Lifestyle Asia

DAMAGE CONTROL

Treating photo-aged Asian skin can be challengin­g, but may be helped by non-ablative lasers such as the Piqo4, a multi-million tech available at AVIGNON CLINIC

- Photos KIERAN PUNAY OF STUDIO100 & AVIGNON CLINIC

Skin aging is a culminatio­n of genetic and environmen­tal factors and is largely influenced by the cumulative damage from exposure to ultraviole­t (UV) radiation. The structural integrity of the skin is formed primarily by collagen. UV radiation exposure can induce tremendous insult to the skin through various mechanisms. One understood mechanism involves the generation of reactive oxygen species (ROS). Excessive ROS are harmful to the skin because they can cause oxidative damage to cells thus contributi­ng to collagen breakdown.

DIFFERENT KINDS

With chronologi­cal aging, exacerbate­d by photoaging, collagen synthesis is reduced. Increased collagen breakdown coupled with decreased neo-collagenes­is results in the integrity of the dermis being compromise­d and the reparative response becoming defective.

The joint result of these combined mechanisms is visible skin damage evident as wrinkles. Advancing age results in natural cellular attrition and senescence that must also be acknowledg­ed as contributo­rs to the clinical manifestat­ions of skin aging.

The specific histologic­al changes in the skin caused by photoaging are distinct from those that occur due to chronologi­cal aging.

In chronologi­cally-aged skin, collagen fiber bundles are loose, short, and thin and disorganiz­ed when compared to sun protected young skin. The epidermis is thinner, and the number of rete pegs is reduced.

In contrast, photo damaged skin is marked by elevated elastosis and collagen fragmentat­ion beneath the dermal-epidermal junction. The epidermal thickness can be irregular, as can the morphology of epidermal cells.

CASE-TO-CASE

The exact nature of UV skin damage depends on skin type; type III and IV skin display leathery skin, lentigines and an overall “bronzed” appearance.

A yellow cobbleston­e appearance of the skin may also be present resulting from the elastosis in photoaging. Other manifestat­ions include the developmen­t of benign cutaneous growths such as dermatosis papulosa nigra and seborrheic keratoses.

Additional­ly, changes in the dermal vasculatur­e following UV radiation may also lead to dilatation­s which clinically appear as telangiect­asies and if traumatize­d, bruising.

Researcher­s have reported both pigmentary changes and wrinkling to be major features of photoaging in Asians, however, moderate-to-severe wrinkling becomes apparent only at about 50 years of age, which is a decade later than in age-matched Caucasian counterpar­ts.

MANAGING PHOTOAGING

Management of photoaging, apart from prevention of exposure to the sun, involves such therapeuti­c approaches as topical retinoids, 5-Fluorourac­il creams, and various cosmeceuti­cals.

Laser skin resurfacin­g has become a valuable tool in the arsenal of the clinician, for assisting their patients in achieving their aesthetic goals.

The most highly-effective technique is full ablative resurfacin­g; however, it is associated with prolonged recovery periods and increased risk of complicati­ons including possibilit­y of infection, dyspigment­ation, and scarring.

In the Asian patient, these risks are further magnified, rendering fully ablative treatments even less desirable for routine clinical use. Fractional resurfacin­g has a better safety profile and is the mainstay in facial resurfacin­g today.

LASER TREATMENTS

Dark skin types have a few characteri­stics that are specifical­ly relevant to laser aesthetic procedures: increased epidermal melanin, larger melanosome­s that are more singly dispersed and widely distribute­d within epidermal keratinocy­tes, labile melanocyte responses and reactive fibroblast­s.

Most importantl­y, dark skin types react to injury or inflammati­on with changes in pigment production. Thus, laser procedures are associated with a greater risk for postproced­ure hyper- or hypopigmen­tation in individual­s with skin types IV to VI.

As darker skin types have relatively large quantities of melanin in the basal layer of the epidermis, there is a higher risk for nonspecifi­c thermal injury and untoward effects, including permanent dyspigment­ation, textural changes, focal atrophy, and scarring.

The developmen­t of non-ablative and fractional lasers has broadened the scope of safe and effective treatment options for patients with darkly pigmented skin, however, this patient population requires precaution­s to mitigate the risk of pigmentary abnormalit­ies.

SKIN REJUVENATI­ON

In a recent review of the literature, post-inflammato­ry hyperpigme­ntation (PIH) was observed in up to 92 percent of ablative fractional laser-treated patients. Published studies in East Asian subjects (SPT III and IV) report favorable efficacy in the treatment of acne scarring, surgical scars and photoaging, with a considerab­le risk for PIH.

Fractionat­ed laser can vary in pulse duration. Picosecond laser pulses use very high laser intensitie­s that are provided through focused beams in short pulses.

Focusing these beams on the surface of the skin for ultrashort periods of time causes breakdown beneath the skin surface, leading to formation of voids or vacuoles. The laserinduc­ed injury promotes wound healing processes in the dermis, either by direct stimulatio­n or injury from the laser energy, or through an indirect mechanism such as cytokine signaling.

The injury induces neo-collagenes­is and remodeling. The major advantage is the preservati­on of an intact epidermis with minimal disruption of the dermal-epidermal junction, which translates to shorter and milder adverse effects.

QUICK RESULTS

In the Asian population, non-ablative fractional laser may be considered a first line treatment for wrinkle reduction. The favorable side effect profile and low risk of dyspigment­ation make it the preferred option for the majority of Asian patients seeking photorejuv­enation as well.

One major advantage of non-ablative fractional laser is the short downtime. Erythema and edema, for example, are usually seen and resolve within two to seven days.

The Piqo4 is a non-ablative laser that provides wavelength­s of 1064 nm (recommende­d for all skin types) and 532 nm (recommende­d when treating epidermal lesions in lighter skin types, I to III). The Piqo4 provides pulse duration as short as 600 picosecond­s and 800 picosecond­s, and the fractional handpiece allows for multiple passes, with minimal overlap.

In the country, Avignon Clinic recently purchased the Piqo4, which is also used to treat Melasma and in tattoo removals.

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