We listen to our patients ask about skin care and it becomes clear that many people are confused. What is a good skin care plan? There are hundreds of products. There are conflicting and exaggerated claims. Much of what you read and hear is based on marketing rather than on scientific information.

Over the counter products can be ineffective for two reasons: the concentration of the active ingredient is often too low, and the "active" ingredient can actually be in a form that does not penetrate the skin.

There is also confusion about professional skin care because different dermatologists and plastic surgeons offer different treatments with peels and lasers. There is more scientific evidence for some treatments than for others.

Protection & Prevention

Even though talking about sunscreens has become boring by now, study after study show that people do not use sunscreens properly. Patients typically apply one fourth to one half the recommended amount and they don't reapply sunscreens frequently enough when outdoors. Also remember that the sun protection factor (SPF) of a sunscreen indicates only its ability to block ultraviolet B (UVB) light. UVB light causes sunburn and skin cancer, but ultraviolet A (UVA) light penetrates deeper into the skin and causes aging. Be sure to use a sunscreen that absorbs both UVA and UVB rays. I believe that non-chemical broad-spectrum sun blocks, such as transparent zinc oxide, are best. One good example is: Ultimate UV Defense by SkinCeuticals. In addition to sun blocks, retinol creams protect against sun damage by preventing harmful chemical reactions and also by preventing loss of collagen. There is also evidence that antioxidants such as vitamin C protect against sun damage when applied to the skin.

Skin Creams to Treat Wrinkling and Pigmentation

1. Rx-A (Tretinoin Cream)

Tretinoin is a Vitamin A derivative. Multiple studies have shown that tretinoin (the active ingredient in Retin-A and Renova) is effective in the treatment of sun damage and skin aging. Tretinoin increases collagen production in the skin, reduces pigmentation, and produces a rosy glow. Our cream (Rx-A) contains 0.05% tretinoin and is compounded in our office by a pharmaceutical company. Its advantage is that it has a much better base for skin penetration. Patient education is very important, because some patients stop using the cream before it has had a chance to work. It can take 3 to 6 months to see the full results. Some patients find that the tretinoin cream irritates the skin with redness and peeling initially. The key is to start very slowly. Apply Rx-A every third night to build up tolerance. Even using Rx-A once a week will help. If to stick with it for several weeks, the cream can then be used nightly. We also have an effective tretinoin-based bleaching cream (Tri-fade).

2. Other Vitamin A Products

As mentioned above, tretinoin is a Vitamin A derivative. Retinol is Vitamin A itself, and we find it useful for patients with very sensitive skin who cannot tolerate the Rx-A cream, because Retinol is milder. Retinol is also effective for patients with rosacea. We use La Roche Posay (Biomedic) Retinol Cream. There are two other Vitamin A derivatives (Tazorac and Differin) which are useful skin creams, but there is less experience with these. Tazorac may be even more effective than tretinoin but it can also be more irritating.

3. Glycolic Acid

Glycolic acid and other alpha hydroxy acids are very popular in skin care products. However, there really is no good scientific evidence that glycolic acid in cream form is effective. What we do find effective are glycolic acid wash and lactic acid wash. These cleansers prep the skin before applying retinol cream or Vitamin C serum. Which wash is best for you will depend on your skin type. We use Purifying Cleanser by LaRoche-Posay-(Biomedic) and Refinity Purifying Cleanser by Cosmederm.

4. Antioxidants

Antioxidants, such as vitamin E, can be effective in treating aging skin. The problem is that in many products the antioxidant molecules are not in a form that can be absorbed by the skin. However, there are two products, Active C Cream by LaRoche-Posay and Topical Vitamin C Serum by SkinCeuticals, which indeed do enter the skin in active form. The Active C cream is better for more sensitive skin.

5. Estrogen Cream

Estrogen cream significantly improves the skin after menopause. It can be used by women who are not on hormone replacement therapy and who are not at risk for estrogen responsive cancers such as breast cancer. Women use vaginal estrogen cream on their face because there are no estrogen creams specifically developed for facial skin. In post-menopausal women, estrogen cream may be a useful adjunct to retinol and vitamin C serum.

Professional Skin Treatments

For prevention and treatment of mild skin damage, skin care at home may be enough. A typical home regimen consists of sunblock, retinol, and Vitamin C. When the wrinkles and pigmentation begin to get worse, we use both superficial chemical peels and MicroPeel Dermaplanning. Superficial chemical peels reduce pigmentation and fine lines. For patients with delicate skin, the Refinity Glycolic Acid Peel is good. For other patients, The MicroPeel Plus Salicylic Acid Peel penetrates a little deeper. MicroPeel Dermaplaning is another good procedure for treating sun damage, superficial lines, and pigmentation. It also improves the texture of your skin. In MicroPeel Dermaplaning, the skin is first cleansed with lactic acid and then a blade is used to exfoliate superficial damaged cells. Then a papaya extract is applied to the skin as an anti-inflammatory. There is no down time with either superficial chemical peels or MicroPeel Dermaplaning. Superficial chemical peels are alternated with the MicroPeel Dermaplaning every six to eight weeks. I feel that for most patients, superficial peels and Dermaplaning are more effective than microdermabrasion. Intense Pulsed Light (IPL) treatments and non-ablative (no down time) lasers are widely used but, in my opinion, the improvement produced by these procedures is very subtle and we do not use them.

Intermediate and Deep Resurfacing

For marked skin damage with wrinkling and pigmentation, I use laser resurfacing. I believe that the laser is safer, more predictable, and more effective than either deep chemical peels (TCA, Phenol) or dermabrasion. But, which laser is used is very important. Carbon Dioxide (Co2) lasers leave the skin red for too long and can cause permanent skin bleaching. Conventional short pulse Erbium lasers are only good for superficial wrinkles. I use the Contour Variable Pulse Erbium Laser. The Contour laser delivers short pulses and higher energy longer pulses as needed. So that with the Contour laser, I can individualize the treatment for each patient and for each part of the face. You can have laser resurfacing of the whole face or just around the mouth or around the eyes.

For Sagging Skin

The treatments described above work for superficial skin aging: that is for wrinkling and pigment changes. The only effective non-invasive treatment for sagging skin is the Thermage skin tightening procedure. Thermage causes collagen contraction and collagen production in the deep layers of the skin and just below the skin. Thermage improves sagging in areas such as the jowls, brows, arms, and abdomen.