CARE AND SELF IMAGE
The biggest asset a woman can have is beautiful skin. Even when features may not be classically beautiful, radiant skin can illuminate the plainest face. When care is taken to ensure the health and function of the skin, it can serve a woman well for a life time. It only takes a little time and effort to learn and incorporate a good skin care regime. The benefits are worth the work.
For women who are regular makeup wearers cleansing is a must. A cleansing regime entails, cleansing to emulsify grime and dirt to the surface of the skin. Rinsing with tepid water, toning to remove excess cleanser and bacteria, and moisturizing to seal and protect skin. Even women who are not regular makeup wearers, should take care to cleanse properly also. Removing dust and perspiration is important not to let it set on the surface and clog pores.
Much emphasizes is placed on a women’s appearance, and it has been that way for centuries. European women have known for years the importance of beautiful skin and take regular steps in the maintenance of their most precious resource.
Regular facials, every 8 weeks, is common even by the most modest woman. Some women think facials are a luxury, and not important, but it is natural hygiene for the skin. Taking time for oneself to relax and refresh can do wonders for a stressed skin.
Manipulation and deep cleansing that is applied to the skin in facial treatment helps to bring oxygen, nutrients, and much needed exfoliation to the skin. Exfoliation takes place every 28 to 30 days in healthy young skin. As we mature, we don’t throw off skin cells as easily as when we were young. We get a build up of dead skin cells that make the skin look dull and lifeless. Regular facials assist in removing them. A series of glycolic peels also helps immensely in deep exfoliation and to kick start the skins metabolism.
There so many avenues for women to take now when faced with problems of the skin. To start, good skin care is basic, followed by regular facials, and then being open to any more aggressive therapy if need be.
There has been no other time on earth when so many things have been accessible to the common person. Taking the time to make one self available to them is all that is needed.
Cosmeceuticals are topically applied products, such as creams, lotions, and ointments, that are not merely cosmetics that make more beautiful camouflage yet are not true drugs that have undergone rigorous controlled studies. This continues to be an area of new product development.
Aesthetic patients are calculating about skin care and often seek professional advice when choosing cosmeceuticals. Cosmeceuticals are moisturizers, serums, and masques that contain active ingredients that confer added skin benefits.
In the aesthetic practice, the use of cosmeceuticals in combination with cosmetic procedures represents a new treatment ideal for skin rejuvenation. Developing individualized skin care products takes time and requires a basic understanding of cosmeceutical ingredients.
Patients with conditions such as rosacea, eczema, seborrhea, and acne require specially selected products that will enhance skin appearance without irritating their underlying conditions.
Pre-treatment with cosmeceuticals can prime the skin for procedures and post-treatment can reduce complications. Thus, an understanding of the benefits of cosmeceutical ingredients is essential in the clinical setting.
Medically based skincare product target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts.
Instituting the correct routine will slow the progression of aging and work towards reversing, to some degree, the extrinsic and intrinsic aging changes.
The goals of the topical regimen are to reverse sun damage, slow the aging process by increasing collagen, elastin, and glycosaminoglycans (GAGs), minimize subsequent oxidative damage, and to address any active disease states (acne, rosacea, melasma).
Topical synthetic retinoids can be viewed as the “workhorse” of any skincare products. There are three generations of synthetic retinoids. The first generation includes tretinoin and isotretinoin; the second-generation retinoids include acitretin and etretinate.
Among the third-generation retinoids are adapalene, bexarotene, and tazarotene. Tretinoin has the longest safety and efficacy record in skin rejuvenation.
Multiple studies have demonstrated efficacy of these in the treatment of wrinkles, reducing pigmentation, acne scarring, and antibacterial activity against Propionibacterium acnes and Stapylococcus spp.
These retinoids have also been combined with other agents such as hyaluronic acid and glycolic acid to improve results in the treatment of wrinkles and scarring. There are a variety of ‘cosmeceuticals’ that use topical retinoids in their products. Most of the topical retinoids used in cosmetic products are precursors to retinoic acid.
ALPHA-HYDROXY ACIDS (AHAS) AND POLYHYDROXY ACIDS (PHAS)
AHAs have been used for centuries as exfoliating agents. They are a family of acids derived from milk or fruits: lactic acid (milk), glycolic acid (sugar cane), malic acid (apples), citric acid (citrus fruits), and tartaric acid (grapes).
They create a smooth feel to the skin by breaking up keratinocyte adhesion in the stratum corneum and the very upper epidermis. This is also how they exert their beneficial effects on acne. Furthermore, their disruption of the stratum corneum allows other skin products to penetrate more deeply when applied to the skin.
Ongoing studies on AHAs demonstrate that their benefits extend far beyond exfoliation. AHAs increase glycosaminoglycan and collagen production and improve the quality of elastic fibers. AHAs also reduce pigment clumping in the epidermis, making them effective skin lighteners.
Although AHAs are extremely effective anti aging ingredients, side effects such as stinging and burning limit their use in some patients. To address this problem, polyhydroxy acids including gluconolactone and bionic acids were developed. Gluconolactone has been used to treat patients with rosacea who are generally sensitive to alpha hydroxys. As an added benefit, the polyhydroxy and super natural acids are also antioxidants.
Hyper pigmentation remains one of the most common disorders for which patients seek treatment. Cause can range from sun damage, melasma, ethnic predilection (under eyes), to post-inflammatory hyper pigmentation (PIH).
Hydroquinone (HQ) has been used for over 40 years to treat hyperpigmentation. Over-the-counter products contain 1–2% HQ, whereas preparation concentrations can be as high as 10%. We combine HQ with other agents that either enhance its penetration (AHA, retinol) or are synergistic in their skin lightening effects (vitamin C, topical steroids). While it can be used to treat focal areas, it is often best to apply this agent to the whole face and apply a heavier amount over the darkest regions. This helps prevent a bleaching complexion. Patients should be reassured that contrary to popular opinion, hydroquinone does not bleach the skin but rather restores the skin to the patient’s baseline skin color.
Licorice extract comes from the root of Glycyrrhiza glabra. It contains glabridin (a tyrosinase inhibitor) and liquitin. Studies on licorice extract have shown that it can reduce ultraviolet B (UVB) pigmentation and has some antioxidant properties.
Arbutin is a naturally occurring derivative of HQ found in bear-berry.
Kojic acid is a chelation agent produced by several species of fungi, is a byproduct of the malted rice fermentation used to manufacture sake.
Azelaic acid is another skin-lightening agent, which works via inhibition of tyrosinase. In addition to its effects on pigmentation, azelaic acid has been shown to be efficacious in treating patients with acne, and rosacea.
Antioxidants are believed to minimize free radical damage, which has been associated with the processes of photoaging and carcinogenesis. Photodamaged and aged skin exhibit a marked decrease in expression of L-ascorbic acid. Vitamin C (ascorbic acid), vitamin E (alpha-tocopherol), and other polyphenols have become popular within the cosmeceutical industry as the understanding of the role of free radical damage grows.
Vitamin C, or L-ascorbic acid, is a water-soluble antioxidant that is a popular cosmeceutical ingredient. Topical application of vitamin C prior to UV exposure confers photoprotection against sunburn and UV-induced immunosuppression. In addition, vitamin C acts as a cofactor for enzymes responsible for the synthesis of collagen. Vitamin C inhibits tyrosinase and reduces melanin, making it an effective skin-lightening agent. Vitamin C is also an effective anti-inflammatory compound and has been evaluated in the post-procedure setting.
Products containing vitamin C in combination with other antioxidants have been shown to provide added benefits when compared with vitamin C alone. A formulation containing vitamin C, E, and the botanical antioxidant ferulic acid provided eight times the photoprotection of vitamin C alone. Combination antioxidants have also been looked at in the post=procedure setting.
Vitamin E is a lipid soluble antioxidant responsible for protection of membranes. There is ongoing debate over the possible role of vitamin E in skin cancer prevention
Growth Factors and Newer Cosmeceuticals
Collagen stimulation and the slowing of the aging process are the goals with newer generation topical agents including peptides, cytokines, and growth factors.
Niacinamide or vitamin B3 readily penetrates human skin reducing skin redness, improving sallowness, and lightening hyper-pigmentation. Topical application of niacinamide enhances skin barrier lipids and improves barrier function.
It also reduces sebum production and pore size, making it an excellent choice for patients with oily skin who desire rejuvenation. Niacinamide increases collagen and glycosaminoglycan production, boosting dermal matrix components that can smooth wrinkles.
Botanical extracts are found in many cosmeceutical formulations. Extracts of green tea, grape seed, resveratrol, pine bark, pomegranate, and Coffea arabica are among the most popular. Botanical extracts contain a variety of phenolic and polyphenolic antioxidants that neutralize free radicals and increase collagen production.
Polyphenols inhibit protein glycation, which contributes to the wrinkling and sallowness seen in sun-damaged patients. They also act as anti-inflammatory compounds. Polyphenols confer photo protection and prevent skin cancers. Botanical extracts topically applied lightening pigmentation, improving lines and wrinkles, and reducing skin redness.
Bio active peptides were first identified through the study of wound healing. Antimicrobial peptides act as part of our innate host defense against pathogens and are important for wound healing. A second type of peptide important in wound healing is derived from the breakdown of proteins such as collagen and elastin.
These small peptide fragments are produced when skin is injured or inflamed act to stimulate synthesis of dermal matrix components such as collagen and glycosaminoglycans. Peptides that inhibit neurotransmitter release are found in cosmeceuticals claiming to have Botox-like effects.
Growth factors and cytokines regulate a variety of pathways important in skin aging. The use of growth factors for skin rejuvenation is supported by the fact that suppression of transforming growth factor beta by UV induced oxidative stress results in overexpression of metalloproteinases and a reduction in collagen production.
There are several cosmeceuticals containing human growth factors and cytokines harvested from fetal fibroblasts. Additionally, plants and animal growth factors are marketed as skin rejuvenating compounds. The topical application of growth factors is limited by the fact that human growth factors are hydrophilic and have a large molecular weight that prevents them from penetrating the epidermis.
Some have suggested that alternative routes to the dermis might include hair follicle penetration. Clinical studies have confirmed that consistent use of cosmeceuticals containing growth factors and cytokines improves skin wrinkling. In aesthetic practice, the use of topical growth factors has gained popularity as an adjunct treatment for patients undergoing laser resurfacing, as they are known to be important in wound healing.
There is a demand for compounded pharmaceuticals in dermatology because they may offer medications for patients that are not commercially available prof Moawad said. Our compounded medications are prepared by high skilled pharmacists specially trained to meet these individual patient needs. This professional relationship between (1) Our patient, (2) Our pharmacist, and (3) Prof. Moawad is known as the ‘compounding triad,’ and each person must interact adequately with the other two individuals to provide safe and cost-effective compounded medications and cosmeceuticals.
Why I Should have MSI Skin Care Products?
Prof Moawad believe that every cosmetic surgeon should be able to formulate a skincare regimen, individualized for each patient, which will help patients enhance the results of in-office treatments and surgery.
Prof. Moawad’s approach to skincare comes from 40 years’ experience treating patients of all skin types and with many skin concerns.
Patients need to know that when they come to MSI, they are going to receive a “medical” approach to their skin care that they cannot get from elsewhere. When selected properly, a topical regimen can often achieve results that are at least equal to, if not better than, current non-invasive lasers and microdermabrasion machines. A topical skincare regimen can also be used to prolong the results of in-office procedures.
Treatment outcomes from lasers, chemical peels and even surgical procedures are significantly impacted using skin care products. For this reason, it is essential to give patients explicit pre-procedure and post-procedure instructions as to what they should and should not use on their skin.
Our trained pharmacist will review the basics of topical skin care and how our compounding cosmeceuticals are used to rejuvenate aging skin and enhance treatment outcomes. Patients are then shown before and after photographs of other patients treated for similar conditions.
These can simply be before and after using skincare regimens or can be of patients that have undergone extensive procedures to repair their skin (laser resurfacing, medium-depth peels, pigmentation lasers, vascular lasers, fat grafting.
All patients receive written instructions on how to use the products and what reactions to expect while they start their new regimen. It is vital to educate our patient on correct product application and how to handle anticipated side-effects, to improve patient compliance Patients are told that the goal of treatment is to return the skin back to its normal, healthy state.
What Does MSI Offer in Skin Care Products?
Topical application of pharmaceutical agents is a basic principle of dermatological therapy. However, the effective barrier function of the skin significantly impairs the bioavailability of most topical drugs.
Many pharmaceutical substances are too hydrophilic or too large (> 500 kDa) to permeate the stratum corneum at relevant concentrations, and therefore must be encapsulated in liposomes, injected, or administered systemically.
Apart from chemical modification of active substances or their vehicles, transdermal delivery of external chemicals has been aided by physical methods such as microneedles, iontophoresis and electro-osmosis, electro-poration, and laser, radiofrequency and ultrasound.
Local increase in temperature increases blood flow and in turn, rate of permeation/transport of active substance into the skin increases. This technique has the advantage of not employing a chemical, is non-invasive and hence, does not require activation of self-repair mechanism by the skin.
Microneedle treatment is simple and inexpensive, and the skin barrier disruption it causes resolves quickly. Therefore, it can serve as an effective physical method of enhancing transdermal delivery of medications for the treatment of many cosmetic and dermatological conditions.
Abrasion techniques involve the direct removal or disruption of the upper layers of the skin to facilitate the permeation of topically applied medicaments. Some of these devices are based on techniques used by dermatologists for superficial skin resurfacing (e.g., microdermabrasion) in the treatment of acne, scars, hyper-pigmentation, and other skin blemishes. The delivery potential of skin abrasion techniques is not restricted by the physicochemical properties of the drug. Application of skin care products post-MDA therapy may be promising to improve their dermal uptake.
Multiple lasers have been used to improve skin penetration for drugs. Laser modalities include ablative skin resurfacing (ASR), nonablative dermal remodeling (NDR), and fractional photo-thermolysis (FP).
Laser treatment frequently is used for dermatological conditions such as acne and to confer “facial rejuvenation” where the laser radiation destroys the target cells over a short frame of time (∼300 ns).
Direct and controlled exposure of a laser to the skin results in the ablation of the SC without significantly damaging the underlying epidermis. Removal of the SC via this method has been shown to enhance the delivery of lipophilic and hydrophilic drugs.
Fractional ablative lasers represent an innovative strategy to overcome the epidermal barrier in a standardized, contact-free manner. The bioavailability of topical agents can be significantly enhanced using laser-assisted drug delivery (LADD).
Ablative fraction radiofrequency (AFR)-assisted drug delivery is a promising tool for the future of dermatology. We expect to see several agents to be paired with AFR for enhanced drug delivery.
Radiofrequency thermal ablation has been used extremely for electrosurgery and ablation of malignant tissues. This involves exposure of skin to high frequency alternating current (∼100kHz) and results in the formation of heat-induced microchannels in the membrane like when laser radiation is employed. Radiofrequency-induced microchannels remaining open for less than 24 h.
Ultrasound involves the use of ultrasonic energy to enhance the transdermal delivery of solutes either simultaneously or via pre-treatment and is frequently referred to as sonophoresis or phonophoresis.
Ultrasound has been shown to enhance transdermal transport of low molecular weight drugs (<500 Daltons) across human skin. Greater transdermal transport by this method is attributed to cavitation induced either inside or outside the skin. In addition, oscillations of cavitation bubbles result in significant water permeation into disordered lipid regions and lead to the formation of aqueous channels in the intercellular lipids of stratum corneum.
Ultrasound parameters such as treatment duration, intensity and frequency are all known to affect percutaneous absorption, with frequency being the most important.
Although frequencies between 20 kHz–16 MHz have been reported to enhance skin permeation, frequencies at the lower end of this range (<100 kHz) are believed to have a more significant effect on transdermal drug delivery with the delivery of macromolecules of molecular weight up to 48 kDa.
The proposed mechanism behind the increase in skin permeability is attributed to the formation of gaseous cavities within the intercellular lipids on exposure to ultrasound resulting in disruption of the SC.
Your Consultation with Prof. Moawad
Initial consultations are carried out in a well-lit room and patients are asked to remove all makeup. Patients are assessed with regards to their cosmetic concerns and any additional flaws are identified. Patients are given a handheld mirror so that they can follow along with their evaluation.
MSI Basic Skin Care :
One of the most important components of any anti aging treatment plan is topical skin care. A basic skin care Product includes a cleanser, moisturizer, and sunscreen. Moisturizers that contain beneficial ingredients are called cosmeceuticals and can be used to improve skin tone, texture, radiance, hyper pigmentation, pore size, fine lines, and wrinkles.
Cleanser and Toners :
Cleansers are the most basic component of a skin care Products. Cleansers are designed to remove dirt, bacteria, makeup, and pollution from the skin and to prepare the skin for product application. Gentle cleansing is dependent on the composition and pH of the cleanser.
Many cleansing products contain surfactants that disrupt stratum corneum proteins and lipids, resulting in compromised barrier function. In addition, cleansing products such as true soaps have an alkaline pH, causing skin irritation. Thus, cleansing products with a neutral or slightly acidic pH are preferable in the clinical setting.
There are four general categories of cleansing products including true soaps, synthetic detergent bars (syndets) and cleansers, combination bars (combars), and lipid-free cleansers. True soaps are made through saponification, which is the chemical reaction between a fat and a base such as lye.
These high-pH cleansing bars are excellent for cleansing the skin but damage stratum corneum lipids and proteins. Repeated use of true soaps causes dehydration of the skin and should be avoided.
Syndets were developed to address the problems created by cleansing with true soaps. Syndets are soap bars and cleansers that contain less than 10% true soap in combination with synthetic detergents. With a more favorable pH of 5.5–7, they can be used daily without causing dry or irritated skin.
Syndets have been tested in patients with sensitive skin and conditions such as rosacea and are well tolerated. Lipid-free cleansers are liquid products that cleanse the skin without the use of fats. They can be used on dry or wet skin and are massaged to create lather. Lipid-free cleansers have excellent tolerability and leave behind a thin moisturizing film on the skin.
Patients who have undergone resurfacing or peeling procedures may benefit from the gentle cleansing and moisturization provided by lipid-free cleansers. Mild cleansing products that are appropriate for post-procedure patients.
Com-bars are soaps with antibacterial agents such as triclosan. These are often used to prepare patients the night before or the morning of a surgical procedure. Com-bars are not appropriate for daily use on the face as they can be drying.
Chronologically aged skin is characterized by an inherent reduction in epidermal lipid content, resulting in dehydration and altered skin barrier function. Epidermal desquamation slows with age, leaving skin dry and flaky. Dry skin is a common cause of itching in older patients, and in more severe cases leads to cracks and fissures that impair function.
Thus, the use of properly formulated moisturizers is essential for patients with aging skin. It is also important to note that moisturization alone can improve skin wrinkling. A temporary plumping of the skin occurs after moisturizer is applied, making lines and wrinkles less noticeable and giving the skin a humid appearance.
Most commercially available moisturizers are oil in water emulsions. Moisturizers contain approximately 80% water in combination with occlusive, humectant, and emollient ingredients. Ingredients such as petrolatum, lanolin, and mineral oil form an occlusive layer on the surface of the skin increasing stratum corneum hydration by preventing trans-epidermal water loss.
Glycerin, hyaluronic acid, sodium lactate, and urea act as humectants that attract water from the dermis upwards into the epidermis and stratum corneum.
Emollients are the ingredients that are responsible for the smooth feel of the skin that is felt after a moisturizer has been applied. Emollient ingredients include lanolin, sunflower, and jojoba oil.
Moisturizers include creams and lotions that differ in their physical properties and chemical composition. Creams contain more oil, less water, and are thicker and more occlusive than lotions. Patients with more advanced skin aging generally prefer creams over lotions.
Creams are also beneficial to treat special areas such as the eyes, décolletage, and neck. Lotions are easy to spread, making them good for treating larger surface areas of the body.
Choosing a moisturizer can be discouraging, since consumers are faced with so many options. Post-procedure patients should be advised to use bland moisturizers, meaning those that do not contain additives such as alpha hydroxy acids (AHAs), urea, and retinol.
These ingredients can be irritating, causing redness, stinging, and burning of recently treated skin. In contrast, moisturizers with actives such as ceramides, niacinamide, or hyaluronic acid are preferable, since they provide effective skin hydration and enhance barrier function without irritation.
It seems counter-intuitive, but patients with oily skin and those who are acne prone also need moisturizers. The concomitant use of moisturizers in acne therapy improves tolerability and enhances efficacy and skin comfort. There are many oil-free moisturizers to choose from that do not contain mineral or vegetable oils.
Oil-free moisturizers use silicone derivatives such as dimethicone and cyclomethicone to retard moisture loss without the greasy feel.
Sunscreen is perhaps the most important component of an anti aging skin care products. Sunscreens are the only topical treatments that have been shown to prevent skin aging and are essential in patients undergoing cosmetic procedures.
Current photo protection strategies include the use of primary and secondary photoprotectors. Primary photoprotection includes sunscreens and sun-protective clothing that prevent ultraviolet (UV) light from reaching the skin. Secondary photoprotection refers to the use of antioxidants and DNA-repair enzymes that can reduce damage caused by UV light.
Sunscreens are traditionally divided into organic and inorganic types.
Inorganic sunscreens utilize particles to scatter and reflect UV light. These particles include zinc oxide and titanium dioxide in micronized forms and essentially block UV light from entering the skin. Thus, they are aptly referred to as sun-blocks or chemical-free sunscreens.
Inorganic sunscreens are an excellent choice for post-procedure patients. They are relatively free from potential allergens and irritating chemicals. Newer formulations with micronized forms of zinc and titanium dioxide provide a more translucent appearance that is cosmetically acceptable.
Inorganic sunscreens are an excellent choice for patients with hyperpigmentation or melasma, as they effectively block both UV A (UVA) and UV B (UVB) rays. They are also of value for preventing post-inflammatory hyperpigmentation that can occur following resurfacing procedures and peels.
Powder-based mineral sunscreens are popular with consumers and can be applied several times a day over moisturizer and makeup. These powders contain organic ingredients and provide excellent photoprotection.
Organic sunscreen ingredients absorb UV light energy and transform it into heat. Commonly used UVB-absorbing ingredients include cinnamates, salicylates, octocrylene, benzophenones, and menthyl anthranilate.
Effective UVA-absorbing ingredients such as avobenzone and ecamsule are now widely available and offer expanded broad-spectrum photoprotection.
Although most organic sunscreens are well tolerated, there is a small risk of contact dermatitis from ingredients like cinnamates and oxybenzone.
Sunscreens were traditionally labeled with an SPF (sun protection factor) number that is largely a measure of protection from exposure to UVB. With the newer understanding that UVA protection is equally important, the FDA regulations have been updated to require that sunscreens labeled as both “broad spectrum” and “SPF 15” (or higher) not only protect against sunburn, but, if used as directed with other sun protection measures, they must state they can reduce the risk of skin cancer and early skin aging.
Furthermore, any SPF >50 is now only labeled as SPF 50+ since there is no hard evidence that SPF over 50 adds further protection. Recent advances in sunscreen technology make sun protection easier and more cosmetically appealing than ever, thus allowing these newer sunscreens to replace moisturizers for almost all patients.
Patients are told to find a sunblock to take the place of their moisturizer rather than a moisturizer that has a little bit of a sunblock in it. Sunblock should be applied daily, year-round, due to the persistent levels of UVA rays even in wintertime.
Patients are told to apply the sunblock as the last step (before their makeup) and to make sure they apply it to the face, neck, exposed areas on the chest, and the backs of their hands.
How to Increase the efficacy of your Home Skin Care Products
The art of skin rejuvenation is in taking a personalized approach to each patient so that the skincare regimen is easy to use, tackles their presenting complaints, and gives visible results.
Additionally, it is important to guide patients through the steps that their skin will go through as it acclimates to the skincare product. Skincare routines must be tailored to the patient’s desires, the speed by which they want to see improvement, and their work/lifestyle.
If patients would like to see results quickly and can tolerate redness, peeling, and flaking, a more aggressive product is prescribed. This is also the case if we are quickly preparing the skin for surgery or resurfacing.
Furthermore, patients with melasma are encouraged to pursue an aggressive skincare product whenever possible, so that results are achieved before the skin builds a tolerance to the topical agents. However, if the patient is prone to quitting and not tolerating dryness, then a milder product is implemented. For all the rest, a moderate approach is taken.
A medical approach to skincare is one in which a thoughtful, personalized product is formulated for each patient in a manner that addresses the function of the cells of the skin.
The skincare routine can be used to prepare a patient’s skin for resurfacing, to address inflammatory conditions such as acne and rosacea, and to enhance the results of surgical procedures. Additionally, as the passage of time continues, and the aging process begins to undo the results of surgery, the skin can be kept vibrant and glowing with the proper topical agents. This further prolongs the results of the surgical procedure.