identifying & treating Structural Skin Damage

identifying & treating Structural Skin Damage

How Collagen and Elastin are Formed The dermis is comprised of three layers: the papillary dermis, the reticular dermis, and the subcutaneous dermis. The process of cellular renewal, which is responsible for the outward texture and appearance of your skin, takes place primarily in the papillary and reticular layers of the dermis. The papillary layer contains fibroblast cells, which contribute to the regeneration of connective tissue through the production of two major structural proteins: collagen and elastin, as well as the production of glycosaminoglycans (GAGs), which comprise the extracellular matrix (ECM). Elastin GAG/ Proteoglycans Fibronectin Dermis Collagen Fibroblast normalized with vitamins A & C Papillary Dermis Reticular Dermis ECM ground substance of the papillary dermis Collagen is by far the most predominant protein in our connective tissues, comprising 70% of our dermis. It is primarily responsible for determining the structure, shape and texture of our skin. Collagen has a triplehelix structure made from peptide chains and amino acids such as lysine and proline. The beginnings of collagen formation occur within the fibroblast. It is here that the fibrils of collagen are assembled together to form collagen, the result of which is an increase in the structural integrity of the skin. It is important to consider what type of collagen we are producing. Of the three types (collagen I, II, and III), we are most interested in producing collagen I. This type of collagen arranges into a mesh-like formation, which leads to greater structural integrity and an overall better appearance of the skin. On the other hand, collagen II and III arrange in a parallel array, which is associated with an inferior skin texture and is often associated with scarring. After collagen, elastin is the most abundant protein in the dermis, and allows skin the ability to stretch or distend without tearing, and then return to its original shape. Elastin is made by linking tropoelastin protein molecules to make a massive cross-linked array. Lysine is the amino acid responsible for this array. Please note that the GAGs are also made by the fibroblasts and are essential in hydrating the dermis and epidermis to ensure enzymatic reactions can occur. To make good quality collagen and elastin, we want to make sure we there is adequate vitamin A in the skin, as it works to address any abnormalities in the fibroblast. Vitamin A also helps to increase the number of healthy fibroblasts available to produce these proteins. The best form of vitamin A for this process is Retinyl Palmitate, which is the fat soluble form of the vitamin. Finally, there must be sufficient vitamin C in the skin, as vitamin C is an important cofactor in the creation of collagen. Papillary dermis 2 3

Examine: What is Structural Damage? When the structure of the skin is damaged it is associated with visible marks or disturbances that can often cause distress and necessitate cosmetic or medical intervention especially if they occur in places that are often visible such as the face, neck, and hands. The structure of the skin can be damaged in a number of ways: Extrinsic Aging The most common forms of extrinsic aging include deep and fine lines, a looser appearance of the skin on the face, abnormal pigmentation, inflammation, and a loss of elasticity. The major contributing factors to these problems that arise extrinsically include exposure to UV, poor nutrition, smoking, emotional stress, and excessive use of alcohol to name a few. By far the most significant of these is UV exposure, causing up to 80% of all damage to the structure of the skin. UV-triggered aging leads to a significant decrease in the number and density of elastic fibers. These fibers become shorter and thinner which is a major determining factor of wrinkle depth, and the skins ability to retain its shape. Lines on the forehead and eyebrows Periorbital wrinkles and lower eyelid Lines around the mouth Photoaging on the neck and décolletage Photoaging on the hands Lax skin and cellulite Scars from cuts Acne Scars Keloids Burn scar, mature Burn scars, active Scars left by esthetic accidents Scars left by split-skin graft Depigmented scars covering large areas Cicatrization: How Scarring Occurs Cicatrization, or the formation of scars on the skin is most accurately described as the replacement of healthy skin with lower quality tissues. Scars occur when the skin receives a substantial wound produced by trauma or medical procedures. They can be differentiated from healthy skin by significant changes in the extracellular matrix in the dermal level, and visible changes to the surface of the skin at the epidermal level. Scars can vary in severity based on the effectiveness of the body s cicatrization process. While scars can be almost invisible with normal cicatrization, they can also produce extensive changes to the texture and level of the skin if this process is inhibited. Striae: How Stretch Marks Occur Stretch marks (also referred to as striae distensae or striae gravidarum pregnancy stretch marks) most frequently occur on areas of the body that are subject to mechanical stress such as the abdomen, breasts, hips, buttocks, and upper arms. Stretch marks occur when the connective tissues of the papilliary and reticular layers undergo extreme stretching to the point of tearing. The most common indicators for tearing are sharp or rapid weight gain, abrupt growth, and in association with cortisone medication. In the case of pregnancy, hormonal effects can also cause a reduction in skin elasticity, increasing the likelihood of stretch marks. The results are reddish-blue bands which may fade with time, but often remain visible in the form of pale and often atrophic scars. Stretch marks (striae) 4 5

Explain: What can you do about it? UV light damage breaks down the ECM (destroys collagen) and inhibits new collagen from being made Vitamin A Vitamin C Normal mesh-like ECM with collagen I maximized Needle TGF-β 3 - binds to the fibroblasts and signals repairs and regeneration mechanisms by stimulating the mitosis of the fbroblasts, which then stimulates synthesis and secretion of collagen elastin, fibronectin, and GAGs TGF-β3 The most important factors indicated in repairing structural damage to the skin are promoting healthy and proliferate fibroblast cells, increasing the expression of growth factor TGF-β₃, and a resulting production of new collagen I proteins arranged in a mesh like structure. We can achieve these results in three steps. 1. Normalize cell: In order to stimulate our body s own repair mechanisms and offer protection against free radicals, there must be adequate levels of vitamin A and C in the skin. Vitamin A plays an essential role in controlling the proliferation and differentiation of all dermal and epidermal cells, as well as for the maintenance of all of the skin s physiological functions. These include wound healing, and the strengthening of the extracellular matrix by maximizing collagen synthesis by the fibroblasts. Vitamin A also serves to maximize the expression and release of transforming growth factor β₃ (TGF-β₃), which is indicated in a mesh-like collagen I network as well as scarless wound healing. This is a dose-related phenomenon, so it is important to step up to the highest levels of vitamin A that you can tolerate. Vitamin C is also essential in its role as a cofactor in the production of collagen, and must be present in the skin in adequate amounts. Vitamin A Vitamin C TGF-β₃ is a protein, known as a cytokine, which is responsible for the proliferation, cellular differentiation, and function of most cells. It plays a key role in wound healing, and dermal remodelling. Of particular significance TGF-β₃, has been shown to increase the production of collagen I in a mesh-like formation during wound healing. Fibroblast Blood platelet When the needling process causes bleeding, blood platelets are released, which in turn release molecular messengers called growth factors Remodelling Increase in Collagen I Through Needling Keratinocyte Needling induces increased proliferation of keratinocyte leading to increased epidermal thickening Papillary dermis 2. Regenerate the Collagen-Elastin Matrix: Our bodies have a natural wound healing response that kicks in when the skin is subjected to trauma. This process involves an immediate influx of fibroblasts to the area of damage, which are then instructed by various growth factors to repair the skin through the production of new collagen and elastin. It is now possible to initiate the same wound healing response in a safe and effective way through a method known as Percutaneous Collagen Induction (also known as needling ). During needling, thousands of microlesions are made throughout the dermis using needling rollers that are applied to specific areas of the skin. These tiny hemorrhages lead to an immediate wound stimulus, which activates the body s own wound healing cascade. During this process, tissue-bound platelets and neutrophilic granulocytes escape from the blood vessels that have been punctured by the needles, and secrete a multitude of growth factors, including TGF-β₃, which instruct the fibroblasts to regenerate the skin through the synthesis of new collagen and elastin. As these proteins are produced, the damaged skin is replaced with new skin that has improved in structure and elasticity. 3. Remodel the Structure of the Skin: The combination of a vitamin A and C rich skin and Percutaneous Collagen Induction has been shown to result not only in a regeneration of the skin through new collagen formation, but it is also indicated in a complete remodelling of the skin through the production of the highest quality collagen possible. When vitamin A and C rich skin is needled, the collagen that is produced is of the type I variety, which organizes itself in a mesh formation associated with higher quality dermal structure. The preparation of the skin with an advanced vitamin skin therapy program leads to an increased expression of TGF-β₃ once the wound healing cascade has been initiated through needling, which will then instruct the fibroblasts to specifically release collagen I. In the six months that follow the needling, collagen I continues to organize itself into a mesh formation, which results in a quantitative and qualitative improvement in both the structure and appearance of the skin. NO DAMAGE Other methods of inducing the wound healing response (such as chemical peels, dermabrasion, or lasers) can also lead to the synthesis of new collagen, however these methods cause damage to the epidermis, and the resulting collagen is predominantly the inferior collagen II and III. These types of collagen arrange in a parallel array, and are associated with micro-scarring and an overall inferior texture. NO DYSPIGMENTATION A common issue arising from laser resurfacing and chemical peels is that they manifest an increased risk of post-inflammatory dyspigmentation especially in darker skin types (Fitzpatrick III through VI). This has meant that these skin rejuvenating methods have been contraindicated for people whose skin falls into these categories. 6 7

Needling Options The results of Medical and Surgical Needling are the same: a qualitative and quantitative improvement in the structure, texture, and overall appearance of the skin. Therefore, in choosing which method to use, the main point to consider is whether you want one inpatient surgical procedure, or a series of outpatient medical procedures. Medical Needling (using 1 mm needles) can be done under local or topical anaesthetic, and requires little to no down time. You will be able to go back to work within 12-24 hours, and no one will be able to tell you've had a medical procedure. However, in order to achieve optimal results, it is recommended that the procedure be repeated once weekly for 6 weeks. With Surgical Needling (using 3 mm needles), you can achieve your desired results in just one session (with the option to repeat the procedure again in 6 months). However, this procedure it is usually done under general anaesthetic, and may require a short hospital stay. It is also associated with greater post-operative care and down time. As your skin will appear bruised and red for a few days after the treatment, you need to be prepared to take up to a week off of work. You must work together with your skin care professional to determine which option is best suited to your lifestyle, particular skin concern, and comfort level. Technique Name Needle Length Desired clinical effect Medical Needling 1-2 mm Lesions of the finest capillaries below the stratum basale, minimal petechial hemorrhages Desired physiological effect Superficial remodling Postoperative reaction Anesthesia Indication Limited edema and bruising, comparable to heavy sunburn Local anesthetic cream, done on an outpatient basis Wrinkles and photodamage, mild elastosis, stretch marks and shallow scars Information About Medical Needling Outpatient procedure Local anaesthetic Non post-interventional analgesia Sunburn-like reddening (a few days, can be concealed with make-up) Regional, mild swellings Avoid direct sunlight until wound healing is complete No time off of work No need to return to the practice for a check up Need for adequate pre- and post-needling skin care regime with vitamin A, C, and antioxidants Slow onset of action Result can be optimized by repeated treatments and continuous care Information About Surgical Needling Procedure performed under general anaesthesia Short hospital stay may be necessary Post-interventional analgesia for the first few hours Sever swelling and bruising may develop (lasting 1 to maximum 2 weeks) Uncomplicated healing if there is adequate pre and post needling treatment Possible skin irritation during wound healing Possible time off work Avoid direct sunlight until wound healing is complete Regular check-ups needed Need for adequate pre- and post-needling skin care regime with vitamin A, C, and other antioxidants Slow onset of action With scars: treatment goal is improvement of the esthetic appearance and quality of the scar Result can be optimized by repeated treatments and continuous skin care Surgical Needling 3 mm Heavier intradermal hemorrhages due to lesions of the whole dermis to upper subcutis Remodeling of the whole dermis More severe swelling and buising, lasting c. 4-7 days General or regional anesthesia Wrinkles and lines, conspicuous scars, burn scars, keloids Please note: There are some skin conditions for which 3 mm Surgical Needling is exclusively recommended. These include scars from cuts, keloids, active or mature burn scars, and scars left by split-skin graft. Please consult your doctor or allied skin health professional. 8 9

Results Results with 1 mm needling with 3 mm needling Before and after pictures are based on continuous use of combinations of Environ retail and professional products over time and prescribed treatment frequency. Results will vary significantly based on skin type, treatment protocol, and individual patient adherence. 10 11