Skin Changes and Dry Skin

Glogau Classification System

Developed to objectively measure the severity of wrinkles and photoaging.

Photoaging

Premature skin aging which reflects long-term skin damage from sun exposure

Type I - Mild (Glogau)

No/minimal wrinkles

No/minimal use of foundation

Mild pigment changes - no keratosis (common noncancerous skin growths in older adults caused by years of sun exposure)

Ages 28-35 years

Type II - Moderate (Glogau)

Keratosis is palpable, but not visible

Wrinkles in motion (e.g., smile lines)

Early senile lentigines - age/”liver” spots, hyperpigmented macules in irregular shapes, appearing most commonly in sun-exposed areas of skin (face, back of hands)

Occasional/light foundation

Ages 35-50

Type III - Advanced (Glogau)

Wrinkles at rest

Clear signs of irregular pigmentation

Visible keratosis

Heavy foundation use

Ages 50-65 years

Type IV - Severe (Glogau)

Wrinkles throughout face

Yellow-gray skin

History of malignancy

Foundation cakes/cracks

Ages 60-75 years

Tretinoin

Renova, Retin-A, Retin-A Micro

Topical Tretinoin Indications

Photodamaged skin

Palliation of fine wrinkles

Mottled hyperpigmentation

Tactile roughness of facial skin

Topical Tretinoin MOA

Reduces melanin production

Increases epidermal thickness

Increases keratinocyte turnover

Increased collagen activity

Tretinoin dosing

Apple daily at bedtime

Wash and dry face 20 to 30 minutes before application

Cover affected area lightly; avoid eyes, ears, mouth and nose

Separate administration times of used with AHAs

Goals of therapy (may take up to 6 months for results) - Smoother skin texture, minimization/improvement in wrinkles, lightening of lentigines (small brown patch on skin)

Tretinoin Safety

Increased photosensitivity (use sunscreen)

ADEs: Skin irritation, burning, drying, peeling

Caution: Current or planned pregnancy, breastfeeding - Tazarotene contraindicated

Tazarotene

Tazorac

Topical tretinoin

Adapalene

Differin

Topical tretinoin

Alpha Hydroxy Acids (AHAs) MOA

Used for photoaging

Chemical peel

Removes dry skin from stratum corneum

Increased moisture retention

May contain lactic, glycolic, citric, or malic acid

2-20% concentration: non-peeling

>20%: Peeling

AHA Dosing

Apply to dry skin 10 minutes after cleaning face

Start gradually (e.g. every other night for one week)

Increase as tolerated to max twice daily use

Effects: Increased thickness of epidermis, decreased fine wrinkles, skin mottling, and alteration in pigmentation

AHA Safety

Increased photosensitivity (use sunscreen)

ADEs: Stinging, burning, itching, hypopigmentation, dryness

Safe to use in pregnancy

Onabotulinumtoxin A (Botox)

Derived from Clostridium toxin

Prevents release of acetylcholine from the synapse

Soft tissue augmentation

Prevents release of acetylcholine from the synapse - results in localized paralysis and atonia

Used on the face and neck (cosmetic purposes)

Onabotulinumtoxin A (Botox) Safety

Side effects: Redness and bruising at injection sites

Clinical effect seen in 24-72 hours

Maximum effect may not be evident for 1-2 weeks

May last 3-9 months

Black box warning: Distant spread of toxin effect, which can cause swallowing and breathing problems.

Hydroquinone MOA

Used to treat hyperpigmentation

Bleaching agent

Reduces conversion of tyrosine to dopamine to melanin —> decreases pigmentation of skin

Hydroquinone dosing

OTC products are 2%; Rx products are 4$

Apply thin layer to affected area BID until desired color achieved

Effects seen in 3 weeks to 3 months

Hypopigmentation is reversible upon UVR

Hydroquinone safety

ADEs: tingling, burning, transient inflammation, photosensitivity

CI: sunburn, depilatory cream use, pregnancy

Other options for Hyperpigmentation

Retinoic acid - Can consider combination with hydroquinone

Laser and light therapy - Two to three sessions may destroy melanocytes, spots may fade over several months

Cryotherapy - Can consider for single or closely grouped spot, risk of scarring or discoloration

Actinic Keratoses

Precursors to the development of skin cancers

UV radiation may induce abnormal keratinocyte changes

Squamous Cell Carcinoma

Most common in older patients

Risk factors: Fair complexion, prolonged sun exposure/UV radiation, long-term immunosuppression

Usually present as firm, flesh-colored or erythematous papules/plaques

Primarily managed via surgical excision

Basal Cell Carcinoma

Usually present as pigmented nodule on head/neck

May develop into ulcerated nodule

Treatment varies, but may involve: Surgical excision, topical imiquimod, antineoplastic agents

Malignant Melanoma

Unless detected early and excised, often produces systemic metastases

Can occur anywhere on the body

Changing mole = get checked

ABCDs of melanoma:

• (A) symmetry

• (B) Orders irregular or uneven

• (C)olor differences within lesion

• (D)iameter usually >6 mm

Treated via excision ± antineoplastic agent

Xerosis Treatment Approaches

Goals:

• Restore skin hydration

• Minimize symptoms

• Control exacerbating factors

Non-Pharmacologic treatments

• Pat (vs. rub) skin dry

• Maintain hydration

• Using non-soap cleansers

• Warm/cool water for bathing/showeing

Most cases can be treated with humectants or emollients

Xerosis Pharmacologic Options

Humectants - Glycerin, Urea, Hyaluronic acid. Hydrophilic; draw moisture from deeper dermal layers

Emollients: Petrolatum, Propylene glycol, Ceramide. Lipophilic; provide a protective “film” on skip surface to trap moisture

Other: Colloidal oatmeal baths, keratinolytics (AHA, salycylic acid), bath oils (ensure fragrance-free), TCS (for cases of severe pruritis, erythema).