin and apply human serum albumin. Painted on wrinkles, it made the wrinkles disappear temporarily, long enough at least to go out to dinner and the opera. We no longer do that.

Retin A

The time honored trick is to use an acne cream, gel, or lotion called Retin A. Retin A has been used for many years for treating acne. Its use for treatment of photoaging of the skin is not approved by the FDA. It's not banned by the FDA. Although rumors of this treatment first appeared in ladies' journals about 1985, no formal articles were published in the medical literature for a while. The first report was by Dr. Albert Kligman, a brilliant dermatology professor at the University of Pennsylvania in Philadelphia. The reference is Kligman, A.M., G.L. Grove, R. Hirose, & J.J. Leyden, Topical tretinoin for photoaged skin, JAAD 15(4,2): 836-859, October 1986.

Dr. Kligman's study claims to show that using Retin A Cream daily for about 10 months caused thin skin to grow thicker, scale and roughness to improve, new blood vessels to grow and restore the rosy glow of the skin, splotchy pigment to become evened out, and many wrinkles to disappear. Does it really work? My experience since 1982 is that it does help.

In addition, Dr. Kligman is claiming that the deep damage to the collagen and elastic fibers is repaired. And, he claims that the precancerous lesions are improved.

Too good to be true? Well, maybe. Here's what I think. I looked at his biopsy pictures of the precancerous cells before and after Retin A treatment. The bad cells are still there but not as many. The difference is that the blotchy color and scale are gone. So it makes the skin look as though the actinic keratoses are gone, but I think some of them are just hidden. The main dangers of using Retin A are: 1. Risk of sunburn. 2. Skin irritation. 3. Risk of masking precancerous skin lesions leading to a delay in their early treatment. However, this seems not to have been a problem in my experience.

I think it is imperative that everyone using topical Retin A cream for treatment of UV-light-induced skin aging be aware of this third risk and make regular visits to a dermatologist to be checked for skin cancer at least once a year. Having said that, I have been generally pleased with Retin A especially since they came out with Retin A Micro.

What won't Retin A do? It won't cure skin cancer. It won't remove the deep wrinkles, furrows, that occur from lines of muscle contraction such as between the eyes or bags and circles under the eyes. You need to see a plastic surgeon or cosmetic dermatologist for that.

My experience with Retin A is that after two to four months, Retin A unmasks actinic keratoses. When these start to show up, I suggest coming in to see me for liquid nitrogen treatment.

Retin A seems to accomplish improvements in small wrinkles in one year that would take sunscreens seven years. In my experience, even deep wrinkles that one would not expect to improve become shallower with Retin A treatment. Retin A appears to repair the sun damage that causes Bateman's purpura (easily bruised skin on the arms in elderly people). This is impressive. It is a real change not a subjective misinterpretation.

Instructions for using Retin A

Apply the Retin A at bedtime. Rub in a thin layer all over the areas of sun damage and wrinkles until the cream disappears into the skin. It is not necessary to use too much. If you are putting on more than you can rub in and make disappear, you are using too much. Apply with the skin dry not wet. If you like to wash your face at bedtime, wait 30 minutes after washing before applying Retin A. Build up slowly. Avoid irritation. The first week, use it every third night.

After the first week, if this is not too irritating, apply it every other night. After the second week, try it every day. If your skin gets irritated, stop using it for a few days. Let the irritation subside, and then use it less often. Use a sunscreen such as Neutrogena Ultra-Sheer Dry Touch SPF 100

WEEK 1 EVERY 3RD NIGHT
WEEK 2 EVERY OTHER NIGHT
WEEK 3 EVERY NIGHT

When can you stop using Retin A? We don't know yet. It may be beneficial to use it permanently. But, I suggest using 10 to 12 months and then stopping and seeing what happens. One lady had no improvement after 1 year. I suggested she stop. She wanted to keep going. At two years, there was no improvement. She kept using it. At three years, her wrinkles got much better.

How to Get Started

If you want to try the Retin A treatment for photoaging of the skin, you need to make an appointment. If you have already had a workup for actinic keratoses by Dr. Tkach, you just need a brief return visit. If you have not already had an actinic keratoses workup, you will need a 15-30 minute initial visit. Ideally, we should plan on a return 15-minute visit in two months to four months to adjust the dose if necessary, and another at one year.

Informed Consent

I have read and understand the above material and the risks of using Retin A for photoaging of the skin, especially the risk of delaying treatment of precancerous lesions. I understand that the FDA has not approved Retin A for this use. In spite of these considerations, I want to use this treatment and thus hereby release Dr. Tkach from responsibility for complications and side effects of this treatment especially skin cancer. I understand that this treatment may not work.

There will be paperwork for you to complete when you arrive at my office for this treatment.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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