If reality were like fiction, many people would choose to let their portraits grow old, a la Oscar Wilde’s “The Picture of Dorian Gray,” while their own faces retained the radiance of youth.
The face, after all, is a billboard advertising a person’s age.
“Skin aging is best thought of as two separate processes,” said Dr. Barbara Gilchrest, chairwoman of dermatology at the Boston University School of Medicine.
“One is the intrinsic aging process, which occurs in the skin as in all other organs in the body and has relatively minor impact on the appearance of the skin, but it is associated with progressive loss of maximum functional capacity throughout life.
“And the second is what is now called photo aging, the superimposition of environmental damage on the intrinsic aging process, and most of the damage is related to sun exposure.”
Areas of the skin subject to chronic sun exposure result in wrinkling, irregular pigmentation, rough texture and various kinds of growths.
“The severity of the changes is a function of how vulnerable the skin is, how fair-skinned one is and how much sun you’ve had over your lifetime,” Gilchrest said. “And skin cancer is almost exclusively seen in sun-damaged skin.”
Sun worshipers who also smoke face a double whammy, Gilchrest said.
“There are several nicely controlled studies that show groups of people who are matched for age and complexion and in general how much sun they’ve had over their lifetimes; those who smoke have much more prominent wrinkling. The more you smoke, the worse your skin looks.”
Fine lines and wrinkles develop with the weakening of the collagen and elastin, connective tissues that keep the skin firm.
“Under the microscope, in the skin of someone who is 50, the collagen looks disorganized, and the elastin looks unraveled,” said Dr. Jerome M. Garden, associate professor of clinical dermatology at the Northwestern University Medical School.
“Most of these changes, I believe, are due to chronic exposure to the sun.”
Dr. Mary Massa, director of the cosmetic dermatology program at Rush-Presbyterian-St. Luke’s Medical Center, said the process of sun damage begins in early childhood.
And worse than the “visible signs of aging,” as cosmetic ads are wont to say, is the specter of cancer.
“Some studies would indicate that sun exposure, particularly sunburns before the age of 18, set the stage for the development of skin cancer later in life,” Massa said.
The usual advice that limiting sun exposure is the best protection against wrinkles and other signs of aging holds true. But in the view of Dr. Nicholas Perricone, an assistant clinical professor of dermatology at the Yale University School of Medicine, wrinkled, sagging skin can be rejuvenated through nutrition and “cosmeceuticals.”
“It’s a disease and you can fight it,” he said.
Perricone’s belief is that inflammation causes aging. As a medical student, he noticed that whenever he examined diseased tissue under a microscope, inflammation was present. The same held true for aging skin.
“There wasn’t aging without inflammation,” he said. Through the years he developed an inflammation-disease aging theory and “more or less” followed it in his dermatology practice.
“When I started putting various forms of antioxidants, like a special form of vitamin C, vitamin C ester and alpha lipoic acid on the skin, sure enough it resolved inflammation, and I was seeing changes that made the skin look more youthful.”
Perricone has outlined his three-tiered program in “The Wrinkle Cure” (Warner Books, $13.95).
The first tier involves an anti-inflammatory diet. That means forgoing red meat, drinking plenty of mineral or spring water and consuming the freshest possible fruits and vegetables combined with low-fat sources of protein and complex carbohydrates.
Not so sweet
Sugar and starchy foods such as bread, rice and potatoes that are converted to sugar are the worst foods to consume, according to Perricone.
“Sugar is pro-inflammatory,” he said.
“When you have high levels of sugar in your body, sugar attaches to collagen, causing cross-linking of collagen and makes the collagen stiff and inflexible, which means wrinkles and sagging.”
As a scientist, Perricone believes that 50 percent of skin aging is from this sugar-protein connection, a process called glycation.
“Now if that goes on in your arteries or your brain, you’re in trouble because in those vital organs it means you die. When it goes on in your skin, it just means you look ugly.”
Inadequate consumption of protein, he believes, is another problem. “It means that cells are deprived of the amino acids they need for repair. Cells break down,” Perricone said, “and you get diseases.”
He noted that omega 3 fatty acids, found in cold-water fish, and other essential fatty acids are anti-inflammatory foods.
“A piece of salmon is a powerhouse of therapy,” he said. “It has omega 3, protein and DMAE [dimethylaminoethanol], a nutrient that stabilizes the cell membrane and is very resistant to creating pro-inflammatory chemicals.”
The treatment
For his patients, Perricone also prescribes a plethora of supplements that, depending on the individual, may include alpha lipoic acid (touted as a super-antioxidant and anti-inflammatory), vitamin C, coenzyme Q10 and vitamin E, among others.
Perricone, who holds 12 U.S. patents and many foreign patents based on his research in topical antioxidants, also sells a line of pricey skin-care products that he developed. They’re available online (www.nvperricone.com), in some physician’s offices and in a few high-end retail stores.
The active ingredients are vitamin C ester, alpha lipoic acid and the aforementioned DMAE.
Perricone is not exactly on the fringe, but are his ideas accepted in the mainstream?
“He may be 100 percent right about carbohydrates,” said Northwestern’s Garden. “It’s hard to know without a multi-center study with biopsies and unbiased investigators.”
Boston University’s Gilchrest said that it’s “certainly true that altered proteins are more prevalent in older people and older tissue.”
As for inflammation, she said: “It has been observed by many people that chronically sun-exposed skin is also frequently chronically inflamed. To my knowledge that’s not true in skin that’s not sun-exposed. I would guess that inflammation contributes [to skin aging].”
Dozens of anti-aging skin-care products flood the market each year, promising the benefits of topical vitamin C, vitamin A, copper, plant antioxidants, lipids and coenzyme Q10 and more.
They’re neither reviewed nor approved by the Food and Drug Administration before they are offered to the public, and their advertising claims usually are carefully worded.
Give products a try
“[It disturbs me that] our regulatory system won’t allow companies to admit if they have any evidence that these things work,” Gilchrest said. “Because as soon as you show something has an effect on the function or structure of the skin, then it’s a drug, not a cosmetic and they can’t sell it anymore.”
Garden said he always tells patients to go ahead and try cosmetic products and let him know if they find them helpful.
“The only product out there today that has been tested scientifically over and over again is tretinoin [a vitamin A derivative available only by prescription],” Garden said. “A whole slew of scientific studies corroborated what was seen with the naked eye. Not only did the skin look better, but underneath the microscope it actually assumed a more youthful type of appearance.”
Dermatologists’ main concern is maintaining healthy skin. But Rush’s Massa noted that many office treatments are available to improve the look of aging skin. “They are topical treatments, generally falling into the category of glycolic acid products, vitamin A derivatives and vitamin C derivatives,” she said. “Some are prescriptions; some are physician’s strength, meaning higher percentages of tretinoin.”
There also are more aggressive measures: chemical peels, micro dermabrasion, laser treatments and botox and collagen injections, she said.
As a part of a multi-center clinical trial, Garden is beginning a study of a topical cream containing growth factors, chemicals released by cells that play a role in the repair process of the skin.
“The hope is that when we apply these factors that we know have been helpful for just healing wounds after trauma or surgery,” Garden said, “it’s going to help the skin also become more pliant, changes associated with youthful skin.”
Uncertain benefits
Garden said that to his knowledge, growth factors are not related to human growth hormone, a controversial treatment that some anti-aging doctors promote to slow or reverse the aging process. Clinical trials of growth hormone have showed that subjects’ skin thickened and became tauter.
More youthful-looking skin is perceived by some women as a benefit of estrogen-replacement therapy after menopause, though there is no research on that specifically. Even the brochure for patients provided by the most widely prescribed brand of estrogen warns that there is no evidence for benefit to the skin and that long-term use may carry risks.
Nevertheless, Gilchrest said, “I would guess that for most people estrogen would have a positive effect, but it’s just a guess. I hope the manufacturers will try to document its effect on the skin.”
You might as well stock up on sunscreen by the gallon
When it comes to aging skin, prevention should be the first line of defense.
Investment in a broad-spectrum sunscreen (one that protects the skin from both the deep-penetrating UVA and the surface-damaging UVB rays) with an SPF of 15 or higher and regular year-round use can pay dividends in preventing wrinkles, brown spots and skin cancer.
The American Academy of Dermatology further recommends wearing wide-brimmed hats, sunglasses that block UVA and UVB rays and tightly woven clothing. Another tip is to avoid the sun between 10 a.m. and 4 p.m. when rays are the strongest, and be especially careful near reflective surfaces such as sand, concrete, water and snow.
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