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Handle With Care
Hands often reveal first signs of aging

By Marina I. Peredo

Originally published in Skin Deep, January/February 2009. Copyright 2009. Associated Skin Care Professionals. All right reserved.

In comparison with the multitude of procedures offered for the aging face, hand rejuvenation has been largely ignored by cosmetic dermatologists and surgeons. Many clients undergoing facial rejuvenation often become aware of the discrepancy between the apparent age of the face and that of their hands
only after the fact.

According to a study published in the June 2007 issue of Plastic and Reconstructive Surgery, most people can accurately discern a person's age just by looking at their hands. Hand rejuvenation is the new must-have procedure. Hands do, in fact, appear to age more quickly than the face. One reason for this is that skin on the back of hands is much thinner than that on the face. There is very little fat on the back of hands, so when collagen and elastin fibers begin to break down in aging, the effects are noticeable. The most common signs of aging hands are textural skin changes, vein prominence, and loss of volume. Atrophy of the epidermis and dermis result in a paper-thin appearance, marked by fragility of the skin. Photoaging certainly plays a significant role in cutaneous atrophy, loss of elasticity, and production of actinic keratosis and lentigines. Crepey-looking skin, skin elasticity, wrinkling, lentigines, liver spots, and tortuous, bulging blue veins are the most common patient and client complaints. But it's the loss of soft-tissue volume with skeletonization that is often the cause of an aged appearance in hands.

So, what can we do to make hands appear more youthful? Youthful hands have smooth, elastic, unspotted skin, and soft fullness, which minimizes the appearance of tendons and veins.
There are topical therapies and resurfacing procedures for aged skin, and your clients may want to know more about sclerotherapy for protuberant veins and filling procedures for subcutaneous atrophy.


Topical Agents and Home Care
Many topical agents partially reduce the signs of photoaging and could be of benefit in reversing cutaneous signs of hand aging. Among the newest advances are creams, mostly derived from plants, that promote new collagen formation. A 2007 study published in the Journal of Drugs in Dermatology reported 83 percent of women between ages 35-65 who tried such creams noticed improvement in hand wrinkles after 60 days. Creams in this category include Neocutis Bio-Restorative Skin Cream, SkinMedica TNS Recovery Complex, and Remergent DNA Repair Formula. Popular agents include alpha hydroxy acid (AHA), antioxidants, tretinoin, and vitamin C. Chronic use of such agents could result in thickening of the epidermis and dermis, as well reducing the translucence of the skin by stimulating keratinocytes and fibroblasts. Various bleaching creams are also commonly prescribed for lentigines. The most common bleaching agent is hydroquinone, typically formulated in prescription strength at 4 percent. Hydroquinone is cytotoxic to melanocytes and decreases melanosome formation by inhibiting tyrosinase. Response is very slow and most patients and clients become discouraged.

For the discouraged patient or client, you can urge them to keep the backs of their hands looking young by avoiding direct sunlight and using a good sunscreen applied to backs of hands several times daily. Among the newest and most protective products are sunscreens like Ombrelle containing mexoyl SX (ecamsule) and developed by L'Oreal, Helioplex by Neutrogena, and Ultimate UV defense by SkinCeuticals. These products operate by blocking harmful ultraviolet A and B rays and offer long-lasting protection. SkinCeuticals sunblock contains zinc oxide, acts as a physical block against the sun, and is cosmetically elegant, offering translucent protection, rather than a white-cream appearance. I recommend clients wear the same sunblock on their hands as they use on their face.


Microdermabrasion
Microdermabrasion is a popular modality for superficial rejuvenation of the skin. Most clients will notice mixed, but appreciable, increases in skin smoothness over a series of treatments. The degree of exfoliation is determined by multiple factors, including the amount of vacuum pressure, the number of passes, particle size, and the speed of the hand piece. In my facility, we often "gift" hand treatments to patients who are undergoing facial microdermabrasion.


Chemical Peels
Photoaging of hands can be improved with chemical peeling. I recommend light to medium peels to avoid risks associated with delayed healing, scarring, or other complications. A series of superficial chemical peels are usually performed monthly; the concentration of the agent can be titrated, depending on the reaction of the peel. The most common agents used are AHA, Jessner's solution, salicylic acid, tretinoin solution, and a 10-25 percent trichloroacetic acid (TCA) formula.


Intense Pulsed Light
Intense pulsed light (IPL) therapy is another noninvasive modality for photo rejuvenation. IPL systems are high-intensity pulsed sources emitting polychromatic light with broad wavelength spectrums of 515-1200 nanometers. This broad spectrum enables selective treatment of targets, such as vessels that have hemoglobin
(580 nanometers) and melanin (400-755 nanometers). Pulse duration can be adjusted for skin type and target. The backs of hands can be treated with good results for telangiectasias and dyschromia. On average, three to five treatments are needed and are performed once a month. When treating hands, the setting should be lower than when treating the face; the energy should be reduced by about 3-4 joules. The beneficial effects of IPL therapy are not limited to the improvement of telangiectasias and dyschomia. There is also stimulation of dermal collagen that appears to be helpful in resolution of senile purpura.

IPL treatment should be avoided if clients are tanning, using medications that may cause photosensitivity, or have recently had filler procedures. If clients have had filler procedures, it is best to wait two weeks before doing an IPL treatment. Three to five IPL treatments are usually most effective.


Sclerotherapy
Sclerotherapy has proven to be a successful treatment for protruding and tortuous veins on the hands, and as a well-informed esthetician, you may recommend your clients see a physician with this in mind. It helps to be familiar with what such a treatment involves.

The procedure entails having a patient elevate the upper extremity after a tourniquet or manual compression have first been applied around the forearm. This empties the vein. A sodium chloride solution is then injected into the vein, an elastic bandage is applied to the elevated upper extremity, and compression applied for 24 hours.

Patients will have several days of swelling and will need to elevate hands and avoid strenuous activity. For this reason, one hand is often treated at a time.

Sclerotherapy of the hands is an effective and simple treatment with 90-100 percent improvement in two to three treatments. The cost is usually $800-$1,200 for the series.


Dermal Fillers
Another treatment for which your clients may appreciate a physician referral are dermal fillers. While these have traditionally been used on the face, they are now being used for the backs of hands. Temporary fillers include hyaluronic acid products, usually requiring two syringes of hyaluronic acid per hand. This costs about $1,400 a hand with results lasting about six months.

Semipermanent fillers are used more often because of the longevity of the results. Unlike the face, where a line is being filled, volume in the hand is created with filler. For this reason, hand fillers need to be thicker and heavier than facial fillers. These also are injected and can cost $1,000-$2,000 per hand.
Some semipermanent solutions require a series of three treatments every two to three months and results last about two to five years. The cost is about $3,000.

Hands are important, but often neglected. Working as a team, we can treat these changes with creams, IPL, sclerotherapy, and dermal fillers, offering clients and patients a multi-modal approach.

Marina I. Peredo, MD, FAAD, is associate clinical professor of dermatology at Mt. Sinai School of Medicine and medical director for Cosmetic Dermatology/Spatique Medical Spa in Smithtown, New York. Contact her at peredomd@optonline.net, www.marinaperedomd.com, or www.spatiquemedicalspa.com.




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