Photodamage is exposure of the skin to ultraviolet (UV) radiation, which causes cumulative damage to all skin types starting in childhood through adult years. Variations in susceptibility, damage classification, presentation, and pathologies can be traced to climate conditions, genetic inheritance, and personal behavior patterns. Systematic treatment options include surgery, a wide variety of chemical applications and injections, cosmetic and laser therapies, and patient education to change the choices that induce preventable damage (Figure 15-1
A. Definition: a term describing the skin of individuals who have been chronically exposed to UV radiation. The condition is identified by clinical and histologic findings.
1. Damage caused by UV exposure starts in early childhood.
2. The promotion of sun protection is a relatively recent campaign. Many older individuals were unprotected and vulnerable to sunburn in the past.
3. Both ultraviolet A (UVA) and ultraviolet B (UVB) rays play a significant role in damaging the skin.
4. Other influences on photodamage include: wind, chemical exposure, and the mechanics of smoking and tobacco smoke.
Melanin is the basic physiologic sunscreen in humans. Individuals with less melanin, people with types I, II, and III skin, are more susceptible to burns and damage from the UV radiation. Individuals with more melanin, types IV, V, and VI skin, can also be damaged by UV rays (Table 15-1
2. Changes that occur because of sunburn and tanning include:
a. Impaired immune response secondary to epidermal cell necrosis
b. Skin pigment darkening; quickly with UVB rays, delayed with UVA rays
FIGURE 15-1. Solar radiation spectrum. (Copyright 2015 by the American Academy of Dermatology. All rights reserved.)
c. Erythema caused by release of inflammatory mediators, such as cytokines and prostaglandins
d. Genetic changes in the cellular makeup due to UV radiation, increasing the risk of skin cancer
3. Between the ages of 0 and 28 years, the skin absorbs UV radiation while individuals participate in outdoor activities, tan on the beach, or are otherwise exposed. The sunburns and tans are only temporary, but the damage remains.
FIGURE 15-2. Induction of a biologic response to solar radiation. (Copyright 2015 by the American Academy of Dermatology. All rights reserved.)
TABLE 15-1 Fitzpatrick Sun-Reactive Skin Types
Always burn, never tan
Usually burn, tan with difficulty
Sometimes mild burn, tan average
Burns minimally, tan with ease
Very rarely burn, tans deeply
Almost never burns, deeply pigmented
4. As we approach the late 40s to early 50s, unprotected skin becomes leathery, dry, and nodular. Genetic changes caused by the UV radiation exposure begin to evolve.
5. Histologically, the UV-damaged epidermis is generally thicker than unexposed skin and shows some cellular atypia and damage.
6. There is a marked elastosis with a decrease in collagen fibers and bundles in the dermis causing thinned and increasing fragile skin.
7. Telangiectasia and solar lentigines develop with prolonged exposure in sun-damaged skin.
D. Treatment modalities.
1. Surgical treatment.
a. Dermabrasion is a standard method that has been successfully used for many years.
(1) It can be used for the total face or smaller local areas where other methods have not been effective.
(2) Some practitioner believe that elderly skin tends not to heal as well, causing greater incidence of hypertrophic scarring when dermabrasion is utilized.
(3) The older person tends to heal more slowly, leaving the skin open to a greater chance of infection.
b. Aluminum oxide crystal microdermabrasion is a relatively new and popular treatment for facial rejuvenation for damage caused by UV light.
(1) It is a simple, noninvasive procedure that can be repeated as often as every week for 4 to 12 weeks.
(2) The aluminum oxide crystals are used to abrade the skin.
(3) Following the procedure, a mild, transient erythema may occur.
c. Chemical peels.
(1) Phenol or various formulations containing phenol is a method of deeper peel for photodamaged skin.
(a) Side effects: there is a risk of renal toxicity and cardiac arrhythmias from phenol.
(b) Good results have been obtained from monitored use by well-trained practitioner.
(2) TCA is a medium-depth peel. TCA is used in various concentrations, 20% to 50%, to obtain good results in photodamaged skin.
(a) It is sometimes used with other agents such as Jessner solution.
(b) Side effects: hypo- or hyperpigmentation, scarring, and infection. Erythema may be persistent.
(c) Because of potential side effects, physicians may use a decreased concentration or a series of peels.
(3) Alpha hydroxy acids (the most common being glycolic acid) are found in natural sources.
(a) Lactic acid is found in sour milk, tartaric acid in grapes, and glycolic acid in sugar cane. Cosmetic manufacturers primarily use a synthetic glycolic acid.
(b) The smaller the molecular structure of the acid, the more it can penetrate the skin. With its two-carbon structure, glycolic acid is the smallest, followed by lactic acid and tartaric acid with three and four carbon atoms, respectively.
(c) Glycolic acid comes in concentrations of 5% to 99%; 50% to 70% solutions are most commonly used in the physician’s office, and 10% to 20% solutions can be found in over-the-counter applications.
(d) Best results of glycolic peels are seen months after a higher concentration peel.
(e) Glycolic acid is less sun sensitizing, but a patient should use a good sunscreen when receiving these peels.
Collagen injections may be used on the expressive lines and fine-line wrinkles caused by photoaging (Table 15-2
TABLE 15-2 Glogau Photoaging Classification
Type I: No Wrinkles
Type II: Wrinkles in Motion
Type III: Wrinkles at Rest
Type IV: Only Wrinkles
Early to moderate photoaging
Mild pigmentary changes
Early senile lentigines
visible Obvious dyschromia and telangiectasia
Yellow-gray color of skin
Keratoses palpable but not visible
Prior skin malignancies
Parallel smile lines beginning to appear
Wrinkles even when not moving
Wrinkled throughout, no normal skin
Patient age, 20s or 30s
Patient age, late 30s or 40s
Patient age, 50s or older
Patient age, 6th or 7th
Minimal or no makeup
Usually wears some foundation
Always wears heavy foundation
Cannot wear makeup—“cakes and cracks”
(1) The patient must have a skin test prior to starting the injections to check for any allergic reactions.
(2) The effects of the collagen injections are not permanent and must be repeated every 6 to 18 months for sustained results.
e. Lipotransfer is the transfer of the patient’s own fat from the buttocks or abdomen and injection into the facial expression lines.
(1) It is a relatively simple procedure done under local anesthesia.
(2) No skin tests are needed.
(3) The most commonly injected area is the nasolabial fold.
(4) Like collagen, it lasts only 6 to 18 months.
(5) An advantage is that extra fat may be withdrawn and frozen for injection several months later.
2. Topical treatment (retinoids).
a. Tretinoin, a retinoid, applied topically helps to even skin coloring, soften fine wrinkle lines, and increase the formation of blood vessels.
(1) Tretinoin acts by gently peeling the skin and also by normalizing the epidermal turnover.
(2) The patient may experience some skin irritation or dryness at first, but this usually subsides.
(3) When a patient is using a tretinoin, a sunscreen with SPF of 30 or more must be used, as this medication makes the skin very sun sensitive. A cream or lotion is preferred, since gels contain alcohol.
(4) Before applying tretinoin, the skin should be gently cleansed with warm water and patted dry. Wait 20 to 30 minutes before applying a thin layer to the skin, as skin irritation can occur when applied to damp skin.
(5) Because of increased sun sensitivity, tretinoin should be applied at night, and a 30 SPF broadspectrum sunscreen should be applied in the morning.
(6) Women who are pregnant, or may be pregnant, should not use tretinoin.
3. Cosmetic treatment.
a. Hylan B gels are derived from hyaluronan, a component of all connective tissues.
(1) Because they are biocompatible, there is no need for skin tests.
(2) Hylan B gels are water insoluble, they resist degradation, and they are unlikely to migrate.
(3) There are three hylan B gels with increasingly greater viscosities, so that each is suitable for a different contour, from fine wrinkles to common wrinkles to deep folds.
b. Many over-the-counter products exist that contain alpha hydroxy acids, vitamin C, and niacinamide; however, the skin is unable to absorb these molecules into the collagen layer.
FIGURE 15-3. Solar lentigo. (From Goodheart, H. P. (2010). Goodheart’s same-site differential diagnosis: A rapid method of diagnosing and treating common skin disorders. Philadelphia, PA: Wolters Kluwer.)
Laser therapy can be utilized for a variety of skinrelated complications (refer to Chapter 3
for further inquiry).
a. Telangiectasias on the face, a result of photodamaged skin, may be treated with vascular lesion lasers, such as the pulsed dye, copper bromide, and krypton laser.
Brown macular lesions (solar lentigines; Figure 15-3
) may be treated with excellent results with several lasers, one of which is the Q-switched ruby laser.
c. Rhytides, fine lines around the eyes or upper lip, and scarring may be treated with BBL.