Ebook Color atlas of cosmetic dermatology (2/E): Part 1

Color Atlas of
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ZEINA TANNOUS
SANDY TSAO

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MATHEW M. AVRAM

MARC R. AVRAM

___


Color Atlas of

Cosmetic
Dermatology


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Color Atlas of

Cosmetic
Dermatology
Second Edition

Ze ina Tannous, M D
Chief, Mohs/Dermatologi c Surgery, Boston VA Medical Center
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Affiliate Faculty, Wellman Center for Photomedicine
Faculty Director for Dermatopathology, Department of Dermatology, Harvard Medical School
Assistant Professor in Dermatology, Harvard Medical School
Boston, Massachusetts

Mathew M . Avram, M D, JD
Director
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Faculty Director for Procedural Dermatology Training, Department of Dermatology, Harvard Medical School
Affiliate Faculty, Wellman Center for Photomedicine
Boston, Massachusetts

Sandy Tsao, M D
Director of Procedural Dermatology
Harvard Medical School
Massachusetts General Hospital, Dermatology Laser & Cosmetic Center
Boston, Massachusetts

Marc R . Avram, M D
Clinical Professor of Dermatology

Weill Cornell Medical School
Private Practice-905 Fifth Avenue
New York, New York

B Medical
New York
Mexico City

Milan

Chicago

San Francisco

New Delhi

San J uan

Lisbon
Seoul

London

Madrid

Singapore

Sydney

Toronto

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Copyright©

2011

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1976,

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D E D I CATI O N

I wou ld l i ke t o ded icate this book t o the memory of m y beloved father,
who a l ways gave me h is u lti mate love a n d s u p port.

Zeina Tannous, MD

I wou ld l i ke to ded icate this book to my wonderfu l pa rents, Morre l l a n d
M a ria Avra m . You have provided me u ncond itional love a n d end less
s u p po rt s i n ce the day I was born . I love yo u .

Mathew M. Avram, MD, JD

To my h us ba n d , Hensi n . You a re my stre ngth a n d i n s p i ration. You r l ove, wisd o m a n d
encou ragement h e l p m e rea l ize a nyth i n g is poss i b l e . You a re a wo n d e rfu l h us ba n d ,
father a n d best fri e n d . I wi l l love y o u a lways . To my sons, Se basti a n a n d H u nter. You r
u nconditional love, enthusiasm a n d sense o f adventure h e l p me remem ber what is truly
i m porta nt. Yo u brighten my days a n d fi l l my l ife with h a p p i n ess and love .

Sandy Tsao, MD

T h i s book is ded icated to my wife R o b i n a n d my two sons Robert a n d J a c o b .
I tha n k t h e m f o r the love a n d s u p port t h a t they give me every day.

Marc R. Avram, MD


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CONTENTS
ix

Preface

SECTION THREE: DISORDERS OF ECCRINE GLANDS

Chapter 16: Hyperhidrosis.... .... ... .. 86
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SECTION ONE: PHO TOAGING

Chapter 1: Analysis of the Aging Face and
Non-Facial Regions
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SECTION FOUR: DISORDERS OF HAIR FOLLICLES

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Chapter 17: Hirsutism
Chapter 2: Topical Treatment Options.

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Chapter 18: Pseudofolliculitis ....

Chapter 3: Soft Tissue Augmentation

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Chapter 19: Male Pattern Hair Loss .... .... 103
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Chapter 4: Botulinum Toxin

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Chapter 20: Female Pattern Hair Loss

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Chapter 5: Chemical Peels .. ...... .. ... 29
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Chapter 6: Nonablative Laser Resurfacing

Chapter 7: Ablative Laser Resurfacing

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Chapter 21: Low Level Light Therapy (LLLT)
and Hair Loss. .
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SECTION FIVE: DISORDERS OF PIGMENTATION

Chapter 22: Cafe Au Lait Macule ... ...... 136
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Chapter 8: Nonablative Fractional Laser
Resurfacing .............. .... 52

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Chapter 23: Ephelides
Chapter 9: Ablative Fractional Laser

Resurfacing
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Chapter 10: Tissue Tightening

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Chapter 24: Lentigines

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Chapter 25: Melasma . .. ...

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Chapter 11: Dermatochalasis........

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Chapter 26: Nevus of Ota

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Chapter 12: Poikiloderma of Civatte

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Chapter 27: Postinflammatory
hyperpigmentation ............ 158

Chapter 28: Vitiligo.... ....

SECTION TWO: DISORDERS OF SEBACEOUS

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GLANDS

Chapter 13: Acne Vulgaris ...... .. ... .. 72
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SECTION SIX: VASCULAR ALTERATIONS

Chapter 14: Rosacea

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Chapter 29: Angiokeratoma

Chapter 15: Sebaceous Hyperplasia ......... 81

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Chapter 30: Cherry and Spider Angiomas ....

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Chapter 31: Granuloma Faciale

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Chapter 32: Infantile Hemangioma

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Chapter 33: Keratosis Pilaris Atrophicans

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Chapter 34: Port-wine Stains

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Chapter 35: Pyogenic Granuloma

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Chapter 39: Warts

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Chapter 41: Becker's Nevus

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Chapter 42: Epidermal Inclusion Cyst

Chapter 43: Epidermal Nevus

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Chapter 54: Lichen Planus

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Chapter 55: Morphea

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Chapter 56: Psoriasis

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Chapter 59: HIV Lipodystrophy/Facial
Lipoatrophy

Chapter 60: Striae Distensae

SECTION TEN: ADIPOSE TISSUE ALTERATIONS

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SECTION NINE: INFLAMMATORY DISORDERS

Chapter 58: Cellulite

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Chapter 53: Squamous Cell Carcinoma

SECTION SEVEN: BENIGN GROWTHS
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Chapter 52: Basal Cell Carcinoma

Chapter 57: Gynecomastia

Chapter 40: Angiofibroma

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Chapter 38: Venous Lakes

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Chapter 51: Actinic Keratosis

. .181

Chapter 37: Lower Extremity Telangiectasias,
Reticular and Varicose Veins

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SECTION EIGHT: CUTANEOUS CARCINOMAS

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Chapter 36: Facial Telangiectasias

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SECTION ELEVEN: WOUND HEALING ALTERATIONS

Chapter 44: Lipoma

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Chapter 61: Hypertrophic Scars, Keloids,
and Acne Scars

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Chapter 63: Tattoo Removal.

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Chapter 64: Torn Earlobe

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Index

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Chapter 45: Milium

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Chapter 47: Seborrheic Keratosis

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Chapter 48: Syringoma

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Chapter 49: Dermatosis Papulosa Nigra

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Chapter 50: Xanthelasma

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Chapter 46: Neurofibroma

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SECTION TWELVE EXOGENOUS
CUTANEOUS ALTERATIONS

Chapter 62: Ear Piercing

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PREFACE
There has been a revol ution in the treatment of med ical a n d cos­

go these proced u res. The decision as to when not to treat a patient

m etic d isord ers of the s ki n . I n la rge part, this is d u e to the ava i l ­

is perha ps the m ost i m porta nt i n this fie l d .

a b i l ity o f procedu res a n d tec h nologies t h a t prod uce clear, cosmet­

With t h i s i n m i n d , Color Atlas o f Cosmetic Dermatology, Second

ic benefit with few side effects a n d l ittle downti m e . With the advent

Edition seeks to provide a succ i n ct yet broad overview of cosmetic

of lasers and l ight sou rces over the past 20 yea rs, cosmetic

thera py. There a re a plethora i l l ustrations and gra phs to e l u c i date

i m prove ment is a m atter of q u ic k , relatively pa i n less proced u res.

consu ltati o n , management, treatment and side effects of n u m e r­

N on-laser treatments such as soft tissue fi l l ers, botu l i n u m tox i n

ous cos metic proced u res. Its pra ctica l format is gea red to the busy

i njections, sclerothera py, h a i r tra ns p l a n tation a n d others have a lso

practitioner or tra i nee who seeks a q u ic k , comprehensive refer­

d ra matica l ly expa nded the scope of this field . These procedu res

ence fo r a pproa c h i n g the cosmetic patient. It a lso e m p h asizes

coincide with the busy l ifestyle of many patients who seek a n

pitfa l l s of treatment in ord e r to ed ucate the reader as to potenti a l

i m prove ment i n a p pea ra nce that does n ot interfere with t h e i r pro­

p r o b l e m s w i t h certa i n treatments. It serves as a n i nva l ua ble

fessiona l , soc i a l or perso n a l obl igati o n s .

resource to both the experienced a n d novice.

These proced u res, however, a re n ot without potentia l side
effects o r co m p l icati o n s . Physicians who perform these treatments

Zeina Ta n nous, M D

in the a bsence of tra i n i ng or ed u cation a re certa i n to encou nter

M athew M . Avra m , M D , J D

poor resu lts , c o m p l ications and i rate patie nts . Beca use patients

Sandy Tsao, M D

a re p u rs u i ng el ective treatments fo r cosmetic benefit, a ny worsen ­

M a rc R . Avra m , M D

i ng o f a p pea ra n c e wi l l u n d e rsta n d a bly a nger patients who u n d e r-

ix


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ACKNOWLEDG M E NTS

We wou l d l i ke to tha n k two people who provided sign ificant h e l p i n the
prod uction of this textbook, D r. R ox Anderson a n d Dr. G a ry Lask. In add iti o n , we wo u l d
l i ke t o tha n k t h e office staff at the M assa c h u setts Genera l H os pita l Dermato l ogy
Laser & Cosmetic Center a n d the office staff of Dr. M a rc Avra m for their h a rd work a n d
d ed ication i n o bta i n i ng high-q u a l ity photogra ph s .

F i n a l ly, w e wou l d l i ke t o tha n k the professiona l staff at M c G raw- H i l l for
t h e i r great h e l p and d evotion in p rod u c i n g this book. Tha n k you for push i n g us to
strive for the best possi ble Atlas.


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ONE
Photoaging


2

I

Color Atlas of Cosmeti c Dermatology

CHAPT E R 1

A n a lysis of the Agi ng Face a nd No n-Facial R eg i o ns

The face is the foc a l point of h u m a n bea uty. Although
va rious factors i nfluence fac i a l bea uty, the aging process
is the m ost common as pect prom pt i n g non-s u rgica l
a n d/or s u rgica l i n tervention. Agi ng is a dyna m i c a n d con­
tinual process . D iffe rent c u lt u ra l , eth n i c , a n d ge nder
norms (Ta ble 1 . 1 ) of bea uty exist; however, there a re cer­
ta i n featu res w h i c h globa l ly tra nscend these d ifferences
to d ete r m i n e what is perceptua l l y pleas i n g . H ered ity a n d
environ mental fa ctors ( e g , s u n expos u re , w i n d , tra u ma )
a re t h e m a i n determ i n a nts o f aging. I n a d d ition , ciga rette
smoking a n d estrogen loss ca n accelerate the aging
process. As one ages, c h a nges c a n be o bse rved i n a l l
fac i a l a n d non-fa c i a l a nato m i c a l com pa rtments, i n c l u d ­
i n g t h e ski n , s u bcuta neous fat, m uscle, a n d b o n y struc­
tu re . Use of a systematic a p proach i n the a n a lysis of
fac i a l a n d n o n -fac i a l aging wi l l a l low for the selection of

a p propriate, safe, a n d effective thera p ies.

TAB L E 1 . 1

Fac ial Age-Related Contour Cha nges

•

M a l a r c rescent
Cheek d e p ression
Nasola b i a l fold formation
P rej owl s u l c u s
P latys m a ! ba nds

A

J owl formation

ANATO M I C CO N S I D ERAT I O N S
S uccessfu l

rej uve nation o f the face a nd

non-fa c i a l

regio n s req u i res a thorough u n d e rsta n d i n g o f age-related
conto u r cha nges ( u nderlying soft tissue aging) a n d tex­
tu ra l cha nges (skin aging) (Ta bles 1 . 1 a n d 1 . 2 ) .

TAB L E 1 . 2

•

Age-Re lated Textura l Changes

S u perficia l a n d deep rhytides
Pigmenta ry d istu r b a n ces
Te la ngiectasia fo rmatio n
Loss o f s k i n elastic ity
Acti n ic ke ratoses

A youthfu l face can be d ivided i nto th ree facial zones:
u p per, m id d le, and lower zones, as wel l as the u pper neck.
The u p per face incl udes the forehead , tem ple, a n d peri­
orbita l region . Agi ng resu lts i n flatte n i ng of the brow a rc h ,
eyelid s k i n red u nda ncy, pseudo fat hern iation , a n d forma­
tion of dyna m i c rhytid es at the latera l canthus. Horizonta l
forehead s k i n creases develop secondary t o sustai ned con­
traction of the fronta l is m uscle i n a su bconsc ious atte m pt to
elevate the sagging brows. A ri m sulcus d eformity d evelops
between the cheek and the eyelid with u p per cheek

B

Figure 1.1 A&B G/ogau type 1 photoaging. Minimal signs of aging present


Secti o n 1: Ph otoa g i n g

th i n n i ng. This sulcus is exacerbated by a preexisti ng tea r

trough deform ity. Orbicula ris oc u l i m uscle ptosis can create
a malar fu l l ness, referred to as a malar crescent.
The m i d face i n c l u d es the cheekbones that form a
s mooth conti nuous convexity fro m the eyeli d to the l i p .
T h e m e l o l a b i a l fol d re prese nts a flat, smooth j u n ction
between the lowe r cheek a n d the u p per lip. The aging
face res u lts i n a downward m igration of the malar soft tis­
sue, accentuati ng skeleto n i zation of the orbital

ri m .

Centra l cheek fat ptos is c reates a fu l l n ess latera l to the
melola b i a l fol d , refe rred to as nasola b i a l fo lds.
The lower face possesses a wel l-defi ned mand i b u l a r bor­
der and a well-defi ned cervicomental a ngle. With aging,
platysma! m uscle ptosis a nd cheek fat ptosis a long the
mandi ble prod uce "jowls" overlyi ng the jawl ine. Soft tissue
atrophy a nterior to the jowls creates a " prejowl sulcus"
which accentuates the skeleton ized a ppea ra nce. P latysma!
ptosis of the u pper neck blu nts the cervico-mental a ngle,
creati ng platysma! ba nds or a "turkey neck" d eformity.
Facial textu ra l cha nges i n c l u d e su perfi c i a l a nd deep
rhytides, pigme nta ry d istu rba nces, telangiectasia forma­
tion, loss of s k i n elasticity, a n d acti n i c keratoses .

P R EOPERAT IVE EVALUAT I O N
A n individual ized treatment plan designed to m i n i m ize sur­
gica l risk is essenti al . The goa l is a youthfu l and natura l post­
operative result. A strategy should be formu lated for eac h of
the three facial zones as well as each ind ividual non-facial

regio n , as each a natomic region req ui res a specific man­
agement which influences the rema i n i ng a natomic regions.
A systematic eva l uation s h o u l d i n c l u d e the d egree of
textura l c h a n ges, rhyti d format i o n , pigmenta ry c h a nges,
loss of su bcuta neous fat, cha nges in fac ia l m usculature,
c a rti lagi n o u s a n d bony structu res, a nd elastic ity l oss.

• G l oga u P h otoag i n g C l ass i f i c at i o n­

Wri n k l e Sca l e
The G loga u P h otoagi ng Classification has been d evised
w h i c h b road ly d efi nes the cha nges that may be seen at
d ifferent ages with c u m u lative sun exposure.

Type 1 -"no wri nkl es" (Fig. 1 . 1 )
•

Ea rly photoaging
- M i ld pigme nta ry cha nge
- N o ke ratoses
- M i n i m a l wri n kles

•

Patient age : twenties o r t h i rties

•

M i n i ma l or n o m a keu p use

Type 2-"wrinkles i n motion" (Fig. 1 .2)
•

B

Ea rly to moderate photoaging

Figure 1.2 A&B Glogau type 2 photoaging. Fine lines barely visible.

- Ea rly se n i l e lentigines visi ble

Minimal pigmentary changes noted

I

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Color Atlas of Cosmeti c Dermatology

- Keratoses pa l pa ble but not visi b l e
- Para l lel s m i l e l i nes begi n n i ng t o a ppea r
•

Patient age : late t h i rties or forties

•

U s u a l l y wea rs some fou n dation

Type 3-"wrinkles at rest" (Fig. 1 .3)
•

Adva nced photoaging
- O bvious dysc h ro m i a , tela ngiectasia
- Visi ble keratoses
- Wrin kles eve n when n ot movi ng

•

Patient age: fifties o r older

•

Always wea rs heavy fo u ndation

Type 4-"on l y wrinkles" (Fig. 1 .4)
•

Severe photoaging
- Yel l ow-gray [A3l color of skin
- Prior s k i n m a l igna nc ies
- Wrin kled throughout, n o normal s k i n

•

Patient age : sixties or seventies

•

Ca n n ot wea r m a k e u p-" ca kes and cracks"

• P i g m e nta ry C h a n ges
A vita l as pect of the patient eva l uation is the dete r m i n a ­

A

tion o f the patie nt's s k i n res ponse t o eryth ema-prod ucing
d oses of u ltraviolet l ight. Fitz patrick's classifi cation of
skin types prov i d e s a stro ng i n d i ca t i o n of t h e pote nt i a l
f o r post- i nfla m mato ry h y p e r p i g m e n ta t i o n a n d hypopig­
m e n ta t i o n and pote n t i a l fo r d ysc h ro m i a u po n e p i d e r­
m a l a n d/or pa p i l l a ry d e r m a l i n j u ry ( Ta b l e 1 . 3 ) .

TAB LE 1 . 3
S k i n type

•

Fitzpatrick's Classification of Skin Types

Color

Reactio n to s u n
Always b u r n s

I

Very wh ite or frec kled

II

Wh ite

U s u a l ly b u rns

Ill

Wh ite to ol ive

Someti mes b u rns

IV

B rown

R a rely bu rns

v

Dark brown

Very ra rely b u rns

VI

B la c k

N ever b u rns

A patient's treatment res ponse c a n be d ete rm i n ed
by assess i ng both t h e d egree of p h otod a mage p resent
and the p i g m e nta ry skin type. A proced u ra l risk­
benefit ratio wi l l d iffer, d e pe n d i ng on the patient's i n d i ­
vid u a l fi n d i n gs ( F igs . 1 . 5 a n d 1 . 6 ) . I n ge n e ra l , patie nts
with Fitzpatrick s k i n types I -I I I can tolerate more e p i d e r­
m a l a n d d e r m a l i n j u ry with m i n i ma l risk of res i d u a l
d ysc h ro m i a . Patie nts w i t h Fitz patrick s k i n types I V-V
have a h igh risk of res i d u a l d ysc h ro m i a with i n c reased

B

s k i n i nj u ry that may p rec l u d e the use of m a n y treatm e n t

Figure 1.3 A&B G/ogau type 3 photoaging. Dyspigmentation and wrinkles

m od a l ities.

are evident


Secti o n 1 : Ph otoa g i n g

• S u b c u ta n e o u s Fat At ro p h y
Agi ng resu lts i n a sign ifica nt d egree of loss or red istri bu­
tion of su bcuta neous fat, espec i a l ly of the forehea d , tem ­

pora l fossae , periora l a rea , c h i n , a n d pre m a l a r a reas.
This leads to a skeleton ized a p pea ra nce. R estorati o n of
vol u m e loss resu lts i n the res h a p i n g of the face for a
fu l ler, ro u nder a p peara nc e .

• Fac i a l M u sc u l at u re C h a n ges
Agi ng a l so res u lts i n m uscu l a r atrophy, contri buti ng to
vol u m e loss. As wel l , dyna mic rhyti d es, which a re m uscu­
lar i n origi n , often create a n a ngry, t i re d , or aged a p pea r­
ance. Selective c h e m ical denervation provides ma rked
relaxation of these l i nes.

• C h a n ges i n Ca rt i l age , B o n y

S t r u c t u res, a n d U n d e r l y i n g
S u p po rt i ve S t r u c t u res
Agi ng resu lts i n sagging and loss of res i l iency. Red ra pi ng,
repositio n i ng, and j u d icious rem ova l of skin and soft tis­
sue assist i n the restoration of a youthfu l a p pea ra n c e .
Once a syste m i c a p p roach has b e e n fol l owed , the fou r
Rs of fac i a l rej uvenation-relax, refi l l , red ra pe, a n d res u r-

A

face-can be a ppl ied solely or in combi nation to h e l p
restore a m ore youthfu l a p pea ra nce.

B I B L I OG RAPHY
C h u ng J H , E u n H C . Angiogenesis i n s k i n a g i n g a n d pho­
toaging. J Dermatol. 2007 ;34(9) : 593-600 .

Davis R E. Facelift and a n c i l l a ry facial cosmetic surgery pro­

Techniques in
Dermatologic Surgery. Lond o n : Mosby; 2003, pp. 333-344.

ced u res. I n : Nouri K, Leai-Nouri S, eds.

Fitzpatrick T. The va l i d ity a n d practica l ity of sun-reactive
ski n types I through V I . Arch Dermatol. 1 998 ; 1 24:869-87 1 .
G l oga u R . Aesthetic a n d a nato m i c a na lys is of the aging
ski n . Semin Cutan Med Surg 1 996; 1 5( 3 ) : 1 34- 138.

Epidermal and
Dermal Histological Markers of Photodamaged Human
Facial Skin. Shelto n , CT: R i c h a rdson-Vicks; 1 988.
M ontagna W, Carlisle K, Kirchner S .

Paes EC, Teepen H J , Koop WA, et a l . Periora l wrin kles:
H i stologic d iffere nces between men and wom e n . Aesthet

Surg J. 2009 ; 29(6) :467-472.
S haw RB J r, Katzel E B , Koltz P F, et al. Agi ng of the
m a n d i ble a n d its aesthetic i m pl ications. Plast Reconst

Surg 2010; 12 5 (9 1 ) :332-342 .
B

Figure 1.4 A&B Glogau type 4 photoaging. Extensive wrinkles and
prominent dyspigmentation

I

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Color Atlas of Cosmeti c Dermatology

Figure 1.5 Female patient who avoided sun exposure throughout her life.

Her skin reflects only minimal signs of photoaging

Figure 1.6 Female patient with a history of extensive sun exposure in her
life. Her skin reflects extensive photodamage with dyspigmentation and
extensive wrinkle formation


Secti o n 1 : Ph otoa g i n g

CHAPT E R 2

I

7

Topica l Treat m e nt Optio ns

M ECHAN I S M OF ACT I O N
•

S u n sc reen
- The u ltraviolet ( U V) wave lengths of l ight associated
with c uta neous da m age a re UVB ( 290-320 n m ) a n d
UVA (320-400 n m ) l ight.
- UVB a bsorption by DNA res u l ts i n a p53 tumor s u p­
pressor ge ne m utation res u lting i n pyri m i d i ne d i mer
fo rmatio n , w h i c h is m utage n i c a n d l i n ked to cuta­
neous carc i n ogenesis.
- Acute UVB expos u re resu lts i n a s u n b u r n ( Fig. 2 . 1 ) .
- Re peat ac ute UVB exposu res over t i m e have been
assoc iated with the formation of basa l cell carc i noma
a n d melanoma .
- Chronic UVB exposure has been l i n ked to the develop­
ment of acti nic keratoses and squamous cell carcinoma.
- UVA is u naffected by wi n d ow glass, a ltitude, time of
d ay, or season and can prod uce a ta n and dyspig­
mentation without preced i n g eryt h e m a .
- UVA l ight penetrates d eeply i n to the dermis, prod uc­
i n g m a ny of the c l i n ical fi n d i ngs associated with
photo d a mage ( Fig. 2 . 2 ) .
- UVA a bsorptio n b y D N A res u lts i n fo rmation o f oxy­
gen free rad icals, thought to contr i bute to ca rc i n o­
genesis. It c auses i m m u nosu ppress ion through the

Figure 2 . 1 Patient with an acute sunburn. There is marked swelling and
redness present. The upper back scar is the site of a previous superficial
spreading melanoma (Courtesy of Richard Johnson, MD)

d e pletion of La ngerhans' cells and red uced a ntigen
prese nti ng cell activity.
- UVA expos u re has been l i n ked to the d eve l o pment of
melanoma in a n i ma l models.
Chem ica l s u n sc reen (Ta ble 2 . 1 )-a bsorbs l ight i n the
UV wave length of l ight ( UVB 290-320 nm) and UVA

TAB L E 2 . 1

•

Chemical Sunscreen: Active Ingred ients

Avobenzone
C i n oxate
Dioxybenzone
H omosa late
M ethyl a nt h ra n i late
M exoryl SX
M exoryl XL
Octocrylene
Octyl m ethoxyc i n n a mate
Octyl sa l i cylate
Oxybenzone
Pad i mate 0
Pa ra-a m i nobenzoic acid ( PABA)
Phenyl benzi m idazole su lfo n i c acid
S u l isobenzone
Tro la m i ne sa l i cylate

Figure 2 . 2 Patient with marked photodamage due to chronic sun exposure.

The patient was an avid golfer and reported only occasional sunscreen use


8

I

Color Atlas of Cosmeti c Dermatology

320-400 n m ) , tra n sfo r m i n g this l ight i nto h a r m less long

First Generation (Nonaromatics)

wave rad iation and re-e m itti ng as heat en ergy.
Physica l screen ( Ta b le 2 . 2 )-scatters or reflects UV
heat.

TAB L E 2 . 2

Retinol

•

Physical Su nscreen: Active I ngredients

Tita n i u m d ioxide
Zinc oxide

COOH

Tretinoin

S u n protective factor-opt i ma l ly a s u nscreen wo u l d p ro­
vide protection aga i n st the fu l l spectr u m of UV rad iation .

�
�

CH20H

rad iati o n . C a n a l so a bsorb U V l ight and release it as

Isotretinoin

�

OOH

The s u n p rotective factor ( S P F ) is the only i nternationa l ly
sta ndard ized measure of a sunsc reen's a bi l ity to filter UV

Second Generation (Mono-Aromatics)

rad iatio n . It is the ratio of the UV e nergy needed to prod uce
a m i n i ma l erythema d ose ( M ED ) on su nscreen-protected
skin to the UV energy req u i red to prod uce an M ED on
c u rrently recom mends the d a i ly use of sunscreen with

�
.l.Ql.
-

u n protected ski n . The American Academy of Dermatology
Etretinate

-

COOH

-

H3CO

-

S P F 30 o r greater.
•

Antioxida nts-theoretica l ly work to red uce a n d neutra l ­
i z e free rad icals t h a t d a mage DNA, cytoskeleta l struc­
tu res, and cel l u l a r proteins. They a lso possess a nti-i
nflammatory effects a n d m a n y play a role in pigment
red ucti o n .

Acitretin

Third Generation (Poly-Aromatics)

- I n ord e r to be b i o l ogica l ly effective, th ese prod ucts
m ust be a ble to penetrate i nto the s k i n a n d rema i n
biologica l l y active l o n g enough t o exert t h e desired
benefits . A majority of the c u rrently ava i la b l e a ntioxi­

Arotinoid

d a nt prod ucts a re very u n sta ble, with oxidation m a k­
i n g them c hem ically i n a ctive. M o l e c u l a r formation
and packagi ng a re key factors i n the sta b i l izatio n of
these prod u cts.
- Antioxida nts may work synergistica l l y to provide thei r

Adapalene

greatest benefit.

�

.£) IAlf)(
�

COOH

0

- Vita m i n C-the only a ntioxi d a nt to date to have
prove n benefit for wri nkle i m p rovement due to its
a b i l ity to i n c rease col lagen formation rather than its

a ntioxidative effects .
- Vita m i n E-d emo nstrated to i n h i b it UV-i nd uced ery­
thema a n d edema in a n i ma l s . It has h igh contact
d e rmatitis risk.

rings has made third-generation retinoids more stable for more targeted
therapy with less potential side effects. (Reproduced, with permission,
from Baumann L. Cosmetic Dermatology: Principles and Practice, 2nd ed.
New York: McGraw-Hill; 2009)

- Coenzyme Q l O-natu ra l l y occ u rring n utrient a d d ed
to m a n y over-the-cou nter prod ucts . C u rrently t h ere
a re no stud ies ava i la ble to docu m ent its long-te rm
benefits on skin aging.
- l d ebeno n e-synthetic a na l og of Coenzyme Q l O .
•

Tazarotene

Figure 2 . 3 Chemical structures of retinoic acids. The addition of aromatic

Reti noic ac i d-reti noids a re natu ra l ly occ u rr i n g d e riva­
tives of I)-ca rotene and la beled as vita m i n A and its
derivatives . I n cl uded a re reti n o l , reti n a l d ehyd e , reti nyl
este rs, and retinoic acid ( Fig. 2.3). Its benefits a re both
preve ntative a n d repa rative .


Secti o n 1 : Ph otoa g i n g

- UVB exposu re res u lts in the u p-regu lation of severa l
col lagen-degra d i ng matrix meta l l o protei nases, includ­
ing col lagenase, gelatinase, and stromelys i n , which

TAB L E 2 . 3
•

Ski n Lighte n i n g Agents

Hyd roq u i none

cause collagen degradation. Reti noids act to i n h i bit the

Aloes in

i n d uction of th ese meta l lo p rote i n ases.

Arbuti n

- UVB exposu re a lso dec reases collagen prod ucti o n .

Ascorbic acid

Reti noids work t o i n h i bit t h i s loss o f pro-co l lagen syn­

Flavonoids

thesis.

Gentisic a c i d

- Tret i n o i n-a fi rst-ge neration reti n o i d which was the

H y d roxyco u m a r i n s

fi rst ava i l a b l e to pica l reti n o i d . I t is a nonsel ective

Koj ic acid

ret i n o i d , a ctiva t i n g a l l reti n o i c a c i d pathways . I t is

Licorice extract

n ot p h oto-sta b l e . I t is ava i l a b le i n a ge neric fo r m , as
we l l as i n bra nd for m u lations s u c h as R e n ova a n d

M u l berry extract
•

Avita . C u rre ntly R e n ova is F D A a p proved fo r p h o­

M e l a n ocyte tra nsfer i n h i bition
Lec ith i n s

toa g i n g . Treti n o i n is a lso ava i l a b l e in com b i nation a s

N ia c i n a m i d e

treti n o i n 0 . 02 5 % w i t h c l i n d a myc i n f o r patie nts seek­

Soybea n/m i l k extracts

ing benefits fo r both acne and p h otoa g i n g and as

•

M e l a n ocyte cytotoxic agents

treti n o i n 0 . 2 5 % i n com b i nation with 4% hyd ro­

Azela i c acid

q u i none a n d

M eq u i nol

0 . 0 5 % f l u o c i n o l o n e aceto n i d e fo r

hyperpigme ntation .

M on o benzone

- Reti nol-this prod uct m u st be converted to reti na lde­
hyde a n d then to a l l -tra ns-retinoic acid with i n the ker­

•

Skin turnover acce l e ration
G lyco l i c a c i d

atinocyte in order to become a ctive, t h u s d isplayi ng

La ctic a c i d

less activity than treti noi n . I t is thought to be a p p roxi­

Linoleic acid

mately 20% less potent than retinoic acid . It is not as

Reti noic a c i d

freq uently assoc iated with i rritation or e rythema . It is
pri m a ri ly fo u n d i n over-the-cou nter prod u cts at va ri­
o u s concentratio ns.
- Ad a pa l e n e-a t h i rd -ge neration reti noid wi t h selective
affi nity for specific ret i n o i c a c i d rece ptors, w h i c h
a l lows for m ore targeted benefit a n d red uction of
potentia l si d e effects . It is m ore c h e m i c a l l y sta ble
t h a n tret i n o i n a nd d oes not brea k d own i n the pres­
ence of l ight. C u rrently ava i la b l e as D ifferin in a 0. 1 %
a n d a 0 . 3 % concentrati o n .

I t i s c u rrently FDA

a p proved for to pica l acne thera py.
- Taza rotene-a t h i rd-ge neration retinoid with sel ective
affi n ity for s pecific retinoic rece ptors for more tar­
geted benefit. Has been associated with sign ificantly
h igher i rritati o n than othe r retinoids. I t is ava i l a ble in

0 . 1 % and 0.05% gels and in 0 . 1 % and 0.05%
c rea m s . It is c u rrently FDA a p proved for topica l acne
thera py a n d plaque psoriasis.
•

•

Tyrosi nase i n h i bitors

Skin l ighte n i ng agents-these prod ucts act to i n h i bit
one o r more ste ps in the mela n i n biosynthesis pathway.
The m a i n target is tyrosi nase, wh i c h is the rate- l i m iting
step i n mela n i n prod uction (Ta ble 2 . 3 ) .
- Hyd roq u i none-phenolic c o m p o u n d fo u n d natu ra l ly
in m a ny pla nts , coffee, tea , bea r, a n d w i n e .
I n h i bits conversion o f tyrosi nase t o m e la n i n .
Decreases tyrosi nase activity b y 90% .
May i n h i b it D N A synthesis.
M ay i n h i b it RNA synthesis.

I

9


10

I

Color Atlas of Cosmetic Dermatology

Ca n be cytotoxi c to mela n ocytes prod u c i n g i rre­
vers i b l e cel l d a m age with monobenzyl ether of
hyd roq u i none.
Concern rega rd ing carci n ogen i c potentia l-cu rrently
heavily regulated a n d/or ba n ned i n E u rope, As i a ,
a n d severa l African cou ntries.
Ava i l a ble i n over-the-cou nter prod u cts up to 2%
and by presc r i ption i n 3 % to 4% concentrations.
Ca n be c o m p o u n d ed u p to 1 0 % concentration .
C u rrently ava i l a ble

in

Table 2.4 • Use of the ''teaspoon rule" for su nscreen application can be
benefi c i a l i n educating patients on the proper of amount of sunscreen
that shou l d be appl ied with each appl ication.
Use of m ore tha n h a lf a teaspoon each on:
•

Head a n d neck region

•

R ight a rm

•

Left a r m

Use o f m ore than a teaspoon e a c h o n :
•

Anterior torso

c o m b i nation with to pica l

•

Posterior torso

reti noid acid a n d to pical stero i d a n d with other s k i n

•

R ight leg

l ighte n i ng agents.

•

Left leg

- Reti noic a c i d

( Data from D raelos ZD. P roced u res i n Cosmetic Dermatology Cosmeceuticals.

Acce lerate e p i d e r m a l turnover res u l t i n g i n i n c re­
ased keratin ocyte s h ed d i n g lea d i ng to pigment loss
May i n h i bit tyrosi nase i n d uction

May res u l t in keratinocyte pigment d ispersion
May i nterfere with kerati n ocyte pigment tra nsfer
- Natu ra l cosmeceuticals
Koj ic a c i d-d e rived from va rious fu nga l species
suc h as Aspergillus and Penicillium. Primari ly used
as a food preservative and to promote the redd e n ­
i n g o f u n r i pe strawberries . Genera l ly u s e d i n 1 % t o
4 % conce ntration . N oted t o have h igh sensitizi ng
potentia l .
Licorice extract-derived from the root of G/ycyrrhiza
g/abra

I ts

linneva.

main

active

i ngred ient

is

gla brid i n . It i n h i bits tyros i nase activity with associ­
ated cytotoxicity. It has been shown to be 1 6 x
m ore efficacious t h a n hyd roq u i none.
Azelaic a c i d-d e rived from Pityros poru m ova l e . I ts
mec h a n is m of action i n not fu l l y u nd e rstood . I t
works best on active melanocytes.

Aloes i n-d e rived from a l oe vera . I t a cts as a com­
petitive i n h i bitor o n DOPA oxidation and noncom­
petitive

i n h i bitor

on

tyros i n e .

When

used

in

c o m b i nation with a rbuti n , it has been demon­
strated to i n h i bit UV- i n d uced melanogenesis.
Arbut i n -derived from the bea rbe rry. I t a cts to
i n h i bit mela noso m a l tyrosi nase activity. Ava i l a ble as
a mono treatment o r i n 1% conce ntration with other
d e pigme nti ng agents.
Paper m u l berry-derived from the roots of an orna­
mental tree, Broussonetia papyrifera.
Soy-acts

to

phagocytosis,

i n h i bit
th us

kerati nocyte
red ucing

melanosome

m e la n i n

tra nsfer.

Cos meceutica l effect noted on ly with fresh soy m i l k .
N ia c i n a m i d e-acts t o i n h i bit m e l a n ocyte tra n sfer.
Also exh i bits anti- i nfla m matory a n d a nti-oxidant
properties.

Saund ers, 2005 . )


Sect i o n 1 : Ph otoa g i n g

Ascorbic a c id-acts at va rious oxidative steps
in mela n i n synth esis by i nteracting with copper ions
at the tyros i nase a ctive site a nd red u c i n g d o pa­
q u i none.
G lyco l i c acid-has a n epidermal d iscohesive effect,
res u lti n g

in

i n c reased

epidermal

turnover

fo r

i n c reased shed d i ng of pigme nted kerati n ocytes.
S h o u l d be used i n lower concentrations to avoid
s k i n i rritation .

I N D I CAT I O N S
•

Red uce t h e occu rrence o f acti n i c keratoses a n d nonmelanoma s k i n cancer

•

Red uce the formation of s k i n aging

•

R hytides

•

Ephelides

•

Lentigin es

•

Melasma

•

Postinfla m matory hyperpigme ntation

P R ET R EAT M E NT EVALUAT I O N
•

Eva l uation of pre-existing a l lergies t o a n y active i ngred ient

•

Past prod u ct use a nd res ponse

I D EAL CAN D I DATE
•

A l l patients benefit from the d a i ly a ppl ication of a topi­
cal s u nsc ree n , SPF 30 or greater

•

Patie nts with rea l istic expectations that topica l medica­

tions may provide preve ntative benefits a n d a re less
l i kely to red uce moderate to d eep rhytides

LESS THAN I D EAL CAN D I DATE
•
•

U n real istic patient expectations
Patients with ma rked ly d ry or sensitive ski n-topical
treatments may exa cerbate cond ition

CONTRA I N D I CAT I O N S
•
•

P re-existing a l lergy t o active i ngred ient
Use of topical treti n o i n , sa l i cyl i c acid, and s k i n l ighten­
i n g agents i n pregnant a n d lactati ng women

APPLI CAT I O N TECH N I QU ES
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A su nscreen shou ld be a p p l ied a m i n i m u m of 30 m i n ­
utes prior t o s u n expos u re .

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Color Atlas of Cosmetic Dermatology

A p p roxi m ate ly 35 m l is the average a m o u nt of s u n ­
screen t h a t s h o u l d be a ppl ied t o t h e average-sized
a d u lt with each a p p l icati o n . T h i s tra nslates to a tea­
spoon ( a p proxi mately 6 mU of s u n screen to each leg,
back, a n d chest a n d h a l f a teaspoon ( a pproxi mately
3 m l) a p pl ied to the a rms, face, a nd neck for fu l l cover­
age (Ta ble 2 . 4 ) .

•

Topical retinoic acid prod u cts s h o u l d b e a pp l ied spa r­
i ngly to treatment a reas 30 m i n utes after was h i n g to
m i n i m ize pote ntia l for i rritation .

•

B l eac h i ng c rea ms s h o u l d

be a p p l ied to hyperpig­

mented treatment a reas on ly, with efforts made to avoid
u n i nvolved ski n .

COM P L I CAT I ON$
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Conta ct a l lergic dermatitis

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Conta ct i rritant dermatitis

•

Ac ne fla re

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S k i n pee l i ng

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Xerosis

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Erythema

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P h otoa l lergic rea ction

•

Ph ototoxic reacti on

•

Theoreti c a l red uction i n vita m i n D a bsorption with s u n screen use

•

Hyperpigmentation with blea c h i ng crea m use

•

Exogenous ochro n osis with bleac h i ng crea m

•

Hypopigm entation with blea c h i ng c rea m

•

Potentia l carc i n oge n i c risk of hyd roq u i no n e use

POSTTREAT M E N T CAR E
•

Strict photo protection s h o u l d b e fol l owed d a i ly, i n c l u d ­
i n g s u n avo i d a n ce as m u c h as possi ble, t h e u s e o f a
d a i l y s u nscreen S P F 30 or greater, use of a wide­

bri m med hat, a n d s u n protective c l oth i n g

PEARLS FOR T R EATM ENT S U CCESS
•

M i n i m ize the n u m ber o f prod ucts a ppl ied d a i ly t o avo i d
the potentia l fo r i rritation .

•

Check the expi ration d ates of a l l prod u cts a p pl ied . Th i s
is pa rti c u l a r k e y fo r s u n sc reens, as the active i ngred i­
ents may not provi d e benefit beyo nd the recommended
d ate of use.

•

Topical retinoic a c i d prod u cts shou l d be d isconti n u ed
2 weeks prior to fac i a l proced u res such as wax in g or
tweezi n g i n order to avo i d s k i n d esq ua mati o n .