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Physiology of the Skin: A New Look at Vitamin A

By Peter T. Pugliese, MD
Posted: April 23, 2008, from the May 2008 issue of Skin Inc. magazine.

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Guidelines for Treating Hyperpigmentation

A search of the literature reveals a rather standardized treatment in the medical profession for these conditions. Essentially, the products contain hydroquinone from 2–4%, retinoic acid at 0.1% and a high-potency cortisone preparation. Treatment is continued twice daily for 12 or more weeks.
      There are many preparations for skin lightening and depigmentation, but following are the combinations of ingredients you should seek.
     A form of vitamin A, such as retinol, retinal, retinyl palmitate, or retinyl acetate, which may vary in concentration from 0.1% to as high as 10%.8 An alpha hydroxy acid, such as lactic, glycolic or malic, or mandelic acid, ascorbic acid (vitamin C) at 2–7%, and a sunscreen with an SPF of at least 15. To this group you can add mulberry extract, arbutin, lemon extract, glucosamine and a host of other ingredients. Remember two things: As you increase retinoid concentration, you will increase irritation; and as you increase the number of ingredients you have, the potential for sensitization and interaction increases. Treatment should be continued for 3–12 months, sometimes longer. Let the client know that these pigmented lesions are produced throughout a long period of time, and will not go away quickly. It is important that the skin care professional has a good understanding of melanogenesis and is able to appreciate the complexity of pigmentation.

Guidelines for Treating Aging Skin

Start with a 0.3% solution—that is about the middle of the road in strength. Apply at nighttime after cleansing the skin. For 40+ women, I prefer an oil-based cleanser rather than a soap of detergent base. The oil base will not damage the skin’s barrier, but will leave a nice microthin lipid layer that will expedite the entry of the vitamin A preparation. Here again, I prefer the vitamin A ester, retinyl acetate. Following are other preparations available for comparison. The literature provides the following informatione.
     In the nighttime treatment program, which should be mandatory before 11 pm, add vitamin C topically—it is an antioxidant and collagen booster. Bioflavanoids such as oligomeric proanthocyanidins (OPC) are powerful inhibitors of collagenase, or matrix metalloproteases. These enzymes break down the collagen throughout the body and are responsible for most of the lax skin seen in women. There are many types, but MMP 1 is the worst of the lot. In addition, add carnitine to assist the formation of ATP, the critical energy molecule that supplies the power to run the bodyf.
     Of course, vitamins D and E should be included. More is being learned about vitamin D as an essential vitamin and hormone for the skin. Make sure a day cream with an SPF of at least 15 is used.
     It will take many weeks to show improvement, except in the mildest cases. If there is no satisfactory improvement in 4–6 weeks, increase the retinyl acetate to 0.5% and add a facial peel once a month. Do not use trichloroacetic acid; rather, use a milder acid such as salicylic, lactic or malic. Remember that the turnover rate for skin increases with age; because of this, frequent chemical peels are not beneficial at intervals of less than four weeks. You may have to treat your client for life. Aging can be slowed, but not stopped at this stage. You can repair, correct and prevent aging changes, but the process, as of now, is relentless. This is not to say there is no hope for advances that are being made. Even today, women of 30 or 40 years of age can hope to look the same, or even better, in their 70s and 80s.

e. The literature refers to the scientific literature, namely periodic journals from which all scientists quote and refer. It is not a specific journal; it is the whole scientific world thousands of journals.

f. ATP is adenosine triphosphate, is made in the mitochondria and is essential to most biological reactions.

Guidelines for Treating Acne

This is a working classification for addressing acne that follows the American Academy of Dermatology recommendations.

     Mild acne—only comedones. Use a salicylic acid 2–5% cleanser twice daily and follow in the evening with retinol or retinyl acetate, 0.5%, at night. Reduce fatty and sugar-laden foods, and make sure green and yellow vegetables are consumed. Lesions should clear in 3–6 weeks. Follow up with bi-monthly visits for at least six months, then, at six-month intervals.

     Mild acne with comedones, macules and papules. Follow the same regimen as mild acne with only comedones, but add 2.5–5% benzoyl peroxide. At this stage, infection has started and the Propionibacterium acnes needs to be stopped from making a pustule. Follow weekly with oxygen treatments—a proven topical oxygen or a water-based aerosol of oxygen is ideal. Dry oxygen is not as effective. Getting into the follicle with molecular oxygen is the goal because P. acnes is anaerobic and does not like oxygen. You should see this client every week until the lesions are clear.

     Papules and pustules. Pustular acne means that the infection has gotten worse. Physicians generally use oral antibiotics at this stage, but you could use all of the aforementioned agents plus 5% niacinamide cream, which is available from some suppliers. Niacinamide at 5% has been shown to be as effective as clindomycin when applied topically.6 If you are not getting a response in a week, the client should be referred to a physician.