Is Skin Damage Reversible?

Ben Johnson, MD
In reviewing all of the treatments that have been prescribed over the last 25 years and their related claims, you would think that we would have solved the problem of aging skin by now.  After all, research clearly showed that collagen formation was activated by Retin A™, multiple different laser wavelengths, the application of heat, infrared and LED, growth factors, amongst other things.  Many of these treatments showed promise in research but have failed to show progressive or permanent changes in the skin.  Potentially aggravating the problem is the additional damage we inflict (often daily) by forcing the skin to exfoliate faster than it could manage on its own.

I’m in the skincare business so I am not doing myself any favors by questioning the activities of a vast majority of skin care professionals in practice today but I think it is important that we take what we already know about skin physiology and apply it to current anti-aging efforts.  We know that the reason the skin ages is due to its inability to repair 100% of the inflammation-based damage that occurs on a daily and/or annual basis.  Every year we lose 1% of our dermis and the processes of the skin continue to slow down.  The question remains, if aging is the result of too much inflammation for the skin to handle, then why do most of the “anti-aging” treatments add inflammation to the skin?  My belief is that we have identified swelling and scarring as successes because they temporarily improve pigmentation or generate a temporary tightening effect that looks like an anti-aging event for the one day to one year that such an effect lasts.  The other misconception (in my opinion) is that people think the results “lasted 6 months” because the body continued to age and caught up with the improvements created by the procedure.  Never mind that the loss of “results” seems to coincide perfectly with how long it takes the body to heal the damage.

All that being said, where we may really be failing our clients and patients is our never-ending desire to assist the skin in the exfoliation process.  We know the benefits… lightening of pigmentation, firming effects that reduce fine lines and acne clearance in many cases.  We also know the downside; increased free radical damage which ages and likely increases skin cancer risk in the skin along with increased environmental toxin absorption, scarring (putting irritants/acids on wounds) and dehydration (leading to oily/combination skin).

Why does the skin slow down over time? Why does it progressively lose its ability to repair itself?  In order to believe in chronic (daily) exfoliation strategies you have to believe that the skin slows its epidermal turnover rate unintentionally.  Personally, I think the skin knows what it is doing!  I am convinced that the skin slows down because it has lost its food/immune cell supply due to lost circulation and overwhelming repair efforts that occur as a part of aging.  Just like every other process in the body, when faced with declining nutrition, skin metabolism (turnover) slows. If a lack of nutrients is the problem then how does daily exfoliation improve turnover? Simple, the skin recognizes that a damaged epidermal barrier is life threatening so it naturally rushes to fix the problem by placing the epidermal “holes” as a priority over maintaining the rest of the dermis.  It diverts scarce lipids, proteins, enzymes, collagen and antioxidants from the daily maintenance activity of the dermis to the “emergency repair” of the epidermis.  Leaving aside the extra work created by the damage of most “anti-aging” procedures, doesn’t it seem counter-intuitive to continue to stress the healing process after they visit your office by increasing free radicals and the workload of the skin with a post-procedure exfoliation approach?  Collagen is being generated as much as three weeks after many of these treatments.  Do we really want to be adding inflammation and depleting resources during this critical time…or at any time?   Have we not already learned that adding inflammation to a traumatic procedure is a recipe for post-inflammatory issues and declining results?  The results from our “20 year experiment” on the benefits of AHA’s, high dose retinol and Vitamin C, Retin A™ and other treatments has proven that we are not reversing (or preventing) aging with these strategies.  It has shown us that the skin, when repeatedly abused, does not get progressively better. Skin cancer, rosacea, melasma/hyperpigmentation and aging are all growing in incidence and severity.

Is there hope? You bet.  There is a growing migration within professional skincare (and the general public) towards alternative strategies that are more gentle.  LED and Infrared appear to have mild-moderate effects on the skin by improving  it’s healing efforts.  You are also starting to see a shift of focus in skincare towards delivery systems as we all recognize that to fight aging we need to target dermal (not epidermal) activity.  These include things like the dermaroller, blading, liposomes and other delivery enhancers.  The first two add inflammation to the skin so I prefer liposomal delivery, especially since it improves penetration by 10-fold over traditional creams.  We have also seen an increase in popularity of niacin and niacinamide usage although most people do not look at their activity in the skin as being a nutrient provider…that is my assessment.  Retin A is toxic and immunosuppressing to the body.  It is not meant to be floating around in our skin and so its positive attributes are ultimately trumped by its toxic effects.  Long term Retin A has not worked, just look at the skin of those on it for years.  There are several non-toxic alternatives, the most potent being retinaldehyde which was proven to be as effective as Retin A on fibroblasts but is stored by the skin after utilization (unlike Retin A).  Retinol and Vitamin C are good for the dermis, but not so good for the epidermis.  Only with appropriate delivery systems will their use increase remodeling without adding inflammation. Without better delivery, both add too much epidermal inflammation and will have a net negative response for aging overall.   There are several other research proven collagen stimulators like Chlorella, Beta Glucan, Lipoic Acid and EGF that do not add inflammation to the process.

In-office treatments are more difficult.  Occasional exfoliation is something the skin can handle so that process does not need to be discarded.  My advice is to choose more conservative options that create quick results for pigmentation, etc but do not put the patient at risk for permanent damage.  I still prefer the strategy of liposomal delivery of high dose dermal stimulants which is something that can also be added to exfoliating procedures to enhance results.  Exciting possibilities are also coming with the improvement in stem cell related growth factor serums and collagen precursor technology, both of which will soon be available from several companies.  If we recognize the delicate state of the dermis and stimulate it without adding inflammation or depleting resources then we give the skin a chance to recover what it has lost in our adult years.  Isn’t that the goal after all?

Ben Johnson, MD started in aesthetics with one of the first medi-spa chains in the country. Soon after he founded/formulated his first skincare line, Cosmedix. Currently he is the founder/formulator of Osmosis Skincare.  Dr. Johnson has also recently developed a technology for the treatment of eczema and psoriasis (amongst many other conditions) that is just being launched. In addition, he is a renowned international speaker/educator. (303) 674-7660

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