elderly skin and its rejuvenation_products and procedures for the aging skin_ramos e silva et al...

8/11/2019 Elderly Skin and Its Rejuvenation_Products and Procedures for the Aging Skin_Ramos e Silva Et Al 2006

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Elderly skin and its rejuvenation M Ramos-e-Silva & S C da Silva Carneiro

2007 Blackwell Publishing Journal of Cosmetic Dermatology , 6, 4050 41

Table 1 Clinical changes seen in sun-exposed and sun-protected skin.

Clinical changesExposed skin Unexposed skin

Thickened and nodular Thinned and smooth

Yellow and sallow Clear, almost transparentCoarse wrinkling Fine wrinklingRough SmoothFrequent telangiectasia and ecchymoses Less frequent telangiectasias and ecchymosesMultiple lentigines Minimal lentiginesMottled pigmentation Even pigmentationElastotic, lax skin Inelastic, saggy, redundant skinComedones MiliaDecreased sweating Decreased sweatingMarked dryness and scaliness Dryness and some scalingEasy tearing and shearing of skin Fragile skinIncreased numbers of seborrheic and other keratoses Few seborrheic and other keratosesIncreased numbers of premalignant lesions Ocasional premalignant lesionsIncreased numbers of malignant lesions Ocasional malignant lesions

Reprinted from Benedetto, with permission from Elsevier Science. 9

Table 2 Histopathologic changes observed in the epidermis and dermis of sun-exposed and sun-protected skin.

Exposed skin Unexposed skin

Epidermal histopathologic changesReactive thickening, with eventual marked epidermal atrophy Slight decrease in thicknessSlight elongation of rete ridges Rete ridges effacementCellular atypia Flattening of dermalepidermal junctionLoss of polarity Decreased dermal and epidermal contactVariability in basal cell morphology with cytoplasmic microfootlets present Nearly normal basal cells with loss of cytoplasmic microfootletsIncreased melanogenesis Decrease in the number and function of melanocytesMarked decrease in the number and function of Langerhans cells Moderate decrease in the number and function of

Langerhans cells

Dermal histopathologic changesGrenz zone present Grenz zone absentThick, degraded nonfunctional elastic fibers Decrease in total volumeIncrease in amorphous elastotic material Decrease in cellularityIncrease in collagenogenesis Degenerated elastinIncrease in soluble collagen Decrease in soluble collagenActivated fibroblasts Less prominent fibroblastsDecrease in mature collagen (insoluble) Increase in mature collagen (insoluble)Increase in collagenase activity Loss of oxytalan fibersFragmented collagen Haphazard, rope-like collagen bundles

Increase in glysosaminoglycans and proteoglycans Increase in glysosaminoglycans and proteoglicansMarked regression and disorganization of small blood vessels Less prominent regression and disorganization of

small blood vesselsMarked thickening of post capillary venular walls, increased number

of veil cellsLess prominent and even thickening of small vessel

walls, decreased number of veil cellsPerivenular chronic inflammation No evidence of inflammationMarked decrease in sweat-gland number and function Reduced sweat-gland number and functionMarked increase in sebaceous-gland size, but decrease in function Increase in sebaceous-gland size, but decrease in function

Reprinted from Benedetto, with permission from Elsevier Science. 9


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42 2007 Blackwell Publishing Journal of Cosmetic Dermatology , 6, 4050

cells in the senescence process are keratinocytes andbroblasts, which are reduced in numbers. Hair and nailgrowth are retarded. Synthesis of vitamin D decreases astime goes by, and last but not least, the immune response

is also impaired. 1013 All these situations lead to alterationof skin functions, such as protection, excretion, secretion,absorption, thermoregulation, and sensory perception.

Besides the reduction in the number of keratinocytes,epidermal changes associated with aging involve the at-tening of its underside, a reduction in the number of Langerhans cells, and also in the number of melanocytesand synthesized melanosomes, leading to reducedpigmentation. 11,12,1418

Dermal changes are represented by a reduction of broblasts, collagen and elastic bers, mast cells andmacrophages, and also dilation of the lymphatic channels.The dermalepidermal junction is attened and thenumber of hair follicles decreases with age, althoughtheir structure remains unchanged. 11,12,1418

There is a progressive reduction in sebum production.Water-binding capacity of the stratum corneum isdecreased. Loss of fat and redistribution of the existing fat

in the subcutaneous layer of the skin result in changes infacial contour. Function of both Meissner and Paciniancorpuscles are decreased. There are changes in cutaneouspermeability to chemical substances and increased pro-duction of free radicals is also observed. 8,1921

Colorimetric measurements show that elderly skin isdarker than young skin even in areas not exposed tothe sun. Epidermal atrophy and increase transparencymay contribute to this, leading to increased visibilityof dermal components. Some pigmented cells, however,particularly in sun-damaged areas, become over-active, producing blotches of hyperpigmentation. 22 Hair onthe face and in the ears and nose may become coarser,more bristly, and more obvious, while scalp and bodyhair turns white because of loss of functioning pigmentedcells. 17,18,23

Computerized images showed that intrinsic aged skinhave the same density of veins and arteries, but reducedcaliber, while the actinic aged skin progressively loosesthe dermal vasculature and their vessel caliber. 24 Otherproblems may appear as years go by, like pruritus, xerosis,and others.

Interleukin-1 (IL-1) alpha family of cytokines/recep-tors are present in normal murine epidermis and theyincrease or decrease after barrier disruption in youngmurine epidermis. IL-1 alpha is capable of initiatingthe cytokine cascade, which triggers homeostatic andpathophysiologic changes in the skin. This cytokinepredominates in keratinocytes and is normally expressedin all epidermal cell layers, and barrier disruption mark-edly enhances both IL-1 alpha mRNA and protein levels.Aged epidermis, on the contrary, expresses subnormalmRNA and protein level of certain members of thiscytokine family. 2527

Figure 1 Sun-exposed area (dorsum of hand): 85-year-old woman photoaging.

Figure 2 Nonexposed area (buttock): same 85-year-old woman ofFig. 1, not intensively sun exposed during her life intrinsic orchronologic aging.


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Actinic radiation

Photoaging, heliodermatosis, actinosenescence, or actinicdermatosis is an accelerated aging of chronically sun-exposed skin, with distinct clinical, histologic, andfunctional features, and an evident relation to skincancer. Photoaged skin, as on the neck, dcollet, face,forearms, and hands, overlaps and superimposes thealterations seen in the normally aged skin. Those changescaused by sun exposure can occur even before signs of chronic skin aging. The clinical features depend on factorssuch as skin type, nature of sun exposure (occupationaland/or recreational), hairstyle, dress, and individual repaircapacity. A leathery appearance with wrinkle formation,increased fragility of the skin, and impaired woundhealing are seen and there are also some dermal changes. 28,29

Many different types of lesions begin to appear as theskin ages, including actinic and seborrheic keratoses,cutaneous horns, and skin cancer; most of them in sun-exposed areas (Figs 3 and 4). 17,18,23 The clinical featuresof actinosenescence may be classied according toGlogau in four types, as observed in Table 3. 13

Epidermal changes are characterized by pigmentaryalterations, such as lentigines and hyperpigmentation,associated with hypertrophic or atrophic epidermis, anddeposition of fragmented elastic bers on histopathology.The horny layer shows hyperkeratosis, but the mostprominent histologic feature is elastosis, which beginsat the junction of papillary and reticular dermis. 30,31

Another prominent feature is basophilic degeneration,representing the replacement of mature collagen bersby a basophilic appearance collagen. 32,33

Ultraviolet light interacts with various cells locatedat different depths depending on its wavelength. The

shorter wavelengths (280320 nm) are absorbed in theepidermis and affect keratinocytes, whereas longer wave-lengths (320400 nm) interact with keratinocytes anddermal broblasts. 30 The induction of matrix metallopro-teinases (MMP) plays a major role in the pathogenesis of photoaging. They are a group of enzymes subfamily of proteinases responsible for the degradation of collagen. 34

UV light affects the post-translational modication of der-mal matrix proteins and induces a wide variety of an everincreasing family of MMPs with proteolytic activity todegrade matrix proteins. Each one MMP degrades differentcomponents of the dermal matrix proteins, for example,MMP-1 cleaves collagen types I, II, and III and MMP-9degrades collagen types IV and V and gelatin. There arealso tissue-specic inhibitors of MMPs (TIMP) to inacti-vate certain MMPs. 29

Mitochondria are cell organelles whose main functionis to generate energy for the cell, by a multistep processcalled oxidative phosphorylation or electron transport

Figure 3 Heavily sun-exposed area (pre-esternal region): 78-year-old woman wrinkles, keratoses, and mottled pigmentation.

Figure 4 Moderately sun-exposed area (face): 79-year-old woman wrinkles, keratoses, and pigmentation.


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chain. The human mitochondrial DNA (mtDNA) shows amutation frequency 50-fold higher than nuclear DNAand may be involved in the process of photoaging. 35,36

Located in the inner mitochondrial membrane are vemultiprotein complexes that generate an electrochemicalproton gradient used in the last step of the process to turnADP and organophosphate into ATP. This process maylead to the generation of reactive oxygen species (ROS),making the mitochondrion the site of the highest ROSturnover in the cell. Close to this site is the mtDNA withits great mutation frequency. ROS can exert a multitudeof effects as lipid peroxidation, activation of transcriptionfactors, and generation of DNA-strand breaks. Assess-ment of the underlying photobiologic mechanism hasrevealed that, similar to UVA-induced MMP induction,the generation of mtDNA mutations is due to productionof singlet oxygen. This indicates that substances withROS-quenching potential may be employed to preventphotoaging of human skin. By inhibiting the translationof transiently damaging ROS effects into geneticallyimprinted mutations, quenchers may not only protectfrom short-term damage of UV but also prevent hazardcaused by long-term UV exposure. 28

Ultraviolet radiation is closely related to the formationof d --aspartyl in the elastic bers of skin. Those biologi-cally uncommon d -aspartyl residues have been reportedin proteins of various elderly tissues. 37

A basic knowledge of collagen formation and break-down is necessary to fully appreciate the results of a fewkey studies and their signicance in photoaging patho-genesis. Mature collagen in skin undergoes continuousturnover, which is required for optimal connective tissueformation. Collagen is the most abundant component of the extracellular matrix. 34

Skin aging in smokers

Smokers look older than nonsmokers of the same age,because smoking has an aging effect on human skin,especially in the facial region. 38 The molecular basis of smoking-induced facial aging is not known, but in vitrostudies have shown that tobacco smoke extract inducesMMP-1 and MMP-3 mRNA in skin broblasts in vitro .39

However, tobacco smoke extract has no effect on tissueinhibitor of metalloproteinases (TIMP-1) and TIMP-3mRNA. Lahmann et al .40 demonstrated that smokinginduces MMP-1 mRNA in skin in vivo, but has no effect onTIMP-1 mRNA. They suggested the multiplicative effectsof sunlight and smoking on facial aging occurred byinduction of MMP-1.

Pharmaceutical products and procedures forthe elderly

The cutaneous stigmata of aging may affect anindividuals mental well-being, body image, and qualityof life.41 Aging, unfortunately, is a fact of life and the olderpopulation is increasing in number. That is why it isworth to keep researching cosmetic products and proceduresfor the elderly because as said by Irene Ravache, a famousBrazilian actress, only those who die early dont age,and by Mario Quintana, one of the most well-knownBrazilian poets, aging is wonderful because the otheroption is worse 4

According to Earle Brauer, cosmetics may be broadlydened as topical agents to effect personal grooming,inuence appearance, and improve self-image. Thereare four kinds of cosmetics: toiletries, skin-care products,camouage products, and fragrance products. The great

Table 3 Glogaus types of actinosenescence.

Type I No wrinkles Type II Wrinkles in Motion early photoaging early to moderate photoaging

mild pigmentary changes 0 early senile lentigines visible no keratoses keratoses palpable but not visible

minimal wrinkles parallel smile lines beginning to appear lateral to mouth minimal or no makeup usually wears some foundation younger patient: 20s or 30s patient age: late 30s or 40s

Type III Wrinkles at Rest Type IV Only Wrinkles advanced photoaging severe photoaging

obvious dyschromia, telangiectasia yellow-gray color of skin visible keratoses prior skin malignancies wrinkles even when not moving wrinkled throughout, no normal skin

always wears heavy foundation cannot wear makeup cakes and cracks patient age: 50s or older patient age: sixth or seventh decade

Adapted from Glogau, with permission from HMP Communications. 13


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changes in elderly skin allow the dermatologist to recom-mend specic products that might be better than others.Multiple factors affect the way skin ages: heredity, sunexposure, chronologic age, emotional stress, repeatedweight gain and loss, diet/nutritional supplements, andexercise. 17,42,43

Sunscreens and sunblocks

The sunscreen agent is thought to prevent cellulardamage and thus prevent dehydration. It may bechemical, physical, or a combination of both.

The best cosmetic a person can wear for preservation of his or her youthful appearance is a sunscreen. It cancause an apparent reversal of some photoaging and keepthe skin youthful looking. Physical sunblocks are impor-tant for individuals who must be absolutely protectedfrom the sun. They also are important to protect the most

vulnerable parts of the body, such as the ears, nose tips,shoulders, and cheeks. There are several types of UVB andUVA chemical sunscreens. 17

Patients should avoid the sun during the peak hours of sunshine, wear protective clothing, and use sunscreenswhile outdoors. 4446 The constant use of a photoprotec-tor can promote an apparent reversion of photoaginggiving skin a younger aspect. A great improvement mayoccur with suppression of exposure or photoprotection,even when started late in life. There is formation of neocollagen and new elastic bers, giving the same aspectas seen in nonexposed skin. 17

Moisturizers and keratolytic agents

The continuous loss of water content of the stratumcorneum through evaporation on the surface to theenvironment leads to xerosis. The cells accumulate, givingthe skin a white and scaling aspect. However, xeroticskin is due to more than simply low water content, andelectron micrographic studies demonstrate a thicker,ssured, and disorganized horny layer. This characteristictends to increase with age due to a decrease in theinherent water content of the stratum corneum, andprobably an abnormal desquamatory process is alsopresent. Moisturizers decelerate the loss of humidity fromthe surface of skin by deposition of an oil lm, avoidingevaporation; help minimize the aspect of ne wrinkles;and maintain appropriate level of skin humidity. Finewrinkles more visible when skin is too dry so hydrationmakes wrinkles less obvious. Rehydration can be achievedwith the use of occlusives, humectants, hydrophilicmatrices, and sunscreens. 47,48 There are many moisturizingagents, such as hydrocarbon oils, silicone oils, vegetable

and animal fats, fatty acids, fatty alcohol, polyhydricalcohols, phospholipids, and sterols, among others.

Keratolytic agents act in the xerosis of the elderly bypreventing accumulation of excessive stratum corneumand removing the cohesive attachment of the corniedcells. The oldest keratolytic agent is salicylic acid, a beta-hydroxy acid. Others are propylene glycol, retinoic andglycolic acids, propylenoglicol in water, and lactic acid,which also act as moisturizers. 47,49,50 Topical applicationof retinoids and analogs are used for aging skin and theones currently available are retinol, retinaldehyde, retinoicacid, isotretinoin, adapalene, and tazarotene. 5158

Antioxidants

Ultraviolet A light acts indirectly through generation of ROS, as well as UVB light, which also generate ROS byinduction of DNA damage. The induction of MMP also

plays a role in the pathogenesis of photoaging. UV lightinduces a wide variety of an ever increasing family of MMPs. 28 If the generation of ROS is an importantproximal step in the UV signaling, which mediatesphotoaging, then the appropriate use of antioxidantsmay be an effective prevention strategy. Althoughcountless commercial products containing one or moreof alleged antioxidant exist, no data have proven that anyof them really affects the UV response.

Antioxidants include vitamins A (retinol), C (ascorbicacid), and E (tocopherols); -carotene; and bioavonoid.Antioxidants act as oxygen scavengers, and seem to affectprimarily the number of sunburn cells, the apoptotickeratinocytes, which appear after UV radiation. 59 Topicalapplications of -tocopherol or ascorbic acid decreaseUVB-induced erythema and edema and decrease thenumber of sunburn cells. Carotenoid preparations andsynthetic phenolic antioxidants similarly are reported toreduce UV-induced erythema and retard development of squamous cell carcinomas in the hairless mouse model.Intervention modalities that would enhance cellularDNA damage repair would be of utmost importance formaintaining health in the elderly. 59,60

Caloric restrictionCaloric restrictions have a benecial effect on somecutaneous functions, but do not seem to affect allfunctions. Pendergrass et al .61 showed that caloricrestriction increased the proliferative potential of cutaneous murine broblasts; however, no difference incellular proliferation between caloric restricted animalsvs. ad libitum -fed animals was found in a study usingrhesus monkeys ( Macaca mulatta ).62 It is possible that


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decreasing energy metabolism by restricting calorieswould reduce the rate of ROS generation and increaselifespan. Caloric restriction or undernutrition withoutmalnutrition is well documented to affect longevity.

EstrogensSkin aging process increases rapidly in postmenopausalwomen after the age of 50. The external symptoms of skinaging observed in this period are connected with adecrease in collagen content, which is conditioned by thesame mechanisms that regulate its contents in bonetissue. 6366

Estrogens inuence the amount of collagen synthe-sized by broblasts, increase the synthesis of hyaluronicacid, and promote water retention. Skin broblasts havereceptors for both androgens and estrogens. Most estro-gen receptors are found on facial skin. They also increase

synthesis of the extracellular matrix and inhibit sebumsecretion, so their regular use should prevent dry skinand skin wrinkling. 67 Hormone replacement therapycontains two main ingredients: estrogens and progesta-gens. Most of the postmenopausal symptoms depend ondecreased concentration of the estrogens. Hormonetherapy was shown to signicantly improve parametersinvolved in skin aging such as hydration, elasticity, andskin thickness. These ndings support the clinicalimpression that an early hormone substitution therapymay restore the initial features of hormonally inducedskin aging. 68 The evaluation of skin condition of post-menopausal women after topical treatment with creamscontaining estrogens (estriol and estradiol) showed asignicant reduction of wrinkles as well as increasedelasticity and better vasculature of the skin. 69

Chemical peels

Destruction of epidermis and, in some cases, supercialdermis does produce edema and, hence, appreciableimprovement in appearance. There is documentedevidence that some of these substances and procedurescan induce formation of new collagen with normalstaining properties. 50,70,71

Trichloroacetic acid 1035% is used to accomplishsupercial chemical peelings on facial and nonfacialareas and may be repeated every 7 to 28 days.

Jessners solution is a combination of resorcinol, sali-cylic acid, and lactic acid in ethanol. Its applicationcan be light or intense and may be repeated after34 min. Jessners solution amplies the effect of 5-uorouracil and this association is called the uor-hydroxy pulse peel.

Salicylic acid is a -hydroxy acid and can be used as a50% ointment on the dorsa of hands and forearms or asa 35% solution in ethanol for the face. Erythema andedema are minimal and the peel can be repeated every 2 4 weeks.

Peels of glycolic acid are excellent facial rejuvenatingtherapies. Although the irritant power of glycolic acidis often directly related to its low pH, irritancy of thevehicle must also be considered. 7275 Other -hydroxyacids include lactic, malic, citric, and tartaric acids; themost commonly used in dermatology are glycolic andlactic acids.

A new era in dermatologic treatment began with theintroduction of retinoids two decades ago. 76 They may beused orally or topically for a wide variety of skin disorders.Topically and in higher concentrations than the onesused for the keratolytic effect, some retinoids may be usedas peelings agents with very good results. 5158

The traditional deep chemical peels formula with fenolwas described in 1961 by Baker and Gordon. 52

Toxin botulinum

Toxin botulinum, just to mention, is a sterile, vacuum-dried puried form of botulinum toxin type A indicatedfor the treatment of strabismus, blepharospasm, andother related condition. It acts by inhibition of acetylcholinerelease of the motor endplates. It temporarily denervatesspecic muscles responsible for certain facial rhytidsincluding the glabelar furrow, horizontal forehead lines,horizontal neck lines, and crows feet. 77

Fillers

Every substance used for soft tissue augmentationpresents features that make it, case by case, the bestchoice, 78 or not indicated for a certain patient. A varietyand countless lling substances are in the market andsome of the defects susceptible to improvement bycutaneous lling presented by the aging patient arecutaneous aging, as furrows and wrinkles, expressionwrinkles, depressed scars, prole defects of the face, lipatrophy, and skin roughness.

Substances successfully employed in soft tissue aug-mentation are bovine collagen, autologous fat, silicone,hyaluronic acid, Goretex, Fibrel, and SoftForm, amongothers, and all need skilled physicians to apply them.

Large wrinkles can improve with injection of bovinecollagen, silicone, hyaluronic acid, or fat extracted fromthe abdomen or thigh of the patient. Each method ishighly effective when used for its correct indications andby skilled physicians. 79


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Plastic surgery

There are many surgical procedures for different areasand objectives. Plastic surgery techniques, includingblepharoplasty and rhitidectomy, and dermabrasion,have been a part of the medical scenario and conceivablywill remain. Full face cryopeeling can eliminate precan-cerous lesions and also improve texture, wrinkles, andpigmentary problems associated with photoaging. 80

Dermabrasion or surgical skin planning is used toimprove the skins contour as new collagen andepidermis replace the abraded skin. The new skingenerally has a smoother appearance. It is indicated inselected patients for ne wrinkles, scar correction,melasma, and perioral wrinkles. 81

Makeup

The skin, as a most important presentation of a person toits counterparts, is essentially the visual calendar bywhich the years are measured. 82 Cosmetics of the skin,hair, and nails represent an area of great importance forthe practicing dermatologist. Cosmetics aspects of agingskin are of intense interest in most societies and theproducts now available can actually improve the appearanceof the skin.

Lips, mainly the inferior, show alterations due to sunexposure, dryness, scaling, loss of the limits betweensemimucosa and skin, and atrophy are characteristics of photoaging (Fig. 5). The careful use of a lip liner can avoidthe vertical bleeding of lipstick onto the wrinkles of theborders of the lips. It can also enlarge the appearance of thin, atrophic lips and correct the lip line if there is an

irregularity due to the removal of a skin cancer or othertype of lesion along the vermilion border. 42 The use of specic products for photoprotection of the lips is essential.

If the upper lid has sagged too much, a thin line of colorapplied just above the lash line may be the best way toenhance the beauty of the eye. 83 Mascara in soft brown orbrown-black may be better than midnight blue or jetblack. This should be applied carefully. Water-washablemascara is easier on the eyelids and may result in less lossof eyelashes. Careful use of eyeliner may be desirable. It isimportant to avoid harsh lines; softness is the key. Pencilsmay be preferable to the straight brown eyeliner. If theupper lids hang heavily, the use of an eyelash curler to liftthe lashes up and around the sagging lids may help. Thecurler must be used before the mascara is applied so thatthe eyelashes do not stick to the curler. 17,83

Nail cosmetics, in the form of nail polish, repair kits,tips, and sculptures, may not only camouage a nail dis-ease, but also be the cause of a problem due to the prod-ucts use. Skin-care products, in the form of cleansers,toners, exfoliation agents, masks, moisturizers, specialtycreams, and antiperspirants/deodorants, may conict withthe treatment or worsen a nail disease. The elderly showsmany types of onychodistrophies, as opacication, longitu-dinal striation (Fig. 6), fungal and/or bacterial infections,onychogryphosis, splinter hemorrhage, subungual

Figure 5 Actinic cheilitis: 73-year-old man dryness, scaling,atrophy, and loss of the limits between the skin and the vermillion ofthe inferior lip.

Figure 6 Longitudinal striae on nail: 62-year-old man.


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hematoma, and others, which are usually facilitatedby circulation alteration, repeated microtrauma duringlife, and postural alterations. These nail lesions mustbe treated, if possible. The dermatologist must be awarethat certain medical and cosmetic products may evenbe the cause of skin problems besides being hazardousto the nail, as for instance nail polish being the majorcause of skin allergy to the eyelids. Care of nails has manybenets, which include improving self-esteem of thepatient. 43,8486

The aged individual has difculty to efciently washhair, thus seborrheic dermatitis and bacterial folliculitisare frequent in this age group. Since most shampoos maydry and irritate scalp of elderly, the best ones for themshould not be very efcient in removing oil and should alsobe nonirritating to the eyes, as the nonionic shampoos. 87

Elderly patients, especially women, use dyes, perma-nent wave, and other hair products very often, because of

the graying and loss of their hair. All these methods may,at the same time they make the hair look better, behazardous to it with constant use. 4

Hair permanent waves: a permanent wave is designedto last 34 months. When hair is permanently wavedwith a strong waving lotion, the result is hair loss by frac-turing at the exit point from the scalp. 88,89

Hair dyes: hair-dyeing products with the ability tolighten, darken, or alter the hair color for various lengthsof time have been developed and can be divided intoseveral types: gradual, temporary, semipermanent, andpermanent.

Hair additions: it is a semipermanent method of camouaging partial and localized hair loss. Failure tocleanse the scalp regularly because of the hair addition canresult in seborrheic dermatitis and bacterial folliculitis.

Hair integration: another method of supplementinglocalized hair loss is through the use of hair integration.This technique does not cause traction alopecia and doesnot use attachment methods. This is an excellent butexpensive alternative for alopecia. 88,89

Adverse reactions to cosmetics

The stratum corneum of the elderly is less capable to actas a barrier; thus, it is frequent to see allergic and irritantreactions to cosmetics. They are caused by endogenousand environmental factors and, besides an irritativedermatitis, cosmetics can produce allergic reactions alsoin elderly patients. They may be acute reaction, irritantdermatitis, mechanical irritation, acneiform eruption,phototoxic reaction, subjective irritation, such as burning,stinging, or itching, contact urticaria syndrome, anddelayed hypersensitivity reactions. 48

Conclusion

The cosmetic aging changes of the skin are not a directthreat to the physical well-being of the patient, but theirpsychological impact, particularly in regard to self-perception, self-esteem, and quality of life, can besignicant and even profound. 90,91 As the population of elderly people increases, patients dissatisfaction withtheir aging skin changes will attract more and more theattention of physicians and merit a response for theircaring. There are already many ways to attenuate skinaging by the use of topical, injectable, oral, and/orsurgical therapies, and the dermatologist is the bestspecialist to prescribe them to the aging patient. Thelimitation of sun exposure by avoiding the sun during thepeak tanning hours (between 10:00 a.m. and 2:00 p.m.),the use of a sunscreen with a high sun-protection factor,and the use of protective clothing when exposed to the

sun are the most important advice physicians can offer totheir patients at any age. 82 Even when its use begins atan older age, the constant use of a photoprotector canpromote an apparent reversion of photoaging, giving ayounger aspect to the skin.

Physicians, especially dermatologists, geriatricians,gerontologists, and plastic surgeons, must know how touse to prescribe cosmetics and toilet articles to this agegroup because they constitute an important part in thelife of the elderly.

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