Understanding the ageing face - sk.in

by dr alek nikolic

introduction

A number of changes take place as we get older, which we typically begin to notice in our forties. However, these ageing changes actually begin as early as our thirties.

Suddenly dark marks appear, the skin begins to look sallow and dull, the texture appears to be rougher, fine lines and wrinkles become more noticeable - especially around our eyes, mouth, and cheeks. We may also see an increase in skin laxity and even hollows, under the eyes and cheeks.

These are just some of the things we may notice, and most of us think only the surface of the skin is changing with age. In reality, a number of changes are happening under the skin which contribute to ageing on the skin and to the face.

When we age, all our facial structures tend to change, including the skin; the underlying fatty tissue, the muscles, and the bone. In our teens and twenties, we tend to have a higher volume of fatty tissue with the best and most robust bony support. Fat and bone is vital for defining the shape of our face and to provide support to the overlying muscles and most importantly, the skin.

To understand the changes we see as we age we should look at these structures separately. The treatment approach will be different for each of these layers.

jump to section

the skin
cellular stimulation
professional treatments
targeting the skin barrier
skin concerns and product recommendations
the fatty layer
the muscle layer

the skin

The skin is the biggest organ of the body and plays a number of vital roles:

Protects us from UV damage and external organisms
Provides sensation and nutrients to the hair follicles and sweat glands
Regulates body temperature

There are a number of factors that contribute to the changes that take place in older skin:

Skin barrier function impairment
Slower turnover of epidermal cells
A reduced blood supply around hair bulbs and glands, leading to less oxygen and nutrients being supplied which in turn leads to atrophy or thinning
A reduction in hyaluronic acid and GAGs (glucose amino glycan) which are vital to keep moisture and plumpness in the skin

The most affected cells in the skin are keratinocytes and fibroblasts, cells which help determine how our skin ages. Keratinocytes are responsible for producing keratin which in turn makes our skin strong and flexible. Fibroblasts are our precursor cells and, when stimulated make more collagen and elastin in our cells.

There are two main treatment approaches for improving the outward appearance of ageing skin: cellular stimulation and targeting the skin barrier. By repairing and maintaining optimal function of the skin barrier you can improve the condition of the skin and visible ageing changes

By using a topical skincare regime and adding other professional treatments we can maximise results to slow the ageing process, improve the stimulation of cells (in particular fibroblasts and keratinocytes) and repair and maintain the skin barrier.

cellular stimulation

Cellular stimulation is a vital part of any skincare regime. Typically, our approach is to use a combination of high concentration active ingredient serums that contain antioxidants, skin cell stimulators, and chemical exfoliators that further enhance cell turnover, added to which, if necessary, professional treatments such as chemical peels and Dermapen, will be included.

topical ingredients for cellular stimulation

My go-to active ingredients are glycolic acid (normal to combination skin types) or salicylic acid (acne and oily skin types), vitamin C and vitamin A.

glycolic acid

Glycolic acid is an alpha hydroxy acid (AHA), originally derived from sugar cane, that has become one of the most popular AHA’s used in skincare products. The small molecular size allows it to be easily absorbed. The primary action is to exfoliate the outer skin layer and to increase cell turnover.

Glycolic acid is a highly hydrophilic molecule, which means that it is easily soluble in water and therefore has the greatest bioavailability of all the AHAs. This results in smoothing of uneven skin tone, refines the appearance of pores and helps to smooth fine lines and wrinkles.

It is normal to experience a stinging or burning sensation which can last between 5 to 10 seconds when applying glycolic acid to the skin. This sensation may be exacerbated with sensitive skin. If you are a first-time glycolic acid user, we recommend introducing it slowly into your skincare regime.

benefits

Smooths rough skin texture
Softens hyperpigmentation
Reduces excess sebum production
Improves fine lines and wrinkles
Enhances GAGS - molecules that are vital for improving skin hydration
Stimulates collagen production

sk.in avenge glyco-10

salicylic acid

There are four main benefits of salicylic acid:

It is a comedolytic agent that inhibits the formation of acne lesions and sebum production and is used for people who suffer from oily and/or acne prone skin
It exfoliates the skin: helps to rejuvenate the skin and prevent and treat ageing skin changes
It improves the penetration of certain topical ingredients: this enhances the effect of your topical skin regime
It has both antibacterial and antifungal effects

oily and acne skin:

The exact mechanism of how salicylic acid benefits people suffering from oily skin and/or acne is not 100% known.

However, research has shown that salicylic acid is a lipid-soluble agent, in contrast with the alpha hydroxy acids (such as glycolic acid which is water soluble). This means salicylic acid can mix with and breakdown epidermal or skin cell lipids and sebaceous gland lipids in hair follicles. Furthermore, salicylic acid has been shown to reduce sebum production. Added benefits include deep penetration in pores, allowing complete cleansing with anti-bacterial and anti-inflammatory effects.

Further studies have also demonstrated that salicylic acid has greater effects on reducing sebum production than other acids including pyruvic acid.

Salicylic acid causes an exfoliation of skin through loosening and detachment of corneocytes, the epidermal skin cells that make up the outermost part of the epidermis. As mentioned above, salicylic acid is a lipophilic agent that has the ability to cause a loosening of the lipid-based adhesions between skin cells.

The importance of this is that salicylic acid does not ‘burn’ or wound skin cells. Exfoliation is allowed simply by the break-up of cells from one another.

Studies have shown that salicylic acid:

Works by disrupting cellular junctions rather than breaking or lysing (damaging or disintegrating) intercellular filaments
Provides a loss of the outermost layer of the skin cells followed by activation of epidermal basal cells and underlying fibroblasts (precursor cells that make collagen and elastin)
Causes a thinning of the outer dead layer of skin without any change in the thickness of the epidermis

We have established that salicylic acid removes the most outer layer of the skin and also will clean deep inside pores, reduce sebum and provide anti-inflammatory and antibacterial effects. This combination allows active ingredients – like retinol, granactive retinol, vitamin C, hyaluronic acid etc – to penetrate better.

sk.in pure | medi shot

vitamin c

There are a number of reasons I recommend vitamin C as a must have ingredient in your morning skincare routine:

Stimulates collagen production which improves elasticity and plumps skin with long term use
It improves the appearance of fine lines and wrinkles
Helps to smooth textured or rough skin
Vitamin C has been shown to reduce the appearance of hyperpigmentation and brown marks or blemishes on the skin
It reduces the inflammatory response of free radical damage from environmental damage and is a highly effective antioxidant
Vitamin C boosts our skin’s sun protection factor and increases the effect of our sunscreens
Vitamin C will also help reduce the appearance of red marks produced by post acne blemishes

We can see why numerous skincare brands use vitamin C in their formulations.

Topical forms of the vitamin C family include:

L-ascorbic acid
ascorbyl palmitate
magnesium ascorbyl phosphate
ascorbyl tetraisopalmitate

The commonest vitamin C ingredient used today in skincare preparations is L-ascorbic acid. There are a number of reasons for this, including that it has been around for a long time and, as a result, has multiple studies that prove its effectiveness in the skin. However, L-ascorbic acid has two negative factors to consider:

L-ascorbic acid is water soluble. What this means is that it flows through and is eliminated from the skin through water channels known as aquaporins. This is a fairly fast process which in turn reduces its effectiveness as L-Ascorbic Acid can only work while in the skin.

L-ascorbic acid in its natural state cannot penetrate the outer lipid rich skin barrier. Formulators need to reduce its pH (make it more acidic) to allow penetration or absorption through the skin barrier. Unfortunately, it is this low pH that contributes to:

Skin irritability
Sensitivity
Pruritus or itchiness

why I chose ascorbyl tetraisopalmitate

When choosing a vitamin C ingredient for the sk.in range I wanted an ingredient that minimised the chances of a skin reaction and was not affected by the water absorption channels, allowing for a longer duration of effect within the skin.

Ascorbyl tetraisopalmitate is an oil-soluble or lipid-soluble tetra ester derivative of vitamin C. This means, very simply, that as an ingredient in its natural state is easily absorbed through the skin barrier and is not eliminated through the aquaporins. There are studies that demonstrate that ascorbyl tetraisopalmitate will stay in the skin cells 40 to 80 times longer than ascorbic acid and will have as much as four times the effect (1).

Other recent studies have shown the following (2, 3):

Faster percutaneous absorption of ascorbyl tetraisopalmitate than other forms of vitamin C, owing to lipid solubility
Better stability
Less irritation
Significant improvement of facial hyperpigmentation
A reduction in trans-epidermal water loss
Increase in skin elasticity
Visible improvement in texture and wrinkles
Increased collagen and elastin stimulation through the reactivation of fibroblasts

sk.in gloss | radiant shot

sk.in bounce | combo shot

sk.in flash | repair shot

sk.in marvel | hydro shot

before and after results

professional skin treatments for cellular stimulation

There are other treatments worth considering to maximise the results you can achieve with active ingredients and a topical skincare regime. Further stimulation of the cells can be achieved with professional treatments such as chemical peels, Dermapen or laser.

dermapen

Dermapen is a progression from the popular needling roller device treatment. Very simply, small thin needles penetrate at specific depths which prompts an inflammatory effect in the skin. This inflammatory effect stimulates and forces the cells to make new collagen and elastin.

Dermapen treatments delve skin deep and are designed to create a safe healing response within the body to ignite natural collagen and elastin production, without harsh side effects and only minimal downtime, along with repairing the surface layers to result in healthier skin; looking brighter, tighter, more even toned, refined pores and reduced wrinkles.

Another added benefit is that the treatment produces micro-channels in the skin which allow up to 80% more active ingredients to feed the skin and be absorbed by the underlying cells.

I recommend adding a topical retinol such as sk.in avenge | HPR 3%, which has been designed for use during needling treatments. This maximises the results by increasing the stimulating effect on collagen and elastin production, lightening hyperpigmentation and improving fine lines and wrinkles.

A course of six treatments every six weeks is recommended to achieve best results. You may start to see an improvement in the skin with just a single session.

Expect a hot, almost sunburnt felling, immediately after the treatment. This redness and inflammation can be hidden with a medical makeup cover and usually subsides within the first 24 hours. You may see small red marks for two to five days, which can easily be covered with your usual make-up.

chemical peels

I am a firm believer in professional superficial chemical peels and recommend them as a professional treatment to boost the effects of a topical skincare regime. Consider starting with chemical peels when you reach your thirties.

This treatment has little to no downtime and provides an instant healthy glow while stimulating collagen and elastin production and improving the skin’s hydration levels.

Light professional chemical peels are the ideal treatment for gentle exfoliation, brightening and hydrating the skin. While they are medical peels, they will not leave you with red or flaking skin, but rather with a soft glowing complexion. They are the perfect maximum result facial treatment.

At sk.in we have formulated three professional chemical peeling systems - use sk.in ProPeel to target ageing skin concerns, oily/acne skin concerns and hyperpigmentation.

fractional skin resurfacing

There are numerous fractional laser devices that are used for rejuvenating the skin, which all work on a similar principle. Energy is used to create micro channels of inflammation in the skin which in turns stimulates the skin’s healing process to produce more collagen and elastin.

In my practice, we use a bipolar radio frequency fractional skin resurfacing applicator which allows us to safely treat all skin types without the fear of post-inflammatory hyperpigmentation, a side effect with fractional laser devices. Fractional skin resurfacing is a perfect treatment for deep dermal collagen stimulation which will result in the reduction of fine lines and wrinkles, improvement in hyperpigmentation, and improved skin texture and clarity. A course of 3 to 6 treatments is recommended at 4 weekly intervals.

Immediately after the treatment a hot almost ‘sun burnt’ feeling can be expected with a visible redness that can be hidden with a medical makeup cover. There will also be some swelling and inflammation which typically subsides within the first 24 to 48 hours. For 5 to 7 days one can see small red marks in a grid like pattern which can be covered by your own makeup.

targeting the skin barrier

The skin barrier is the outermost layer of your skin’s surface, and it consists of cells and lipids (fats). The best way to understand the skin barrier is to use the analogy of a brick wall developed by Dr Peter M. Elias who described the cells (corneocytes) as the bricks and the lipid bilayer as the mortar.

Corneocytes are dried out, non-living skin cells that are ready to shed. However, the mortar which is the stacked lipid bilayers that surround the corneocytes is responsible to act as a barrier that is highly impermeable to prevent the loss of water out of skin and to prevent the entrance of harmful microorganisms or irritants.

why is it important?

The skin barrier has numerous essential protective functions:

It prevents water and electrolytes from evaporating through the skin
Serves as a protective shield against harmful microorganisms by producing antimicrobial peptides and proteins
Helps to maintain the skin’s immunity
It regulates inflammation
It regulates the absorption of ingredients that we apply topically

what causes damage to the barrier?

Natural intrinsic skin ageing
Applying the wrong topical skincare regime or applying too frequently especially active ingredients
Environmental free radicals (oxidative damage) such as pollution, blue light emitted from screens, etc
UV sunlight
Cigarette smoke
Harsh climates
Cleansing too frequently
Physical and emotional stress
Disturbed or lack of sleep

Very simply if your skin is normal without any symptoms, the skin barrier function is optimal and healthy. If you feel dryness, tightness or inflammation, chances are your skin barrier is not optimal. Other tell-tale symptoms include a skin that gets very easily sensitised to topical products or becomes itchy through the day.

The biggest culprits that damage the skin barrier are environmental free radicals that cause oxidative damage, UV damage, harsh chemicals and using the incorrect skincare products or too much of them.

Darker skin types have a lower ceramide level in their skins so this may predispose them to a higher water content loss and to dry skin issues. On the other hand, dark skin types have a higher sebum content and have greater tolerance to mechanical and chemical skin exposures.

Hyaluronic acid, ceramides, and antioxidants such as lipid soluble vitamin C and vitamin E help to maintain and repair the skin barrier and at the same time delay and correct intrinsic and extrinsic skin ageing causes.

sk.in marvel is a great skin barrier repair serum as it contains a high concentration of low, medium, and high molecular weight hyaluronic acid and ceramides combined with lipid soluble vitamin C and vitamin E.

skin concerns and product recommendations

When it comes to visible changes on the skin surface, a good topical skin care regime will include the addition of active ingredient serums. Further improvement can be achieved by having professional chemical peels every 4 to 6 weeks or undergoing needling device treatments such as Dermapen MD or fractional laser.

If professional treatments are not possible, then have a look at our sk.in avenge range of super serums that will help to boost the effect of your daily serums.

hyperpigmentation

sk.in avenge | glyco 10

Contains 10% glycolic acid to help exfoliate the skin and lighten superficial hyperpigmentation. Also enhances the effect of the sk.in serums.

sk.in gloss | radiant shot

High concentration of lipid soluble vitamin C to soften visible pigmentation, prevent new pigment formation and to increase the skin’s natural SPF.

sk.in bounce | combo shot

Contains a combination of high concentration of granactive retinol and vitamin C to further enhance the effect of lightening pigmented marks.

Read this in-depth article for more information on hyperpigmentation

acne/oily skin

sk.in pure | medi shot

Formulated with salicylic acid, hyaluronic acid, niacinamide, zinc PCA, and papaya/pineapple extract to help control acne breakouts and remove acne-causing bacteria. These ingredients also work to control sebum production and to reduce the appearance of pores.

sk.in flash | repair shot

Contains granactive retinol that will help to reduce and control sebum production, minimise pore number and size, and reduce the number of breakouts.

fine lines and wrinkles

sk.in gloss | radiant shot

High strength lipid soluble vitamin C serum that is indicated for the use as an antioxidant, to help repair and prevent skin ageing concerns such as fine lines and wrinkles, textured skin, sallow complexion, and dehydrated skin.

sk.in flash | repair shot

Contains granactive retinol and vitamins C & E, Ceramides and hyaluronic acid to target and delay intrinsic skin ageing such as fine lines and wrinkles. The added benefit of sk.in flash is that it repairs the skin barrier and protects the skin against environmental free radical damage.

Add sk.in avenge | HPR 3% once or twice weekly to the above regime to provide spikes of cellular stimulation as a full-face treatment or as a targeted application to more stubborn lines and wrinkles.

the fatty layer

When we are younger the fat in our face provides shape and - more importantly - support of the overlying skin. As we smile or lie on our face the fatty layers prevent excessive folding of the skin which prevents signs of early ageing.

The fat in our face does not really resemble a layer - anatomically it is found in distinct, separate compartments. Studies have shown that when skin has this youthful fatty support, fibroblasts in the skin (precursor cells that make collagen and elastin) are stimulated. Conversely, as we lose the fat, the skin becomes less supported and the fibroblast stimulation is reduced which in turn minimises the collagen and elastin in our skins.

Visualise the fat packets as a balloon. When it is filled with air, the balloon stretches and looks smooth and taut. When deflated, the balloon surface is pliable and folds easily.

As we age, these fat pockets tend to thin and drop, which reduces the skin’s support and allows a sagging appearance. Visually, the face starts to develop hollows, indents or shadows, and structures like the jowl become visible below our jaw lines.

As this fatty support is lost our skin’s ageing accelerates.

recommended treatment

Unfortunately, there are no topical products that will help to slow down or replace the fatty pads in our face. Currently, the only solution is dermal fillers, which have progressed a great deal in the last decade or so. When we first started to treat patients with dermal fillers, the focus was filling lines or grooves. Now, with the advent of new fillers designed to treat specific areas and concerns, our focus has shifted from lines to creating balance and harmony in the face. By restoring the fatty pads and placing the filler at the correct level we can achieve a degree of skin support and even lift sagging facial structures, such as the jowl and neck.

This slows down ageing in the skin as fibroblasts are ‘woken’ up and stimulated to make more collagen and elastin.

the muscle layers

With repetitive facial expressions such as frowning, we fold the skin which causes wrinkles and folds to appear. This is exacerbated by a reduced production of collagen and elastin and indenting the underlying layer of fat. Common areas that develop wrinkles and folds include the frown, forehead and around the eyes, or more commonly known as crow’s feet.

Some topical products may provide some benefit and softening of these expression wrinkles - here my go-to ingredient is vitamin A, such as granactive retinol or hydroxypinacolone retinoate, an ingredient shown to stimulate collagen production helping reduce the appearance of fine lines and wrinkles.

retinol serums to consider

sk.in flash | repair shot

sk.in avenge | HPR 3%

sk.in avenge | HPR 4%

sk.in avenge | HPR 5%

recommended treatment

To achieve the best results with wrinkles or lines caused by repetitive movement or facial expression, consider Botox®.

Even though this treatment may have received a bad rap in the past, with some patients experiencing a frozen expression after, I believe it is the best option currently available - if it is performed correctly.

These days we have the ability to tailor-make the treatment to suit each individual and achieve the desired effect. We can cater for personal preferences, ethnic and cultural differences (as beauty norms vary around the world) and achieve a natural end result.

By injecting certain muscles and avoiding others, or by changing the number of units injected in the muscle, we can leave as much - or as little - movement as desired with Botox®. A fantastic natural result can be achieved, which allows facial expression and movement and prevents changes in the natural shape of the face.

Other muscular changes that occur with ageing include an elongation of the muscles and a resorption of bone in the skull.

Muscles are responsible for facial expressions and also help to hold structure in the face. The smile muscles tend to be attached high on our cheek bone and insert at the corner of the mouth. As we age these muscles elongate, contributing to less support and a slight downward appearance to the corners of the mouth.

In conclusion, when we approach the ageing face, take into consideration changes that are visible on the skin as well as changes below the surface, including the fatty layer, muscles and bone.

This holistic approach will guide us in choosing the correct topical products and ingredients as well as additional professional treatments if required, in order to achieve the best possible overall results.

Dr Alek Nikolic

References

Elderly skin and its rejuvenation: products and procedures for the aging skin. 2007 Journal of Cosmetic Dermatology, 6, 40–50; Marcia Ramos-e-Silva, MD, PhD1 & Sueli Coelho da Silva Carneiro, MD, PhD.
Facial Plast Surg. 2011 Feb;27(1):16-22. Anatomic Considerations in the Aging Face; Richard A Zoumalan 1, Wayne F Larrabee Jr.
Facial Plast Surg 2015; 31(01): 03-09. Structural and Volumetric Changes in the Aging Face. David J. Gerth.
Stabilised Oil-Soluble Vitamin C Derivative, BVOSC, Barnet.
September 2018 Volume 79, Issue 3, Supplement 1, Page AB222. Pilot evaluation of safety, efficacy, and tolerability of a new topical formulation for facial hyperpigmentation, combining ascorbyl tetraisopalmitate and crosslinked resilient hyaluronic acid.
Double Blind Half Face Study Comparing Topical Vitamin C and Vehicle for Rejuvenation of Photodamage. Dermatol Surgery March 2002. Fitzpatrick and Rostan.
Lin AN, Nakatsui T. Salicylic acid revisited. Int J Dermatol. 1998;37:335–342.
Draelos ZD. Rediscovering the cutaneous benefits of salicylic acid. Cosm Derm. 1997;10(Suppl 4):4.
Grimes PE. Salicylic acid. In: Tosti A, Grimes PE, Padova MP, editors. Color Atlas of Chemical Peels.2nd ed. New York, NY, USA: Springer-Verlag; 2006.
Brackett W. The chemistry of salicylic acid. Cosmet Derm. 1997;10(Suppl 4):5–6.

Kligman AM. Salicylic acid: an alternative to alpha-hydroxy acids. J Geriatr Dermatol. 1997;5:128–131.

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