A dermatologist talks: Breaking down anti-ageing treatments
Turn back time
As we examine the topic of anti-ageing, we will look at the different treatments that can be done to address various issues — from pigmentation to wrinkles — as well as the importance of safety and efficacy.
Lights and lasers for pigmentation
As skin ages, one may develop areas of blotchy pigmentation as well as harmless overgrowths of skin, known as seborrheic warts. Skin pigmentation itself is caused by over-activity of the melanocytes (pigment producing cells). It is due to genetic as well as environmental factors such as sun-exposure as well as inflammation, for example, from use of inappropriate cosmetics/medications or skin conditions like eczema. Sun spots, also known as solar lentigines are harmless flat brown growths on skin that increases with age. Some genetically predisposed individuals may also have several freckles from a young age and these increase as one grows older and with increasing sun exposure.
Lasers are often the first treatment lay people think of for treating their pigmentation woes, but just as not all brown patches or growths are sun spots, neither are lasers the same nor equal. Dermatologists first developed and used lasers for treating true medical conditions such as birthmarks and warts. Benign facial growths such as seborrheic warts have to be removed with cautery or ablative laser techniques and these get rougher and larger if left untreated and may be disfiguring. The same lasers when applied to a pigmentation problem like melasma, end up worsening the condition and potentially resulting in permanent discoloration.
Melasma is a challenging hormonal related skin pigmentation disorder common in Asian and Hispanic women which should be treated early with an appropriate gentle laser, such as a 1064nm q-switched laser together with a depigmenting cream like hydroquinone. A word of caution: Use of an inappropriate laser and setting can result in worsening of the condition so always seek the care of an accredited dermatologist (check your doctor's accreditation here) rather than an aesthetician. Depigmentation creams should also be prescription items only from your dermatologist after evaluation, as those purchased over the counter either do not work, or may contain illegal, unsafe concentrations that can cause permanent scarring. Be safe!
Light treatments (e.g. blue and red light), target several skin conditions. Red light has been shown to increase skin radiance. Blue light helps suppress the growth of Propionebacterium, which causes acne. These are delivered via specialised medical devices with a certain intensity that is proven to stimulate the skin. Home devices rarely deliver sufficient energy for measurable effects.
Why is it important to seek the care of a dermatologist for pigmentation concerns
In the age of medi-spas and aesthetic doctors, one should not throw caution to the wind simply because every other clinic or spa claims to treat your pigmentation woes. A lot of times, potential skin cancers are missed by non-dermatologists and a potentially cancerous growth should never be treated with a laser. Dermatologists are trained in the diagnosis and management of pigmentation as well as potentially dangerous conditions like skin cancers.
Under untrained hands and with a disregard for safety, there is an increased risk of use of inappropriate lasers which result in poor results or even worsening of the condition, many of which can be harder to treat in the future. Besides, treatment of cancerous growths with a laser is downright dangerous and can lead to increased morbidity and mortality. Lasers are medical devices that can also cause blindness, burns and scarring from burns and should be handled by a trained medical specialist. In Singapore, dermatologists are the only recognised specialists in cosmetic skin problems and aesthetic procedures that do not require additional Certifications of Competency (COC) to carry out such treatments in Singapore.
Injectables: Toxins and fillers
In my practice, botox and fillers dominate the requests for anti-ageing procedures. While dermatologists are at the forefront of the development of these technologies in humanity's race to reverse time, they would also caution that things can go wrong.
Botulinum toxin — often known by its commercial names like Botox or Dysport, is a toxin that paralyses facial muscles to reduce wrinkles and give skin a tightened, lifted appearance. The first use for aesthetic enhancement was by a Canadian dermatologist back in the nineties. It is used effectively for forehead and frown line wrinkles. If you are looking angry or cross due to those age wrinkles over your forehead, then using Botox is right for you. For slimming the jawline to produce the popular V-shaped face, injection of larger quantities of Botox can achieve a good effect. I usually combine injection of Botox with a lifting laser as well as high intensity focused ultrasound to enhance the effects.
Using small amounts of the toxin in a technique known as Dermolift, or meso-botox, an effect can also be achieved that lifts and tightens facial skin without a surgical face lift.
When injecting the forehead wrinkles, poor technique can increase the risk of complications, i.e. diffusion of the toxin into the eyelid muscles and cause drooping of the eyelids. For face-slimming injections, using botox for example, plastic surgeons and dermatologists are trained in facial anatomy and know clearly to avoid danger zones of the face. Under untrained hands, injecting into the facial nerve can cause potentially irreversible facial nerve damage and disfigurement.
Fillers are used to plump up facial volume, the loss of which is one of the key signs of ageing. One of the benefits is also the appearance of a refined skin texture and reduced pore size when facial volume is restored. The technique, choice of constituent and location of the fillers is all important as these factors interplay to influence the aesthetic outcome. The filler type affects the texture, (i.e. how natural it looks) while restoring facial contours, as well as the longevity of the outcome. Hyaluronic acid based fillers are regarded as temporary and tend to last around six months, however, combining the use of dermal fillers with other techniques such as toxins and lasers can increase the longevity of the desired effects.
While fillers are regarded as safe and effective for restoring a youthful complexion, poor technique can lead to complications such as lumpiness where the filler is injected, injection into facial blood vessels which can lead to blindness as well as infections. Under the Singapore medical legislation, dermatologists and plastic surgeons are the only specialists trained in filler injections that do not require additional certification for providing filler injections.
Do you feel that your facial skin is getting leathery with age and yearn to regain that plump, healthy skin which you had in your twenties? The ageing face is beset with wrinkles, sagging and loss of radiance. Skin just looks shrivelled and rough and pores are enlarged. For the last two decades, dermatologists have looked to retinoids as the anti-ageing wonder molecule, with derivatives of it such as retinol being sold in over the counter anti-ageing cosmetics. The problems associated with these vitamin A-derived cosmetics, AHAs (alpha-hydroxy acids) available without a prescription, was that while these were in sufficiently lower concentrations compared to a clinical formulation that would be prescribed by a dermatologist, they still were irritating to the skin when used over a long period, resulting in conditions like facial sensitivity and eczema. In this millennia, the dermatological research community has concentrated its efforts on phytochemicals, or plant-derived antioxidant formulas, that simultaneously prevent UV-damage and anti-age the skin by stimulating collagen secretion. Another area of development would be in oligopeptides — a wonder molecule that has retinoid-like effects without the side effects of skin irritation. Resveratrol is another potent plant-derived molecule with antioxidant prowess, combating free radical formation that is responsible for ageing.
For skincare, it is important to note that cosmeceuticals are not regulated by the FDA or Health Sciences Authority in Singapore and so are not bound to the claims on their packaging. As such, it's difficult for the consumer to know if a given product can do what it claims it can do, contains the ingredients it claims to, or if the ingredients have the potential to cause harmful reactions such as phototoxic conditions when exposed to the sun or cause allergic or irritant contact dermatitis. As a quick rule of thumb, a product recommended by a dermatologist would be safe bet. Looking down the ingredient list may not be sufficient, because even when the correct active ingredient is present, it may lack effectiveness because of an inappropriate drug delivery system, compound instability, poor penetration, inadequate dosing or the ingredient itself may lack good clinical studies to back it up.
In an era where everyone wants a share of the aesthetic dermatology market, you find spas, beauticians and even doctors who are not trained dermatologists who venture into the realm of aesthetic medicine.
Cosmetic treatments may look easy. However, to know if a treatment is safe for you as an individual, with your personal medical history, your lifestyle and skin colour/type takes in-depth medical knowledge of the skin. Besides, dermatologists are bound by their accreditation boards to practise only evidence-based medicine rather than sell you the latest fad. The skin is the largest organ of the human body and dermatologists have the unique training to deliver the best results with safety. Without this training, complications become more common. I have seen patients who have burns after having laser hair removal at a medical spa, another had severe post-inflammatory hyperpigmentation after being treated with a chemical peel by an aesthetics doctor. After developing complications, these women saw a dermatologist for corrective treatment. Thankfully, the problems are treatable in most cases.
Dr. Teo Wan Lin, founder and medical director of TWL Specialist Skin & Laser Centre, is an accredited dermatologist specialising in medical and aesthetic dermatology. She integrates her artistic sensibility with her research background and specialist dermatologist training, by means of customised, evidence-based aesthetic treatments using state-of the-art machines, injectables (fillers and toxins) which work synergistically with her proprietary line of specialist dermatologist-grade cosmeceuticals Dr.TWL Dermaceuticals. Follow them on Instagram here.