Category: skin

Platelets are a rich source of growth factors that can be applied to facial aesthetics

The use of platelet-rich plasma for rejuvenation and augmentation is discussed by Dr Sabine Zenker

Dermal stimulation and augmentation continues to grow within the facial aesthetics industry. A bioresorbable material such as hyaluronic acid (HA) is
commonly used. Many exogenous fillers rely on an autologous fibrotic response for volume augmentation—but disadvantages include the transient effects of temporary, resorbable
fillers and foreign body reactions such as persistent erythema and swelling and encapsulation, granuloma formation and chronic or delayed infections. An autologous source for soft tissue augmentation is therefore a desirable alternative.
Human growth factors (GFs) have been extensively investigated, but there are now clinical applications of individual GFs: keratinocyte growth factor (Kepivance, Sweden) for oral
mucositis; and platelet derived growth factor (Regranex, UK) for non-healing diabetic wounds. But applied outside their normal environment, these exogenous GFs may have untoward effects— for example, the FDA introduced a black box warning on becaplermin in 2008 for increased cancer mortality. The safety of palifermin has so far not been established.
Platelets are an excellent source of GFs in their naturally-occurring and biologically determined ratio, and are successful in acute wound healing. The application of platelet-rich plasma (PRP) has been proven to enhance early wound healing and
healing in diabetic ulcers. Concentrated platelet preparations have been used clinically since the 1990s to simulate the native wound healing environment compared with that after isolated growth factor application. There is also substantial clinical proof
of PRP in other areas of medicine—platelet gel is widely used inorthopaedics and oromaxillofacial surgery.
Platelet recovery systems have been developed where erythrocytes are separated from white cells and platelets in distinct fractions. Platelet pellets are resuspended in recovered plasma, usually with 6–7 times the normal concentration of platelets in peripheral blood. This concentration is an autologous source of growth factors. After injection into the dermis and subcutaneous layers, the platelets are activated endogeneously by the
body’s own coagulation factors such as thrombine and collagen.
This leads to platelet degranulation, releasing platelet GFs such as PGDF, ILGF, EGF and TGF-beta. Activated platelets also release proteins such as the adhesive glycoproteins fibrin, fibronectin and vitronectin. These proteins and GFs interact with cells
in the subcutaneous tissues, such as fibroblasts, endothelial cells and stem cells and after binding to their cellular receptors, they activate intracellular signaling events—mediating cell proliferation,migration, survival and production of extracellular matrix proteins. This results in tissue rejuvenation. For the enhancement of skin texture, glow and hydration,
PRP is applied via superficial dermal injection using a mesotherapy technique. When used as a filler, PRP is injected dermally or subdermally to volumise and reshape the skin. The autologous character of this agent means there are minimal side effects, but these usually take form of mild bruising, swelling or, theoretically, infection. Contraindications include pregnancy, breast feeding, autoimmune or blood disease and cancer.
There are several kits for PRP harvesting, including MyCells, Selphyl and Regen. The MyCells kit is designed for autologous PRP re-injection and has been approved by the FDA, the Medical Device Committee of the European Union and by the Israeli
health ministry. PRP for facial rejuvenation is currently injected in three countries: Japan, England and Israel.

There is poor clinical data available to prove the safety and efficacy of PRP injections. An initial pilot study of 10 women showed that PRP injections for facial rejuvenation is an effective way to address some of the more difficult areas on the face, around the eyes and the neck.
MyCells performed a clinical investigation in Japan, the UK and Israel with over 400 patients. In this study, the clinical effects and potential side effects of MyCells PRP skin rejuvenation were evaluated. The patients were facially injected with the MyCells PRP skin rejuvenation kit. Follow up was performed three to six months after primary injections. Treatment was performed for the following indications and techniques:
• Layer specific transplant
• “Tenting” of the skin
• “Cul-de-sac” and needle bevel up
• Over-correction up to 50%
• Serial treatments, providing an accumulative effect
• Minimal-trauma technique using a long needle

Patients were treated with intradermal injection using long 30G needles, injected in deep folds or wrinkles using the linear threading technique, and with superficial injection using the mesotherapy technique. Following injection, Auriderm XO gel (vitamin K) was applied.
Patients were reviewed at three-monthly intervals. Results were age-dependent. Younger patients less than 35 years were found to respond quickly with the main indication being skin rejuvenation and prevention—treatment every 12-24 months should suffice.
Patients up to 45 years required a second treatment 9-12 months later and annual booster injections. Patients aged 50–60 years required a second treatment at six months, a third at one year and three months, with a touch up two years after the first treatment. Patients over 60 needed a second treatment at three months, a third at nine months and a fourth treatment 1.5 years later. Over-corrections were performed on 30-50% of patients.
My clinical experience with PRP has shown that this modality may be an alternative or adjunctive therapy for tissue regeneration to any of the existing therapies. Its application for superficial or deep dermal stimulation leads to skin rejuvenation and global facial volumisation.
This biostimulation is safe, creates an immediate and long lasting volumetric effect and a natural result. It is easy to perform and the procedure has virtually no side-effects and high levels of patients satisfaction.

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Article by by Carmia Borek, Ph.D. /taken from Life extension/

The promise of repairing sun parched aging skin is alluring, especially if damage control may be attained by applying a substance that is abundant in our body. Thymosin beta 4 (Tb4), a molecule that accelerates wound healing in animals and cultured cells, “may be valuable in repairing skin damage caused by sun or even by the wear and tear of aging?” This hopeful message of Tb4’s potential to restore damaged human skin was voiced at the 5th International Symposium on Aging Skin, in California (May 2001), by Dr. Allan Goldstein, Chairman of the Biochemistry Department at George Washington University and founder of RegeneRX Biopharmaceuticals. RegeneRX is carrying out preclinical research on Tb4 as a wound healer, in collaboration with scientists at the National Institutes of Health.

Skin is the largest organ of the body, which makes up 16% of total body weight. It is also the largest organ that provides immune protection and plays a role in inflammation. Composed of specialized epithelial and connective tissue cells, skin is our major interface with the environment, a shield from the outside world and a means of interacting with it. As such, the skin is subjected to insults and injuries: burns from the sun’s ultraviolet radiation that elicit inflammatory reactions, damage from environmental pollutants and wear and tear that comes with aging.

An effective healer, Tb4 can be administered topically on the surface of cells and systemically, through injection. Besides healing skin wounds, Tb4 has been shown to promote repair in the cornea of the eye, in rats, thus preventing loss of vision.

There are several layers in the skin; the outer epidermis and beneath it the dermis and the subcutaneous layer. Cells in the epidermis include keratinocytes, its major cell type, that move continuously from the lower basal layer where they are formed by cell division. Other cells in the epidermis are the melanocytes that synthesize pigment and transfer it to the keratinocytes, giving our skin its color, and a wide variety of immune cells that maintain immune surveillance and secrete substances called cytokines, like interleukin 1 and 2, which are active in inflammation. The dermis contains connective tissue, mainly collagen, blood vessels, various types of immune white cells and fibroblasts.

The structure that provides the cell with form is the cytoskeleton, whose protein actin, a housekeeping molecule in cells, comprises 10% of the cell protein. Actin is essential for cell division, cell movement, phagocytosis (engulfing foreign bodies in immunoprotection) and differentiation.

Cells on the surface of the skin are constantly being replaced by regeneration from below. The repair of a wound is a scaling up of this normal process, with additional complex interactions among cells, formation of new blood vessels, collagen, more extensive cell division and cell migration, as well as strict control of inflammatory cells and the cytokines they release to resolve the inflammation.

Skin damage and aging are induced to a large extent by free radicals from the sun and environmental pollutants and from oxidants produced during infection and inflammation. Lipid peroxidation of membranes and increased inflammatory substances, such as thromboxanes and leukotriens, add insult to injury. While skin damage accumulates with age, repair processes slow down. Thus, any boost by a molecule that would reduce free radicals and accelerate molecular events in healing has the potential to hasten skin repair. Tb4 has such healing qualities.

The nature of Tb4

Thymosin beta 4 is a small 43 amino acid protein (a peptide) that was originally identified in calf thymus, an organ that is central in the development of immunity. Tb4 was later found in all cells except red blood cells. It is highest in blood platelets that are the first to enter injured areas, in wound healing. Tb4 is also detected outside cells, in blood plasma and in wound and blister fluids.

Its unique potential as a healing substance lies in that it interacts with cellular actin and regulates its activity. Tb4 prevents actin from assembling (polymerizing) to form filaments but supplies a pool of actin monomers (unpolymerized actin) when a cell needs filaments for its activity. A cell cannot divide if actin is polymerized. Tb4 therefore serves in vivo to maintain a reservoir of unpolymerized actin that will be put to use when cells divide, move and differentiate.

The promise of repairing sun parched aging skin is alluring, especially if damage control may be attained by applying a substance that is abundant in our body.

Tb4 has other effects that are needed in healing and repair of damaged tissue. It is a chemo-attractant for cells, stimulates new blood vessel growth (angiogenesis), downregulates cytokines and reduces inflammation, thus protecting newly formed tissue from damaging inflammatory events. Tb4 has been shown to reduce free radical levels (with similar efficiency as superoxide dismutase), decrease lipid peroxidation, inhibit interleukin 1 and other cytokines, and decrease inflammatory thromboxane (TxB2) and prostaglandin (PGF2 alpha).

An effective healer, Tb4 can be administered topically on the surface of cells and systemically, through injection. Besides healing skin wounds, Tb4 has been shown to promote repair in the cornea of the eye, in rats, thus preventing loss of vision.

Wound healing

A critical step in wound healing is angiogenesis. New vessels are needed to supply nutrients and oxygen to the cells involved in repair, to remove toxic materials and debris of dead cells and generate optimal conditions for new tissue formation. Another important step is the directional migration of cells into the injured area, joining up to repair the wound. This requires an attractant that will direct the cells to the wound and propel them to the site. These critical steps in wound healing are regulated by beta 4, as seen in the following experiments.

Endothelial cells

Cells that line blood vessels (endothelial cells), taken from human umbilical chord veins, were grown in culture and the layer of cells subjected to a scratch wound. Cultures were then treated with Tb4 or kept in growth medium without Tb4. When examined four hours later, Tb4 treatment attracted cells to migrate into the wound and accelerated their movement, showing it is a chemoattractant. Cell migration was four to six times faster in the presence of Tb4 compared to the migration of untreated cells. Tb4 also hastened wound closure and increased the production of enzymes, called metalloproteases, that could pave the way for angiogenesis by breaking down barrier membranes and facilitating the invasion of new cells to the needy area, to form new vessels. Other experiments showed Tb4 acts in vivo. When endothelial cells were implanted under the skin in a gel supplemented with Tb4, the cells formed vessel-like structures containing red blood cells, indicating the ability to stimulate angiogenesis in the animals.

Skin repair

Thymosin beta 4 accelerated skin wound healing in a rat model of a full thickness wound where the epithelial layer was destroyed. When Tb4 was applied topically to the wound or injected into the animal, epithelial layer restoration in the wound was increased 42% by day four and 61% by day seven, after treatment, compared to untreated. Furthermore, Tb4 stimulated collagen deposition in the wound and angiogenesis. Tb4 accelerated keratinocyte migration, resulting in the wound contracting by more than 11%, compared to untreated wounds, to close the skin gap in the wound. An analysis of skin sections (histological observations) showed that the Tb4 treated wounds healed faster than the untreated. Proof of accelerated cell migration was also seen in vitro, where Tb4 increased keratinocyte migration two to three fold, within four to five hours after treatment, compared to untreated keratinocytes.

Repair of the cornea

After wounding, timely resurfacing of the cornea with new cells is critical, to prevent loss of normal function and loss of vision. Therapies for corneal injury are limited. Therefore, the recent finding that Tb4 promotes corneal wound repair offers hope for a therapeutic product that will improve the clinical outcome of patients with injured corneas.

The cornea is the outer thin layer of epithelial cells protecting the eye. After wounding, timely resurfacing of the cornea with new cells is critical, to prevent loss of normal function and loss of vision. Corneal epithelial healing occurs in stages, with cells migrating, dividing and differentiating. Therapies for corneal injury are limited. Therefore, the recent finding that Tb4 promotes corneal wound repair in animal models offers hope for a therapeutic product that will improve the clinical outcome of patients with injured corneas.

In the experiments, an epithelial wound was made in the corneas of sedated rats. A Tb4 solution was applied at several concentrations to the injured eyes in one group of rats while another group was treated with a solution without Tb4. Following 12, 24 and 36 hours, the eyes were tested by microscopic observation for epithelial growth over the injured site. Investigators found the Tb4 accelerated corneal wound repair at doses of Tb4 similar to those found to repair skin wounds. When tested 24 hours after treatment, the rate of accelerated repair was proportional to the concentration of Tb4, with the highest dose (25 microgram) showing a threefold acceleration of epithelial cell migration, compared to untreated. Treatment with Tb4 showed anti-inflammatory effects, helping resolve the injury. An application to human cells in a model of human corneal cells in culture showed that Tb4 enhanced epithelial cell migration in vitro.

RegeRx and Tb4

Thymosin beta 4, developed by RegeneRx Biopharmaceuticals as a pharmaceutical for the healing of wounds, is a synthetic version of the natural peptide. As Dr. Allan Goldstein emphasizes, “Tb4 represents a new class of wound healing compounds. It is not a growth factor or cytokine, but rather exhibits a number of physiological properties which include the ability to sequester and regulate actin, its potent chemotactic properties. . . and its capability to downregulate a number of inflammatory cytokines that are present in chronic wounds.” When a wound heals there are many growth factors produced in the area so that additional factors, such as those currently on the market for wound healing, may help but are not necessarily lacking. Tb4 treatment, however, adds a new dimension to wound repair by providing cells with actin as needed, for cell migration, replication and differentiation.

RegeneRX Biopharmaceuticals is focusing on the commercialization of Tb4 “For the treatment of injured tissue and non-healing wounds, to enable more rapid repair and/or tissue regeneration.” Especially needy are diabetics who suffer from poor blood circulation and loss of sensation of pain that keeps their wounds unnoticed and unattended for days, leading to ulcers that may not heal. Other hard healing wounds are pressure ulcers in patients who are bed ridden and often receive skin grafts as treatment, or reconstructive surgery.

RegeneRx is continuing with pre-clinical research, in collaborative arrangements with the National Institutes of Health, accumulating data on the effects of Tb4 and aiming for an IND application (Investigational New drug App-lication) to proceed with clinical studies. Phase I clinical trials will determine the ability of Tb4 to repair ulcers in diabetic patients and to reduce inflammation and accelerate recovery from burns and abrasions to the cornea.

Aging skin

Ultraviolet radiation damage or other injuries to skin that are associated with aging may be in the future repairable with Tb4, similar to the success with wound repair. It is a hopeful prediction that this small anti-inflammatory molecule, which plays a vital role in regeneration, remodeling and healing of damaged tissues, would help rejuvenate aging skin.

The potential of Tb4 to repair sun damaged and aging skin is yet to be established by extensive studies. Many of the biological events that occur in wounding are involved in skin impaired by sun and aging. Ultraviolet radiation damage or other injuries to skin that are associated with aging may be in the future repairable with Tb4, similar to the success with wound repair. It is a hopeful prediction that this small anti-inflammatory molecule, which plays a vital role in regeneration, remodeling and healing of damaged tissues, would help rejuvenate aging skin. The effects of Tb4 in accelerating wound repair are important following surgery; Tb4 would then have practical applications following cosmetic surgery, a procedure growing in popularity in our society, in dealing with aging skin.


What are growth factors?

A growth factor is a naturally occurring substance capable of stimulating cellular growth, proliferation and cellular differentiation.  Usually it is a protein or a steroid hormone. Growth factors are important for regulating a variety of cellular processes.

Growth factors typically act as signaling molecules between cells. Examples are cytokines and hormones that bind to specific receptors on the surface of their target cells.  (

What does that mean?

Growth Factors are responsible for signaling our cells to make changes in our body, usually when repairing damaged cells or replacing dead cells.

How many growth factors are in the human placenta?

The human placenta contains potent amounts, over 128, rich growth factors.  Recent scientific research has shown that placenta is a rich healing and development agent for the body.  Inside the womb these growth factors are responsible for triggering cell mitosis (cell division) or the making of new cells.  Because the faetus grows at such a rapid rate many growth factors are needed to facilitate the growth process of the unborn baby’s organs, tissue, nerves, bones and the brain in such a short period of time.

Are growth factors necessary to heal after birth?

Yes, growth factors will play a large role in the bodies healing process after birth, however as we age our bodies produce less and less of these growth factors slowing our bodies natural regeneration processes.  As well, new mothers will be passing most of their body’s important nutrients to their new baby through the breast milk, leaving little nutrients for themselves. When the placenta is consumed after birth the rich growth factors give direct attention to damaged or developing tissue in the body, most importantly uterine, vaginal and breast tissue.  We believe these growth factors have a direct connection with the almost immediate slowing of blood loss after consumption of the raw placenta smoothie.  Mammals who consume the placenta never bleed after birth because they consume their entire placenta raw giving the body a large boost of the growth factors needed to heal the body completely and immediately.

What research has been done to prove these effects?

Mitogenic action of cytokines from placenta are shown to have physiological affects on the body including anti-inflammatory properties, regulation of the autonomous system, improvement of blood circulation, wound tissue healing, inhibition of protease, enhancement of nerve generation, balancing multiple hormone levels, immune boosting, analgesic effect and improvement of intestinal environment. (MFIII Human Placenta Injection, 2009)

Around the world many pharmaceutical companies are researching the benefits of using growth factors from human or animal placenta to aid in tissue regeneration.  MFIII Human Placenta Injection is sold on the Internet for a heavy price giving the public a chance to benefit from placenta extract for a wide range of health problems.  Famous footballers from UK premiership teams are being flown to countries like Switzerland and Serbia to have placenta injections to aid in the recovery process after serious injuries.  Placenta extract is also used in high end face creams and anti-aging balms and serums.

Research into placenta extract and the benefits of using growth factors for medicinal purposes is still ongoing however the benefits of using the placenta outside of the womb are now clear and only proves more why new mothers should consider keeping their rich organ for themselves.  After all, do we really know what the hospitals do with unwanted placentas???

The materials currently used in soft tissue regeneration, which include collagen, hyaluronic acid, silicon, and other filler materials, have several disadvantages such as high cost, immunogenicity/allergenicity, and the risk of transmitting infectious diseases. Meanwhile, autologous fat grafts are more widely available; however, one limitation of this technique is the poor long-term graft retention in current clinical practice (Min et al., 2010). The transplanted fat grafts can lose volume over time due to tissue resorption that can result in the loss of 20-90% of the original graft volume (Cherubino et al., 2009). The ideal solution for soft tissue regeneration would promote the regeneration of vascularized adipose tissue to completely fill the defect volume (Brayfield et al., 2010).

Recently, Frerich et al. (2005) reported an in vitro co-culture model using human adipose stromal cells and human umbilical vein ECs, where perfused tubes formed capillary-like networks that sprouted from the central lumen wall. Kang et al. (2009) developed an in vitro 3D model of tissue regeneration in which human vascularized adipose tissue, human ASCs, and human umbilical vein ECs were co-cultured on 3D aqueous silk scaffolds. After two weeks of co-culture, continuous endothelial lumens formed. Furthermore, Min et al. (2010) demonstrated in an in vivo murine model that the transplantation of fat tissue with non-cultured ASCs improved long-term graft retention. Compared with transplanted fat tissue alone, fat tissue transplanted with non-cultured ASCs had a higher density of capillaries six and nine months after transplantation. The reasons for these successful results might be the pro-angiogenic growth factors secreted by ASCs, as described previously.

Wound healing might be interrupted by a variety of pathological conditions, such as diabetes, radiation and immunosuppression, resulting in refractory chronic wounds (Lorens et al., 2006). Growth factors involved in wound healing have been individually applied to the wound to promote wound healing in unfavorable conditions. However, the theoretical promise of this approach was unfulfilled due to the complex nature of wound healing, which involves a number of different growth factors (Ebrahimian et al., 2009; Brem et al., 2009). To achieve optimal results, all these growth factors should be applied continuously, as opposed to the intermittent applications of individual growth factors (Brem et al., 2009; Blanton et al., 2009).

ASCs secrete nearly all of the growth factors that take part in normal wound healing (Ebrahimian et al., 2009; Blanton et al., 2009; Kim et al., 2007; Rehman et al., 2004). After application, ASCs may remain viable at the wound site and secrete growth factors in a continuous and regulated manner in response to environmental cues, just as occurs in the natural wound healing process (Badillo et al., 2007). ASCs promote wound healing by increasing vessel density, granulation tissue thickness, and collagen deposition (Ebrahimian et al., 2009), and they also improve the cosmetic appearance of resultant scars (Blanton et al., 2009).

A ready blood supply is crucial for wound healing. VEGF secreted from ASCs induces the migration and proliferation of ECs, increasing the vascularity of the wound bed (Lorens et al., 2006; Rehman et al., 2004). It was both experimentally and clinically shown that the topical administration of ASCs to full-thickness radiated wounds increase the healing rate of the wound (Ebrahimian et al., 2009; Rigotti et al., 2007). Kim et al. (2007) demonstrated that ASCs stimulate fibroblast proliferation and migration and type I collagen secretion in an in vitro wound model. These findings suggest that ASCs may promote in vivo wound healing.

Musculoskeletal Regeneration

Current therapeutic approaches for muscle loss cannot restore muscle function effectively. ASCs can differentiate into chondrogenic, osteogenic, and myogenic cells in vitro, and thus could potentially be used to regenerate tissue in musculoskeletal system disorders (Zuk et al., 2001; Mizuno et al., 2002).

Muscle tissue contains muscle progenitor cells called satellite cells that lie underneath the basal lamina (Kim et al., 2006; Di Rocco et al., 2006; Mizuno et al., 2002). These cells can divide and fuse to repair or replace damaged fibers in response to acute muscle injury or in chronic degenerative myopathies (Kim et al., 2006; Mizuno et al., 2002). However, continuous muscle degeneration-regeneration cycles in chronic cases lead to a depletion of the satellite cell pool. Moreover, it is difficult to expand satellite cells in vitro and they rapidly undergo senescence (Di Rocco et al., 2006; Mizuno et al., 2002).

ASCs may provide an easily accessible and expandable alternative cell source for the cellular therapy of muscular disorders. ASCs were successfully differentiated into skeletal muscle cells and smooth muscle cells in vitro (Jeon et al., 2010; Mizuno et al., 2002; Di Rocco et al., 2006). Differentiated ASCs even exhibited a contractile function similar to that of smooth muscle cells in vivo (Rodríguez et al., 2006). ASCs have also shown a capacity for myogenic differentiation in vivo. Allogeneic ASCs injected intravenously or directly into the affected muscle could restore muscle function in a murine muscular dystrophy model without any signs of immune rejection (Di Rocco et al., 2006). In another study, poly lactic-co glycolic acid (PLGA) spheres attached to myogenically-induced ASCs were injected subcutaneously into athymic nude mice. Injected ASCs differentiated into muscle cells and regenerated into new muscular tissue (Kim et al., 2006). However, it is still unclear whether ASCs directly differentiate into myogenic lineage cells or whether they become incorporated into muscle fibers via cell fusion. It is likely that ASCs contain different subsets of cells capable of either function (Di Rocco et al., 2006).

ASCs can form osteoid in vitro and in vivo (Hattori et al., 2004). ASCs combined with biomaterials were successfully used to repair critical bone defects (Di Bella et al., 2008; Yoon et al., 2007). Moreover, ASCs secrete osteoinductive growth factors, which may potentially recruit host bone-forming cells and induce osteogenesis when implanted in vivo (Hao et al., 2010). ASCs genetically modified to secrete bone morphogenic protein-2 (BMP-2) may also be an effective method for enhancing bone healing (Peterson et al., 2005).

Use of ASCs in intervertebral disc regeneration has also been reported (Hoogendoorn et al., 2008). Other applications of ASCs in musculoskeletal system are periodontal tissue regeneration and tendon regeneration. Tobita et al. (2008) reported that implanted ASCs were differentiated into the periodontal tissues including alveolar bone, cementum, and periodontal ligament in a rat model. In addition, topical administration of ASCs to tendon repair sites in rabbits accelerated tendon repair and significantly increased tensile strength (Uysal et al., 2011).

Skin Treatments and Dermatological Procedures to Promote Youthful Skin
Paul G Sator
Department of Dermatology, Municipal Hospital Lainz, Vienna, Austria
The skin, the largest organ of the body, is the organ in which changes associated with aging are most visible. With increasing frequency, patients are requesting information and treatments that improve the appearance of their skin. Corresponding to this trend, there is an increasing number of products and methods available that claim to aid this pursuit. First, a change of the patient’s lifestyle (eg, sun behavior, nicotine abuse, and nutrition) must take place. Only then may other methods be used. This article reflects on the following topics: topical retinoids, peels, botulinum neurotoxin, soft tissue fillers, lasers, topical and systemic endocrinological therapies, and phytohormones. A thorough knowledge of the properties (benefits, limitations, and complications) of the expanding array of possibilities for rejuvenation of the skin is essential for any physician treating patients with cosmetic complaints.
Keywords: skin aging, topical retinoids, peels, botulinum neurotoxin, soft tissue fillers, lasers, topical endocrinological therapies, systemic endocrinological therapies, phytohormones
The skin is one of the largest organs of the body and, like all other tissues, it undergoes degenerative processes during aging. The skin represents the major organ in which aging-related changes are visible (Zouboulis and Boschnakow 2001). Skin aging is associated with increased rates of skin diseases including skin tumors, and with concomitant psychological distress caused by the deterioration in appearance. Although the main focus of public medicine has long been on age-related chronic diseases of other systems, such as arthritis, heart disease, and cancer (Kligman and Koblenzer 1997), skin aging and its diseases have become increasingly important. Most women in developed societies can expect to spend one-third or more of their lifetime in the postmenopausal period (Kligman and Koblenzer 1997) when the external signs of aging are of utmost importance for most.
Skin aging is caused by a combination of factors including genetic disposition and endocrinological background as well as UV light, life habits (nutrition, nicotine, alcohol, and drugs), catabolic (infections and tumors), and further environmental factors. Many women notice a sudden onset of signs and symptoms of skin aging during menopause, such as a rise in skin dryness, loss of firmness, decrease in elasticity, and increase in skin looseness. There is a connection between these clinical signs and such phenomena as decrease in collagen and elastin, changes in basic substance, the ratio of type I/type III collagen, and alterations in vascularization (Brincat 2000). The external signs of skin aging are reflected in the histopathologic findings of the skin (Broniarczyk-Dyla and Joss-Wichman 2001).
Dermatology patients are requesting information and treatments to improve the appearance of their skin with increasing frequency. The number of products and methods claiming to aid in this pursuit are rising. Many different ways may be helpful. Patients look for a prompt improvement while physicians emphasize safety and efficacy.
General procedures
Sun protection
Sun protection is essential for every age and is a necessary addition to all other interventions against skin aging. Chronic low-dose irradiation by the sun causes wrinkles (Kambayashi et al 2001; Gordon 2005). Ultraviolet irradiation reduces production of type I procollagen, the major structural protein in human skin (Quan et al 2004). To avoid photoaging, it is essential to use sunscreens every day and to protect one’s skin against UV A and B rays (a sun protection factor 15 is adequate, but a higher one is better). In addition, it is also important to use protective clothing or hats and to avoid the sun wherever possible.
Skin care
Cleansing and moisturizing the skin is important for many people. Properly cleaned and moisturized skin feels good to most people and looks better than dry skin. Effective products are available from most cosmetic companies and prevent irritant skin reactions and improve barrier functions. Sun protection, avoidance of cigarette smoke, and balanced nutrition is essential for the prevention of skin aging.
Topical retinoids
The topical retinoids, tretinoin and tazarotene, improve mottled hyperpigmentation, fine wrinkles, roughness, and lentigines (Kligman et al 1986; Kang et al 2001; Weiss 2005). One problem is skin irritation. To minimize this problem, it is useful to start with a relatively mild concentration of topical retinoids. If this is not enough, patients should reduce the application frequency. The aim must be to use the highest concentration that can be tolerated without significant irritation of the skin.
There are three categories of peels: deep peels (eg, phenol peel), medium peels (eg, 30% trichloracetic acid peel), and superficial peels (eg, alpha hydroxyl and salicylic acid peel). Creams with alpha hydroxyl and salicylic acid are also available for the everyday use of the patient. Depending on the depth of the peel, peels remove the uppermost layers of the skin.
Botulinum neurotoxin
Botulinum neurotoxin is a paralysing substance. It is used for softening glabellar frown lines, horizontal forehead lines, crow’s feet, perioral smile lines, platysmal bands of the neck, and to elevate the eyebrows and lateral corners of the mouth (Gordon 2005).
A careful history should be taken to avoid complicating neurologic problems or the ingestion of medications that may interfere with the toxin. The toxin diffuses about 1 cm–1.5 cm from the injection site. This must be considered to avoid eyelid ptosis, for example. The patient should not manipulate the treated area after treatment to avoid unintended diffusion of the toxin. The contraction of the treated muscles after treatment may increase toxin uptake and increase the effectiveness of treatment. The effect of the toxin is seen after about a week.
Soft tissue fillers
Physicians have been searching for the ideal filler for more than a century. The use of injected paraffin for cosmetic purposes more than 100 years ago resulted in paraffinomas (Murray et al 2005). Many substances are available today.
Collagen is a fibrous, extracellular, insoluble protein comprising a major component of connective tissues. Injectable collagen consists of varying concentrations of highly purifed bovine or human collagen. Sensitivity reactions and granulomatous responses have occurred in 1%–3% and 0.5% of patients, respectively (Cooperman et al 1985). Minor side effects such as bruising, redness, and swelling are seen after injection, but tend to resolve after a few days. Reimplantation is usually required in 3–6 months.
Bovine collagen
Bovine collagen is available in several formulations for fine lines as well as for deeper lines and folds. Patients must be allergy tested because of the possibility of rare allergic reactions. Two tests must be performed 3 weeks apart and treatment cannot be started until 3–4 weeks after the second allergy test.
Human-based collagen
No allergy testing is required.
Hyaluronic acid
Hyaluronic acid is a component of all connective tissues and is abundant in the human dermis. It is a naturally occurring glycosaminoglycan biopolymer, which provides a fluid matrix or lattice on which collagen and elastic fibers may develop. Its hydrophilic nature attracts and retains water (Pollack 1999). The incidence of allergic reactions is so low that no allergy testing is required. Corrections with hyaluronic acid generally last longer than with collagen.
There are also several formulations for fine to deep lines. There are products that are manufactured through bacterial fermentation and there are others that are extracted from rooster combs. Patients using the latter must not have an allergy to avian products.
Unusual hypersensitivity and granulomatous foreign body reactions have been reported, but hyaluronic acids are generally safe and practical and need no allergy testing (Murray et al 2005).
Autologous fat
Neuber introduced the use of autologous fat for tissue augmentation in 1893 (Neuber 1893). Over the years, the popularity of Neuber’s method has grown, but there is still no evidence-based gold standard method around. The longest lasting results are seen when used for atrophic skin conditions. Adverse events, such as fat necrosis, are temporary but not uncommon.
Allogenic products
Allogenic material is either obtained from cadaveric dermis or fascia, or engineered by methods using human cell lines and has a high biocompatibility with low antigenicity. These products are similar to the bovine collagens in indication and technique, but do not require allergy tests and have a shorter longevity.
Synthetic products
The production of synthetic products is cheaper and they are semipermanent or permanent implants. One of the first synthetic fillers was silicone. Today there are several substances available such as polylactic acid, polyalkylamide, polyacrylamide, and polytetrafluoroethylene. Adverse reactions with these agents can be serious.
Laser is the acronym for “light amplification by the stimulated emission of radiation”. Schawlow and Townes developed the first laser in 1958 (DiBernardo and Cacciarelli 2005). Lasers use light at various frequencies to attain a specific clinical result. They can be categorized by the medium in which the light energy is produced. Mechanisms of action include selective thermolysis and specific cell stimulation while leaving normal tissue unaffected. The immune system clears the unwanted material. Lasers can be used to cut, destroy, cauterize, and vaporize tissue. Dermatological indications are skin rejuvenation, tattoo removal, hair removal, and improvement in various skin abnormalities. For example, an ablative laser such as CO2 or erbium would be considered for skin rejuvenation. Complications could be pigment changes, superficial skin changes, scarring, infection, bleeding, and accidential eye injury.
Surgical procedures
There are many methods of cosmetic surgery such as facelifts not covered by this article. Space limitations preclude an extensive discussion of this field.
Endocrinological therapies for skin aging
Skin is a target organ for various hormones (Zouboulis 2000). Sex steroids have a profound influence on both skin development and composition; adequate levels are required to facilitate its structural integrity and functional capacity (Raine-Fenning et al 2003). Hormonal action requires the binding of the hormone to specific receptors (Zouboulis 2000). Estrogen and other hormone receptors have been detected, inter alia, in keratinocytes, fibroblasts, sebaceous glands, hair follicles, endocrine glands, and blood vessels (Schmidt et al 1990). The receptors vary in density according to site, with higher concentrations of estrogen receptors in facial skin than in the skin at the pelvis or breast. Decreased sex hormones thus induce a reduction of those skin functions that are under hormonal control.
In clinical terms, many females experience a sudden onset of skin aging symptoms several months after menopause. One of the first signs which women experience is increasing skin dryness followed by a loss of skin firmness and elasticity. The increasing looseness of the skin at that stage outweighs other symptoms such as wrinkles. These symptoms correspond to changes in collagenous and elastic fibers that have been reported to be due to estrogen deficiency (Schmidt et al 1994). A significant decrease in skin collagen starting at menopause has previously been demonstrated (Castelo-Branco et al 1992). This negative effect of the menopausal years on the skin was first described by Albright in 1940, who noted that older women with osteoporotic fractures had a higher incidence of altered skin (Albright et al 1940). Among the various types of collagen, types I and III are of major relevance. Type I collagen represents the predominant collagen type in adult human skin whereas type III collagen, also widely distributed throughout the body, predominates in fetal tissues. Both total collagen content and the ratio of type III to type I collagen decline with age (Sawas et al 1993). Skin collagen contents in adults decreases by 1% every year (Shuster et al 1985). This process is more evident in women than in men. Approximately 30% of skin collagen is lost in the first five years after menopause, with an average decline of 2.1% per postmenopausal year over a period of 20 years. Estrogens reverse this trend and increase skin collagen (Zouboulis 2000). Estrogens also enhance the synthesis of hyaluronic acid and promote water retention (Epstein and Munderloh 1975). Animal studies indicate that estrogens induce several changes in the connective tissue of the dermis, including increased mucopolysaccharide incorporation, hydroxy-proline turnover, and alterations in the extracellular matrix (Holland et al 1994).
Epidermal cells – keratinocytes, Langerhans’ cells, and melanocytes – are also target cells of steroid hormones (Zouboulis 2000). The estrogen receptor complex is able to support the expression of growth factors such as insulin-like growth factor type one (IGF-I), a mitosis-enhancing protein for keratinocytes (Tavakkol et al 1999). The Langerhans’ cells are influenced by progesterone, with their number increasing during the luteal phase. Melanocytes are stimulated by 17β-estradiol (Gruber et al 2002).
Sex steroids are involved in many extragenital organ systems such as the urogenital tract, skin and hair, breast, and cardiovascular, nervous, or skeletal systems. Considering that most women spend one-third of their lives with estrogen deficiency, the potential field of action for hormone replacement therapy (HRT) is becoming increasingly larger.
Topical treatment
A placebo-controlled study examined the effect of a topically applied conjugated estrogen skin care cream (Premarin® 0.625 mg/g ointment) in 54 women (Creidi et al 1994). Evaluation criteria were profilometry and measurements of skin thickness by ultrasound. After a 24-week treatment period there was a significant increase in skin thickness in the Premarin® group as compared to the placebo group. Even in regard to small wrinkles, a significant reduction was observed in comparison to the placebo group after 12 and 24 weeks. No side effects were found.
A study was published on the action of topical 0.3% estriol and 0.01% 17β-estradiol in 59 patients (Schmidt et al 1996). The criteria evaluated by the authors were profilometry, corneometry, and clinical signs. Wrinkle depth was significantly reduced and skin hydration was improved. Apart from a rise in prolactin, no other systemic hormonal effects were detected. Histological tests of collagen parameters in 10 patients showed a significant increase in the collagen III fraction at the end of therapy after 24 weeks.
In a recent study, the effects of a 0.01% 17β-estradiol cream were compared with those of a 15% glycolic acid cream and a combination of both (Fuchs et al 2003). The effects examined in 65 patients after 6 months indicated an increase in epidermal thickness and were most marked in the combination group (38%), followed by the glycolic acid group (27%), and the 17β-estradiol group (23%).
Systemic hormone replacement therapy
A HRT consists of two components: estrogens and progestagens. Estrogens administered as monotherapy may result in undesired hyperplasia of the endometrium. To avoid this event, synthetic derivatives of progesterone and testosterone, known as progestagens, are combined with an estrogen compound and may be applied in a cyclical or continuous mode. An estrogen monotherapy is feasible in hysterectomized women, with a choice of oral, transdermal, and vaginal forms of application available.
Beneficial effects of HRT on the skin have been documented by several studies in respect of skin thickness as a mirror image of collagen content (Brincat et al 1987; Maheux et al 1994; Dunn et al 1997; Sator, Sator, et al 2001). A large retrospective multi-center study, NHANES I, conducted in 3825 women in the USA, showed that women under long-term substitution had one-third fewer wrinkles than non-substituted patients (Dunn et al 1997). Postmenopausal women with an HRT had significantly higher collagen content than untreated women (Brincat et al 1987).
One study examined the effects of three types of HRT in terms of skin aging in menopausal women (Sator, Schmidt, et al 2001): one group was given estrogen only via the transdermal route (Estraderm TTS® 50), the second group received estrogen by transdermal application in combination with vaginally applied progesterone (Estraderm TTS® 50 and 0.4 g progesterone vaginal suppository), and the third group was administered oral estrogen and vaginal progesterone (2 mg Progynova® and 0.4 g progesterone vaginal suppository). One group without treatment served as a control. Treatment was continued for 6 months. Skin surface lipids, epidermal skin hydration, skin elasticity, and skin thickness were measured at monthly intervals. Mean levels of epidermal skin hydration, elasticity, and skin thickness were improved at the end of treatment based on both subjective and objective evaluation in patients with HRT. Skin surface lipids were increased during combined HRT, which may reflect stimulatory effects of the progestagen component on sebaceous gland activity, while estrogen alone has a sebum-suppressive action (Zouboulis 2001). A comparison of skin hydration and elasticity in UV-exposed and non-exposed areas revealed no significant difference. This finding suggests that both photoaged and UV-protected skin benefit equally from HRT. These results were confirmed by animal tests using the skin of rats (Tsukahara et al 2001).
Although the majority of publications consider the influence of HRT on skin aging to be positive, there are some authors who doubt or reject any effect of hormone replacement on skin thickness, collagen synthesis, or elastin (Oikarinen 2000).
Alternatives: phytohormones
The estrogen-like effects of some plants were first described in 1926 (Loewe et al 1927). Phytoestrogens are classified in three categories: isoflavones, coumestans, and lignans. The most thoroughly examined group of substances are isoflavones, which display some similarity to the mammal estrogen molecule and are found, inter alia, in soy, beans, lentils, and red clover. Flavonoids are also contained in wine, especially red wine. The most important isoflavones are genistein and daidecin. The group also includes the precursors formonontein (for daidecin) and biochanin (for genistein). Coumestans only occur in the sprouts of legumes. Lignans have no influence on estrogen receptors. The structural similarity to 17β-estradiol explains the estrogen-like effects, which may be traced back to the interaction of these substances with the estrogen receptor (Wang et al 1996). Nutrition in Asian countries, with its large phytoestrogen content, is thought to be the reason why Asian women rarely suffer from climacteric symptoms. The biological potency of isoflavonoids is significantly inferior to that of synthetic estrogens (Markieicz et al 1993). When phytoestrogens are topically applied, they behave like estrogens by causing a proliferation of the epidermis, supporting collagen synthesis and reducing enzymatic collagen degradation.
A controlled open European multicenter study examined the effect of a cosmetic cream preparation including isoflavone (Novadiol®) on 234 women: maximum age 65 years, at least 3 years since menopause, no HRT or other substances affecting the skin aging process (Bayerl and Keil 2002). The length of therapy was 12 weeks. The isoflavone cream was applied two times daily (in the morning with a concentration of 0.0075% isoflavone and in the evening with a concentration of 0.015% isoflavone) on the face, neck, and one upper arm. The other arm was untreated and served as a control. Skin dryness and roughness were significantly improved at the treated areas by 32.9% and 22%, respectively, in comparison with the untreated skin areas. Facial wrinkles were significantly reduced by 22% and skin looseness was significantly reduced by 24%.
Summary of hormonal therapies
Numerous publications on the effects of sex hormones on the aging process are available today. Without claiming that HRT can or should ever be regarded as an independent treatment of skin aging, these findings are still interesting to note, considering that they indicate a beneficial effect of HRT on the skin despite the fact that the results of the “WHI-Study” (Rossouw et al 2002) and the “Million Women Study” (Beral 2003) have shown negative effects of HRT on other organs. What is clear is that HRT must be rejected when it is solely considered for the prevention of skin aging. As an additional benefit in the treatment of menopausal conditions provided by a dermatologist with sufficient experience in the discipline of endocrinology, however, it is a very effective instrument to control intrinsic skin aging.
While the topical application of hormones is certainly a suitable alternative to a systemic HRT, it must be ensured that such a treatment is also administered by a dermatologist experienced in endocrinology given that concentrations and application areas need to be observed in order to avoid systemic side effects.
Phytoestrogens, topical and systemic, appear to be an effective method in the treatment of intrinsic skin aging. However, further data are still required, especially from controlled studies on long-term results of systemic application.
An increasing number of products and procedures exists to promote youthful skin. First, a change of the lifestyle (eg, sun behavior, nicotine abuse, nutrition) of the patient must take place. Only then can other methods be used. A thorough knowledge of the properties (benefits, limitations, and complications) of the ever-expanding array of possibilities for rejuvenation of the skin is essential for any physician treating patients with cosmetic complaints.

Photodamage to the skin is due to extrinsic, ultraviolet radiation (UVR). There are currently two theories about aging: the first maintains that aging is genetically pre-determined,1 while the second suggests that aging is
related to the cumulative effects of environmental damage.2,3 Our perception of a person’s age and beauty mainly depends on the appearance of his or her skin.

Photoaging—Clinical and Histological Features

The clinical features that are associated with photodamage include dyspigmentation, laxity, yellow hue, wrinkling, vascular ectasia, thickened skin, and malignancies. In contrast, intrinsically aged skin shows signs of laxity, skin sagging, and wrinkles, but lacks evidence of UV damage. Histologically, photodamaged skin has undergone changes termed ‘heliodermatitis.’4 These changes include increased fibroblasts, flattened dermo-epidermal junction, atrophy, inflammatory infiltration, disorganized collagen fibers, and accumulation of amorphous elastincontaining material.2,5,6 Glogau classified photoaging into four types (see Table 1). Type I patients
with early photoaging are in their 20s to 30s and experience mild pigmentary changes, but no rhytides. Type II patients have moderate photoaging and are in their 30s to 40s, and have dynamic wrinkling and
dyspigmentation. Type III patients have advanced photoaging and are typically in their 50s. They have wrinkles at rest, dyschromias, vascular ectasias, and visible keratoses. Type IV patients have severe photoaging.
Generally, they are in their 60s to 70s, but may be younger. They have wrinkles covering the majority of the face, thickened coarse skin, a yellow-gray skin color, and a history of cutaneous malignancies.
There is evidence that reactive oxygen species (ROS) formation in response to UVR leads to photodamaged skin. Levels of antioxidants and enzymatic protection decline with age.7 Both UVA and UVB cause photodamage. UVB induces DNA mutations with subsequent carcinogenesis. UVA is believed to induce ROS, mitochondrial DNA damage, and carcinogenesis, and contributes to the aging process.8,9 The other biological effects of photodamage include dyschromias, such as lentigines and guttate hypomelanosis.2 Sunburn as a result of UV exposure is thought to be induced by nuclear factor-kappa B (NF-κB) pathways. UVR induces angiogenesis by increasing vascular endothelial growth factor (VEGF) production. An extremely important biological effect of UVR is immunosuppression—both local and systemic. After UVR exposure, Langerhan cells are depleted from the epidermis,10 which prevents the immune system from fighting photodamage.

Intrinsic Protection Against Photodamage
There are various responses and mechanisms utilized by the skin to counteract or reduce photodamage. Melanin production and distribution provide a protective mechanism against photodamage, as is evidenced by
a comparison of black and white skin, which have different levels of response to UVR exposure. UVR exposure induces protein (p)-53, which participates in the repair process, halting the cell cycle in the G1 phase
for DNA repair.11 There are conflicting reports regarding the role of tissue inhibitors of metalloproteinases (TIMP) after UV exposure. Human skin possesses antioxidants such as vitamin E, co-enzyme Q10 (CoQ10),
ascorbate, carotinoids, and enzymatic antioxidants such as superoxide dismutase, catalase, and glutathione peroxide. These antioxidants are  depleted as a result of excessive UVR exposure.12

Treatment Options for Photodamage
The treatment options for photodamaged skin can be categorized into a disease-prevention-based paradigm (see Table 2).13 Primary prevention refers to the reduction of risk factors before a disease has occurred.
Secondary prevention includes early detection, prevention, postponement, and attenuation of a clinical condition. Tertiary prevention is the treatment of an existing disease.

Sun protection is both a primary and a secondary preventive measure  against photodamage. Sun protection can be achieved by the use of protective clothing, hats, sunglasses, etc. Photoprotective clothing is measured by its ultraviolet protection factor (UPF) value. For example, a clothing item with UPF 40–50 protects by transmitting only 2.6% of effective UVR.14 Sunscreens are designed to protect against UVB 290–320nm, UVA 320–400nm, UVC <290nm. The deeper penetrating UVA rays are mostly responsible for photoaging, while UVB rays are more responsible for photocarcinogenesis. In studies, sunscreens with both UVA and UVB protection have provided better protection than sunscreens with only UVB filters.
Sunscreens have different formulations worldwide (see Table 3). The ideal agent should be cosmetically pleasant, non-toxic and non-allergenic, effective against both UVA and UVB, photostable, and water-resistant.
Sunscreens have traditionally been divided into chemical or organic sunscreens that absorb UVR and convert it to heat, thus preventing UV interaction with skin. Sunblocks or inorganic agents have particles that reflect photons away from skin. UVB-absorbing sunscreens include p-aminobenzoic acid and its esters (padimate A and O), the cinamates, and salicylates. UVA sunblocks contain titanium dioxide and zinc oxide, and UVA-absorbing sunscreens include avobenzone (Parsol® 1789). Titanium dioxide provides excellent UVA II protection, but is less effective for UVA I. Parsol 1789 and zinc oxide have good UVA I protection, but lack UVA II protection.15 There are newer products on the market such as Mexoryl® and Helioplex™. Mexoryl has been shown to decrease DNA damage and instability in the melanocyte layer by reducing the formation of free radicals. It has also been shown to reduce the p53 mutations caused by UVA radiation.16 The new chemicals being developed provide efficient UVA coverage and better photostability.
Albert Kligman first reported the beneficial effects of tretinoin on photoaged skin of middle-aged women undergoing treatment for acne.17,18 Statistically significant improvement was noted in their appearance, surface roughness, fine and coarse wrinkling, mottled pigmentation, and sallowness in a clinical trial.19 Epidermal acanthosis and hypergranulosis regressed within the first 12 months of therapy.
Improvement of wrinkling corresponded to increased papillary dermis collagen deposition.21 Tretinoin treatment also appears to reverse histological changes of aging both in vivo and in vitro.

Tazarotene has also been shown to reduce roughness, wrinkling, mottled pigmentation, and pore size. There is convincing evidence that topical tretinoin repairs mild to moderate photodamage.
Many studies have established a link between the application of topical antioxidants and the treatment of photoaging. These studies are small and most of the changes are considered to be associated with use of the antioxidant, and may not be statistically significant (p<o.05). Topical vitamin C has been shown to reduce erythema and sunburn cell formation. Vitamin C upregulates collagen and TIMP synthesis in human skin.22 CoQ10 is part of the mitochondrial electron transport chain. Topically applied, it has been shown to reduce wrinkles23 and is a potent antioxidant.
Oral soy isoflavinoids enhance the endogenous anitoxidant enzymes. Genistein and N-acetyl cysteines reduce collagenase upregulation after UV exposure. Gluconolactone has antioxidant properties and alphahydroxy
acids (AHA)-like effects. When taken orally, green tea propophenols inhibit metalloproteinase expression after UV exposure.
N-furfuryladenine is a synthetic plant growth hormone with antioxidant properties.24 The list grows daily and has led to a booming cosmetic industry known as ‘cosmeceuticals.’
Growth Factors and Cytokines
A fructose-rich polysaccharide, ‘FROP3,’ increased glycosaminoglycan  synthesis by fibroblasts.25 In a pilot study, a cream containing FROP3 showed a 10–15-year decrease in apparent age after four weeks of use.

Chemical Peels

Chemical peels with AHAs, salicylic acids, trichloracetic acid, and phenol are used to treat photodamage and mottled pigmentation. The peels are classified as superficial, medium, or deep correlating to the depth of
injury induced.27 Glycolic acid is an AHA that reduces fine wrinkling.  It has also been shown to thin the epidermis and induces dermal collagen synthesis.

Cutaneous Resurfacing Techniques
This process exfoliates and ablates the superficial dermis. Microdermabrasion activates a closed, dermal wound-healing process and increases cytokines, matrix metalloproteinases (MMPs), and type I procollagen messenger (m)-RNA production.29 Significant increases in papillary dermal thickness and improved elastin organization have been observed.

Lasers, Light Sources, and Radiofrequency Devices
Ablative Laser Systems
These systems include CO2 lasers and erbium-yttrium aluminium garnet (Er:YAG) lasers. The CO2 laser was once the gold standard in facial resurfacing, and can produce dramatic improvements in skin tone, wrinkle severity, and atrophic scar depth.31–34 The Er:YAG was developed to reduce the morbidity associated with CO2 and has demonstrated comparable results. The biochemical changes seen with ablative resurfacing include increased interleukin (IL)-1β, tumor necrosis factor (TNF)-α, transforming growth factor (TGF)-β1, type I and III procollagens, and MMPs.
Non-ablative Laser Systems
Treatment of photodamaged skin with non-ablative lasers has become increasingly popular and effective. These devices induce target-specific rejuvenation and non-ablative skin remodeling. The targets are three-fold:
reduction in vascular anomalies, pigment anomalies, and static fine wrinkles.36–38 Various lasers systems have been used for this purpose and will be briefly discussed. Hemoglobin is the primary target, and melanin or
pigment the secondary target, of 532nm lasers. The main benefit is for facial telengiectasis, but it is also good for lentigines and tattoos.
Flashlamp pulse dye (FPD) lasers are the gold standard for vascular lesions, and operate at 585nm/595nm. Success with dermal remodeling has recently been reported.40 The current trend is to use the longer wavelength of 595nm for less severe vascular bruising. Cooling is accomplished by a dynamic cooling device, e.g. the Candela V Beam™, the Cynosure V Star, or the NLite laser.40–43 Quality-switched (QS) lasers deliver an ultra-short pulse duration, which is critical for target disruption. Primary wavelengths used are 532, 694, 755, and 1064nm. The first three treat vascular and pigmented lesions, and the fourth treats dermal pigments such as tattoos and melanin. The QS 1064 has shown efficacy in dermal collagen deposition and remodeling.44,45 Long-pulsed (LP) near-infrared lasers include the LP 755, 800, and 1064nm models. They target hemoglobin and melanin. If cooling is inadequate, it can lead to full-thickness scar formation.46 LP mid-infrared lasers do not cause melanin or hemoglobin absorption; instead, they target water. New collagen synthesis without epidermal damage has been reported.47–49 The devices include Cool Touch® 1320nm neodymium-doped (Nd):YAG, Candela Smoothbeam 1450nm Diod laser, and Aramis 1540nm Er:Glass laser.

Broadband Light Sources
Broadband light sources are versatile and have proved to be effective clinically and histologically,49–52 and the intense pulsed light (IPL) version is the most studied.53–55 These devices emit light of 515–1200nm that can
be manipulated with various filters. Photothermolysis is obtained via absorption by deoxyhemoglobin, the chromophore at 600–750nm. IPL systems can achieve photorejuvenation by improving mottled pigmentation, telengiectasis, and skin texture. The data also support long-lasting effects of up to five years.56 It is anticipated that after three to five treatments improvement in pigment, vasculature, pore size, and fine wrinkles will occur. Examples include Lumenis Quantum, DDD  Ellipse, Palomar Medilux™, and Starlux®. Fractional Photothermolysis A hybrid novel technology combining ablative and non-ablative resurfacing is fractional photothermolysis. The technique has been validated by many studies and supporting results.57 A mid-infrared laser at 1550nm is used with vertical microthermal columns of 100–160μm width, which can be adjusted for 300–700μm penetration.58 The pixilated laser leaves 70% of the treated area undamaged and promotes rapid healing. There is a reported patient-to-patient consistency in collagen remodeling and epidermal regeneration. Examples include the Reliant Fraxel® Laser, Palomar’s Star Lux, and Cynosure’s Affirm.
Radiofrequency and Infrared Heating
The first non-surgical treatment to address the soft-tissue redundancy has been radiofrequency (RF) with Unipolar RF (ThermaCool TC, Thermage, Inc., Hayward, California).59–62 RF does not target a specific  hromophore; instead, it produces controlled volumetric heating of the deep dermis with subsequent collagen degeneration and tissue shrinkage. Unipolar RF carries a risk of subcutaneous atrophy. More recently, bipolar radiofrequency has been used. Syneron’s Aurora is a widely used bipolar device.

Photomodulation utilizes non-thermal neo-collagen synthesis. Most widely used are light-emitting diodes (LEDs) such as Gentlewaves® 590nm LED (LightBioScience LLC, Virginia). LED treatments are administered
immediately after fraxel or photorejuvenation treatment.

Soft-tissue Augmentation by Fillers
Restoration of facial volume and contour by fillers has become a popular and effective treatment of photoaged skin. Fillers are used to either correct pre-existing defects or augment existing facial structures. There is a plethora of available filling substances and the choice of the filling material depends on many factors.
Autologous fat is one of the oldest fillers and is still widely used. Its advantages include high volume, ease of use, and low cost, and, being autologous, it causes no reactions. Fat is excellent for nasolabial folds, marionette lines, and cheeks. It is transplanted to the face after being harvested from another region of the body, such as the abdomen or thighs.
Bovine collagens have been available for many years, e.g. Zyderm I, Zyderm II, and Zyplast. They have been used for depressed scars, nasolabial folds, and lips. Two of the disadvantages are adverse reactions and a need for skin tests prior to administration.
Synthetic human collagens are available i.e. CosmoDerm I® and CosmoPlast®, and the advantage is avoidance of reactions. All collagens are limited by longevity, and rarely persist six months after injection. They can
be used for many sites, but are most often used for lip augmentations. A new collagen called Evolence™ promises one-year longevity.
Hyaluronic acid (HA) materials are derived from rooster combs or bacterial sources.63 They are less immunogenic than other methods, as HA is identical across species. It is a naturally occurring polysaccharide, and is the most plentiful glycosaminoglycan in the dermis. It is negatively charged, and able to hold large amounts of water. Compared with bovine collagen, no signs of incompatibility are noted in HA products.64 These products last for six to 12 months and undergo isovolumic degradation. There are no skin tests required, and there is no overcorrection with the injections. Many products are available, including Hylaform®, Achyl®, Restylane®, Dermalive®, Perlane®, Hyacell®, Juvederm®, and Viscontour®.
The products are used for various conditions such as facial rhytides and contouring, nasolabial folds, patulous scars, and lip volumization. These products are not suitable for dynamic rhytides, ice-pick scars, striae, or actinically damaged lips. Absolute contraindications include
hypersensitivity, history of anaphylaxis, and implantation for breast, muscle, bone, and tendon augmentation.
Long-lasting filler agents include Sculptra™ (containing poly-L-lactic acid), Radiesse® (calcium hydroxylapatite), and silicon. Sculptra is approved by the US Food and Drug Administration (FDA) for treating HIV-lipoatrophy for high-volume correction of the face, and it is easy to use. Often, several treatment sessions are required to obtain the desired effect. Radiesse is approved by the FDA for facial rhytids in the nasolabial folds. It is similar to HA in many ways, but the injection technique is slightly deeper. Radiesse is not yet recommended for injection into the lips.
Photodynamic Therapy
Actinic keratosis (AK), a pre-malignant condition, is a feature of chronically
photodamaged skin. Topical photodynamic therapy (PDT) with aminolevulonic
acid (ALA) (Levulan Kerastick®, DUSA, Wilmington, Massachusetts) and
methyl-aminolevulonic acid (MAL) (Metvix®, Galderma, Watford, UK) is an
effective treatment option for AK and also offers excellent cosmesis.65
Recent studies show that PDT induces photochemo-rejuvenation of some
manifestations of photoaging. Both ALA and MAL have been used in
conjunction with blue light, IPL, and other laser wavelengths for
treatment of AK. Many of the studies have also shown other benefits of
PDT for photodamaged skin, including improvement in skin texture,
global quality, fine wrinkling, and sallowness.66 In recent studies,
ALA–IPL–PDT has shown superiority over IPL alone in reducing mottled
pigment and fine wrinkles.67 Clinical findings indicate that Levulan with
blue light and Metvix with red light induce a high clearance of AKs, as
well as improved fine wrinkles, texture, and sallowness, whereas IPL–PDT
assists in improving telengiectasis and erythema.68 So far, the mechanism
of action of PDT in photochemo-rejuvenation is largely unknown.

Botulinum Toxin A
In 2002, botulinum toxin A was approved by the FDA for treatment of glabellar lines. The toxin blocks the post-synaptic release of acetylecholine, thereby inhibiting muscle contraction. Botulinum toxin does not directly
reverse photodamage, but delivers a rejuvenated look by relaxing muscles causing dynamic wrinkling of the face. The effect typically lasts for between three and nine months.

Fluorouracil and Imiquimod
Both fluorouracil (5-FU) and imiquimod have been successfully used to treat AK, Bowen’s disease, and superficial basal cell carcinomas. All of these conditions are as result of UV photocarcinogenesis and a part of chronically photodamaged skin. The treatments of AK result in excellent cosmesis and prevention of skin cancers.
Effective treatment of photodamage is complex. Cosmetic treatments often target complaints of discoloration or wrinkling. Medical treatments target carcinogenesis. The number of healthy older patients is increasing
and thus the demand for better, longer-lasting treatments is on the rise. It is an exciting time in the field of treatment of photodamage.


Turns out that stanozolol, the good old “Winny”, has unique collagen synthesis stimulating properties, that no other steroid has..

Stimulation of collagen synthesis by the anabolic steroid stanozolol

Researchers: Falanga V, Greenberg AS, Zhou L, Ochoa SM, Roberts AB, Falabella A, Yamaguchi Y; University of Miami School of Medicine, Department of Dermatology, Miami, Veterans Affairs Medical Center, Florida, USA.

Source: J Invest Dermatol 1998 Dec;111(6):1193-7

Summary: In this report, we measured the effect of the anabolic steroid stanozolol on cell replication and collagen synthesis in cultures of adult human dermal fibroblasts. Stanozolol (0.625-5 micrograms per ml) had no effect on fibroblast replication and cell viability but enhanced collagen synthesis in a dose-dependent manner. Stanozolol also increased (by 2-fold) the mRNA levels of alpha1 (I) and alpha1 (III) procollagen and, to a similar extent, upregulated transforming growth factor-beta1 (TGF-beta1) mRNA and peptide levels. There was no stimulation of collagen synthesis by testosterone. The stimulatory effects of stanozolol on collagen synthesis were blocked by a TGF-beta1 anti-sense oligonucleotide, by antibodies to TGF-beta, and in dermal fibroblast cultures derived from TGF-beta-1 knockout mice. We conclude that collagen synthesis is increased by the anabolic steroid stanozolol and that, for the most part, this effect is due to TGF-beta-1. These findings point to a novel mechanism of action of anabolic steroids.

Discussion: I must first acknowledge that the commonly held belief is that anabolic steroids predispose an athlete to tendon rupture. This conclusion is drawn from animal studies showing that some steroids produce a larger, stiffer tendon in rats and that these steroid-induced tendons “fail” before the tendons from the control animals. The term fail refers to the breaking point.

The interesting thing about the present study is that the steroid stanozolol (Winstrol) had a different effect than testosterone. If you are a regular reader of MESO-Rx you should be well aware that not all steroids act in the same manner. And that because of subtle differences in there molecular structure they are able to elicit different responses. For example, Deca seems to act primarily through the androgen receptor (AR) where as Dianabol has effects beyond those associated with the AR.

Because synthetic steroids have differ in their chemical properties it should not be surprising that testosterone did not have the same effect as Winstrol. Winstrol increased collagen synthesis as opposed to testosterone which did not in this study. Interpreting the results of this study are more difficult than simply describing them. Other researchers have suggested that steroids cause a rapid increase in protein synthesis within tendon fibroblasts which results in fibroids or fibrous nodules within the tendon (Michna,1988). These fibroids alter the mechanical properties of the tendon perhaps predisposing it to rupture. It is also noted that during short term use of steroids there is an alteration in the alignment of collagen fibers which may also lead to rupture. Interestingly these alterations in collagen metabolism are transient with markers of collagen turnover returning more or less to baseline after 3-4 weeks of steroid administration (Karpakka,1992). These same researchers noted that low dose anabolics effect primarily muscle collagenous tissue with tendon being effected only at higher doses (i.e. 5 times the therapeutic dose) which would more closely represent what is needed by bodybuilders to put on mass.

The question remains, dose this mean that Winstrol will actually help prevent tendon injury or will it lead to bigger yet stiffer tendons prone to injury? It is difficult to take animal research and extrapolate the results to humans. Stanozolol is used therapeutically in humans to treat a variety of connective tissue and vascular disorders and its clinical effects suggest that it can modulate connective tissue breakdown in people. Despite being labeled as “ineffective” by many bodybuilders it is very popular among athletes. As with most hormones, dosage plays a role in what effects are seen, be they positive or negative. Hopefully future studies will shed light on the therapeutic effects of different steroids on tendons in humans.


Michna H Appearance and ultrastructure of intranuclear crystalloids in tendon fibroblasts induced by an anabolic steroid hormone in the mouse. Acta Anat (Basel) 1988;133(3):247-50

Karpakka JA, Pesola MK, Takala TE. The effects of anabolic steroids on collagen synthesis in rat skeletal muscle and tendon. A preliminary report. Am J Sports Med 1992 May-Jun;20(3):262-6