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Medical Author:

Gary W. Cole, MD, FAAD

Gary W. Cole, MD, FAAD

Dr. Cole is board certified in dermatology. He obtained his BA degree in bacteriology, his MA degree in microbiology, and his MD at the University of California, Los Angeles. He trained in dermatology at the University of Oregon, where he completed his residency.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Certain vitamin A analogues have been shown to induce the remodeling of the upper dermis by inducing fibroblasts to synthesize new collagen when applied topically over a long period of time. Of these "retinoids," tretinoin (Retin-A, Renova, Atralin, Retin A Micro, Avita) is easily available and has been shown to produce subtle but discernable changes in the appearance of fine wrinkles induced by ultraviolet exposure. This outward transformation is accompanied by an alteration in the microscopic appearance of the upper dermis. Topical retinoid use needs to be accompanied by the compulsive avoidance of sun exposure to be most effective. Tretinoin or tazarotene use is associated with a side effect termed retinoid dermatitis, the so-called rosy glow, which in many patients seems to be cosmetically desirable. Tretinoin or tazarotene (Avage, Tazorac) is available as a number of different brands which are prescription only. In a recent study, 1.1% Tri-Retinol Complex ES, an over-the-counter topical medication produced by SkinMedica, was found to be as effective as 0.025% tretinoin cream in a study funded by the company. This medication seems to be marketed only through certain spas and physician's offices.

There are a variety of invasive procedures which can change the appearance of collagen in the dermis which hopefully result in a global cosmetic improvement to the treated skin. These include the use of lasers, dermabrasion, and chemical peeling. As a group, these technologies damage the dermis just enough to induce the scar-forming cells (fibroblasts) to reconfigure the photo-damaged collagen sufficiently to reduce fine wrinkling and yet produce no unsightly scarring. This is a fine line which only those health care professionals with sufficient expertise dare tread. No matter who performs such a procedure, the prudent patient ought to seek to confirm the accuracy of any claims with a number of previous patients.

Recently, low-power radio frequency (Polaris WR and Thermage) and ultrasound devices (Ulthera System) have been touted as potentially useful in reducing fine wrinkling. These devices presumably work by producing heating of the collagen sufficiently so there is protein denaturation and shrinking. This so-called "skin tightening" seems to produce some cosmetic benefit. If heating of collagen is a necessary requirement, special care should be taken to ensure no burn injuries occur. The efficacy and safety of these devices remains to be demonstrated.

Microdermabrasion is a technique in which air propels sand particles at the skin. The result is a diminution in the degree of fine wrinkling. This technology is unlikely to produce significant damage to the skin so that collagen remodeling is unlikely. It seems reasonably safe and may work by producing mild temporary swelling (edema) in the treated skin. This procedure must be repeated at regular and frequent interval to maintain improvement.

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