The skinny on 50+ skin care

Confused by the constant hype about new beauty products and cosmetic treatments, I decided to track down Dr. Niels Krejci of the Boston University Center for Cosmetic & Laser Surgery, which is affiliated with both Boston University School of Medicine and Boston Medical Center. A practitioner with extensive hands-on experience as well as an impressive body of published research, Dr. Krejci talked about the value of slowing or reversing the effects of aging for 50+ skin.

What happens to our skin as it ages?

I just wrote a book chapter on skin aging, which happens in two ways. Endogenous aging happens simply because your skin is getting older; your cells are dividing less. Then there is external aging, which happens in response to influences such as smoking and exposure to the sun's UV rays.

Within these categories are three levels of changes. First, are the superficial changes, such as age spots. You get irregular pigmentation, sunspots, and broken blood vessels, which make your skin look a little dull and uneven but not terribly old.

Next are medium-deep changes that happen in the collagen layer. This is where wrinkles form. You frown, you concentrate, you wrinkle your forehead. If you do that a lot over a lifetime, you get furrows, which are a clear indicator of age.

The third level is the deep changes that occur when your face's skeletal and muscular system ages. They are the infrastructure that that keeps everything up and tight, so when they age, your skin sags. You get a hanging neck, baggy eyelids, and jowls. To an observer, these changes are the strongest indicators of age.

Do non-surgical treatments have any real effect on these changes? We are seeing an explosion of dermatologist-developed skincare lines at beauty counters and pharmacies. Is one any better than the others?

To put it bluntly, much of that is really bogus. When you see a "dermatologist developed line," it doesn't mean that the doctor sat down and picked out the ingredients, specifying, "Oh, I want 2 percent of this and half a percent of that."

Some of these doctors just go to a retailer and say, "Give me your generic white label line of products" and then put their own name on the packaging. Plastic surgeons who have absolutely no education in skin care treatment have their own lines but don't understand what's inside the jars.

So these products are not better than any others. The only advantage is that the dermatologist may prescribe and sell a lot of a particular product through his office, so he will know what it does well and what the side effects might be.

Women should keep in mind that over-the-counter cosmetic products are not regulated; the FDA doesn't evaluate them for efficiency, safety, or effectiveness. You could put motor oil into a bottle and make whatever claims you want: "proven to reduce wrinkles"; "satisfaction guaranteed." No one could stop you; it would be legal.

Some creams and products have been around forever. Do their formulations change over time to incorporate advances in the field of dermatology?

Creams do evolve a little bit over time. Many now include sunscreens, for example, including some delivered via microspheres or microcrystals. But there has not been a big breakthrough in over-the-counter treatments. So a cheap moisturizer is probably just as good as an expensive one. I urge my patients to set up a consultation with my esthetician because she sees so many face creams and talks to so many patients. She gets the best feedback on what creams are really effective. Most physicians don't get that feedback because we don't talk much about nonprescription products.

Another approach is to get a sample from the cosmetic counter and put it on only half of your face. That is the only true way to see whether it really does anything -- whether it's worth your money. You will also find out whether the product is compatible with your skin. If you put something on that's too oily for your skin type, you might break out in pimples. Conversely, the treatment might be too dry or too thin a lotion for your skin, especially in the winter. This approach is a way to avoid spending $150 and then finding out that you can't even use the product.

It is also how clinical testing is done for prescription medicines, like Renova. If a product doesn't do anything, the FDA will not consider it an effective medicine. Most over-the-counter creams are not submitted for FDA approval because the manufacturers know they couldn't pass an efficiency test.

Are topical creams effective for treating age spots, or are lasers the superior choice?

It depends on what caused the age spots. Those on the hands are mostly sun-induced. They're the same as freckles -- not the keratoses that are also sometimes referred to as age spots. There's a new bleaching solution called Solage that's good for sun-induced age spots. It comes in what looks like a nail polish bottle, with a little brush that you use to paint the solution onto your age spots. It works, although it's a bit cumbersome. And most men are not going to use it.

Laser is really the best treatment for these spots; it just takes out the pigment, and ten days later the spot flakes off.

There is a lot of hype around creams that claim they promote collagen production. Are these claims valid?

They are merely hype. Collagen and peptide creams have not been proven to do anything. The only ingredient that is proven to reverse sun damage, produce new collagen formation, and remodel sun-damaged skin is retinoic acid. That is in prescription compounds such as Renova, Retin-A, Tretinoin, and Tazaroc. And they're great. I think everyone should be on them -- just like everyone should stop smoking, wear sunscreen, and get a dermatology check-up once a year.

What about antioxidants in pill form? Do oral supplements have the same effect as the topical, vitamin A-derived creams?

I don't know. I haven't seen any controlled clinical studies -- the rigorous studies you must do to bring a product through the FDA and market it as anti-aging or anti-skin aging. However, I've seen scientific reports and observations, and they certainly make it seem as if the pills do something.

Botox seems to be the preferred treatment among dermatologists. Some use it themselves. It seems to have become less of a splurge and more an accepted part of routine anti-aging skincare.

All age groups are using Botox to treat every facial, neck, and body muscle. In my opinion, that is going a little too far. However, for the original treatment areas -- the vertical frown lines between your eyebrows, the horizontal lines on your forehead, and the crows feet around your eyes -- Botox truly is a god-send. It makes a huge difference for many, many, many patients who would look and feel a lot older if they had to keep those deep lines.

But it's interesting: Many patients come back after their Botox wears off, and they are so relieved to return. "Oh my god, I can frown again," they tell me. They can express tension and worry that they haven't been able to show on their face in three or four months. And being able to do that is uncomfortable, because the internal feedback is "Uh, oh. I'm tense; I'm worried; I'm uptight." If you relax the muscle - and you can do this artificially - it can restore the patient's inner calm.

Is a facelift a good way to reverse some of the changes that come with age?

Not in my opinion. There's a whole school of thought now that says traditional facelifts are the wrong approach to looking good. For these, they surgeon takes skin that no longer has volume, pulls it backwards, and cuts off the slack. The result is an oddly stretched face that looks a little like a dog in a wind tunnel. It does not look natural or young.

Today, we're seeing various levels of facelift. The most aggressive are deep-plane facelifts, where you undermine directly over the bone instead of the muscle. Then, there's a whole range of less radical facelifts that you can do with local anesthesia. Those have shorter healing times. The procedure is shorter, it costs less, and you get much the same effect from it.

A step down from that are string lifts, which involve little cutting. You just insert a string with hooks on it and pull back, so it lifts the skin. The question with these is longevity. Traditional facelifts have been around for a long, long time. You go under the skin, find the muscles that suspend everything in your face, and pull them up. That's how you get the lift. And the effects can last for many, many years. With the string lifts, we don't know. I don't think they're long-lasting. Certainly, the string lifts that we've seen in the past few years were sort of disappointing -- they broke and migrated.

We are evaluating a whole new set of strings, but I have trouble believing that they're going to do what a facelift can -- even the short incision facelifts. My opinion is that we should be getting rid of the wrinkles and the sagging by filling up volume with fat transfers. I could show you some great before and after pictures for this kind of treatment.

Are you referring to "filler" treatments?

Yes. Fillers are to the lower face what Botox is to the upper face. You cannot immobilize many of the moving muscles of the lower face because you have to smile and chew and pronounce words properly. So you can't use Botox on the nasal labial folds, which are the lines from the nose to the corner of the mouth, or on the marionette lines that go from the corner of the mouth down to the chin. But when you fill these in and plump up the skin, it looks very nice.

But these procedures still involve injecting a foreign substance into the face. What should people know before they decide to pursue any of these treatments?

I advise my patients to start small. Use a small amount of a short-lasting filler. Go for something that lasts for between three and six months, such as collagen or hydrolaunic acid. That will give you an idea of how you tolerate the procedure. Is it too painful? Can you deal with the swelling that's there for a day or two? Do you like the results?

Then the next time, you can be a little more adventurous and make your lips a little bigger. Everyone gets smaller lips as they get older. Even if you don't smoke, you get lines around the lips because your lips get less full and so the skin wrinkles. Filling in lip volume is very rejuvenating; the lines go away.

We now have FDA-approved fillers in the US, including calcium hydroxyl apatite, or Radiesse, which can last over a year. On some patients in some locations, it can even last two years, although that's not typical.

When you've done it five times, you and doctor will know exactly the look you want. Then you can go for something longer lasting.

Many people complain that aging dulls their skin. Can a skin peel help with that?

Absolutely. Superficial peels - like those made with glycolic acid, the beta peels, and the new vitalize peel -- are all skin refreshing treatments, similar to a microdermabrasion treatment. They last for a month, and they really renew your skin. You can either do one when you have something coming up - say you want to look great for the holidays - or make it part of a regular routine to keep your skin looking great.

Using Renova or other retonic acid products gives you a similar effect. But then you have to apply it yourself, every evening. Men often prefer to go once a month, get a peel, and be done with it. It's like getting their hair cut, and it's become popular with a lot of men.

We've been focusing mainly on the face. Do women have a tendency to neglect the skin on other parts of their body?

Many young women neglect to provide proper sun protection for their neck, shoulders, arms, and hands. It's heartbreaking to see patients in their thirties and their forties with dry, old, sun damaged skin. When you turn their arms over, you can see how smooth, soft, and shiny their skin would look like if they had protected it.

Is there anything to be done for that damage? What advances do you see coming in the field of skincare and dermatology?

For 10 or 15 years, we've been pursuing the promise of non-ablative skin tightening, which we learned about when CO2 laser resurfacing first came out. Laser resurfacing burns off the top layer of skin; you can actually see the skin shrink a little with each pulse that you position on it. A new, smooth skin forms that has no age spots. And it is much tighter.

Did you ever do a shrink-wrap treatment on a window? When you stretch the plastic over the window and apply heat, the plastic shrinks, and all the wrinkles go away, The same thing happens with the face. The skin shrinks, all the wrinkles go away, and the person looks fabulous. But there is a high risk of burns. So after learning that heat tightens collagen and tightens the skin, we have spent the last 15 years trying to replicate the effects without burning people's faces off.

Thermage, a popular radiofrequency technique, came out of this research, as did many new products. And the FDA just approved something called Refine. All of these approaches are based on heating the skin and contracting the collagen to get a tightening effect.

Despite all of the marketing hype, these approaches are not that great. You see tiny increments of improvement. But the real promise of non-ablative skin tightening has not been fulfilled yet. It's still in the works.

If I decide to try one of the techniques we've been discussing, how should I go about finding a reliable dermatologist and plastic surgeon?

I think the best approach is to call a university in your area and ask to speak to one of the chief residents in training to become a dermatologist, plastic surgeon or facial EMT. These people are usually young and helpful; they are in constant contact not only with doctors in that hospital but also with private practitioners who come in for training. They have very good sense of what's out there in the community.

When I need an optalmologist or a dentist, I'll call the chief resident in that specialty and ask whom to go to. The residents know who's good at what. If you were to say, "I need help; I have a skin cancer," they would send you to the best person.