ALPHA-HYDROXY ACIDS, BETA-HYDROXY ACIDS, RETINOL, RETIN-A, VITAMIN C--WHAT ARE THEY? WHAT CAN THEY DO FOR YOU

You are likely to have heard of a number of products which are being promoted to help the skin in diverse conditions--acne, pigmentary disturbances such as melasma, dryness and roughness, and wrinkling associated with chronic sun damage and that awful bugaboo, aging! Studies have indicated that certain agents indeed do have beneficial effects on the skin in these conditions, although, of course, all of them may have undesirable side effects, as well, in some people

The agent with the longest use is TRETINOIN, or RETIN-A. (Its patent ran out recently; thus, there are other brands of tretinoin currently on the market, such as Avita. Renova is the same as Retin-A 0.05% in a perfumed, moderately more emollient cream.) Tretinoin requires a prescription and has a number of common side effects--such as burning, redness, itching, peeling, and stinging; but it is very effective at increasing the shedding of corneocytes, the cells of the topmost layer of the epidermis, contributing to smoother-feeling skin. It also reduces pigmentation and more evenly distributes pigment in the epidermis, resultiing in improvement in mottled hyperpigmentation. Over time, it normalizes atypical cells in the epidermis and stimulates the formation of a band of new collagen in the upper dermis, helping to lessen fine lines, and causes new blood vessels to develop in the upper dermis, resulting in redness (or a "rosy glow," depending upon your perspective!) and reduces sallow skin hues. It may prevent collagen and elastin breakdown, helping to offset further damaging effects of sunlight. However, use of tretinoin greatly increases susceptibility to sunburn--making the use of effective photoprotective measures imperative.

RETINOL (retinyl acetate, retinyl alcohol) is a naturally occurring form of vitamin A and is found in many fruits and vegetables with an orange, yellow, or red color. Cosmetic chemists have recently been successful in stabilizing retinol--which is light-sensitive--for topical application. It is biologically active, and some of it is converted by the skin to tretinoin, accounting for its anti-aging changes in skin similar to those produced by Retin-A--such as accelerating epidermal cell renewal and improving fine lines by forming new collagen in the upper dermis--but with less or no irritation. Additionally, retinol functions as a natural humectant, attracting moisture and increasing the water content of the epidermis. Since water is the plasticizer of the skin, retinol use improves skin appearance and performance.

Retinol is the active ingredient in the AFIRM products. These products are similar in their action to Retin-A and Renova, with the 1X AFIRM being similar to Retin-A 0.025% Cream, 2XAFIRM similar to Retin-A 0.05% Cream and Renova, and the 3XAFIRM similar to Retin-A 0.1% Cream. Their difference is that they are much less irritating and drying than similar strengths of Retin-A and Renova.

ALPHA-HYDROXY ACIDS (AHAs) are compounds found naturally in many common fruits and other foods. The principal AHA is GLYCOLIC ACID, which is found in sugar cane and sugar beets. Other AHAs include LACTIC ACID from dairy products and MALIC ACID from fruit. Glycolic acid is the most skin-active AHA; and its primary action is to accelerate shedding of abnormal cells in the topmost layers of the skin by decreasing their cohesiveness. Continued use of glycolic-acid-based products results in a normalized, more compact top layer of the epidermis. This makes the skin smoother. Additionally, it helps to remove comedones (blackheads); and, like retinol, it helps to restore the barrier function of the skin, thereby helping naturally to increase its own moisture content (and not humidify the environment!). It, too, leads to increased collagen production in the upper dermis, resulting in diminution of fine lines. Glycolic acid also has an anti-inflammatory effect and is able to enhance the effects of other topical agents, such as hydroquinone and salicylic acid. It is well-tolerated by many people, but it can cause irritation and stinging in some. It, too, can make the skin more sun-sensitive; thus, use of effective photoprotection is essential.

BETA-HYDROXY ACIDS are SALICYLIC ACID. This occurs in nature in sweet birch and in wintergreen leaves. Its effects on the epidermis and upper dermis are similar to those of Retin-A, but with less irritation. It is soluble in lipid (oil) and can exfoliate oily skin areas, even within oil-rich pores. Thus, it, too, has beneficial effects in acne, pigmentary disturbances, and photo-aging. Again, use of sun protection is needed.

VITAMIN C is an anti-oxidant which is theorized to help protect cells from the damage of free radicals, molecules resulting from environmental pollution and ultra-violet light rays. To be effective topically, the Vitamin-C-containing product must be at an acidic pH and contain at least 10% L-ascorbic acid. It may cause irritation and stinging when applied to the skin.Although it may itself act as a mild natural sunscreen (at least it does so in guinea pigs!), it is not adequate protection and should be used with a high-SPF sunblock, just as all of the other agents which I have described.

All of these products can be beneficial to many people. Their main limiting factor is that of side effects, a problem most often seen with tretinoin, or Retin-A and its clones; however, any of these agents--since they are biologically active to at least some degree--may cause irritation in certain people. If you decide to use any of these products, be sure to start gradually, and to "ease into" daily use, especially if you know your skin to be sensitive or very dry, or if you have a history of eczema. 

None of these products causes "overnight success"--it will take time for the beneficial effects to become clinically evident! (Of course, it also took time to develop the problems that you are trying to remedy!) Your program will probably entail use of a cleanser (to enhance the penetration of the active agent and to help remove the desquamating epidermal cells), a lotion or cream which will contain the active ingredient (such as glycolic acid or retinol), and a sunblock. Depending on the problem or problems which you are "attacking," you may be using more than one "active agent" at a time--such as a Vitamin C-containing product and/or a bleaching agent in conjuction with another product--and you may be using different products in the morning and at night. (For example, tretinoin, or Retin-A, is used exclusively at night, and cannot be used at the same time as most other active agents, except for bleaching agents, because it tends to inactivate them.) 

In order to accelerate progress, or to enhance the effects of a home-care program, CHEMICAL PEELS can be utilized. Chemical peels are considered by insurance companies to be COSMETIC procedures, and their costs are NOT COVERED by them. The cost of the procedure is borne by the patient at the time of service.

The desired benefit of a chemical peel is related to the depth of the peel. A superficial peel removes the topmost layer of the epidermis and stimulates epidermal growth, and is generally very safe, with few complications, yet with good results--improving mottled hyperpigmentation, epidermal melasma, acne, acne scarring, oily skin, skin texture, and fine wrinkling. Peels can also be used beneficially.on skin of the hands, neck, chest, and back.  

Glycolic acid peels seem to exert their effects by diminishing the cohesion of the corneocytes at the innermost levels of the stratum corneum and by stimulating stratum corneum renewal and increasing skin thickness, promoting formation of new epidermis and new dermal collagen, resulting in skin shrinkage, reduction of wrinkling and "crepe-paper-like" skin, softening of "crow’s feet," and often helping to lighten hyperpigmentation.

The salicylic acid peels (Beta-Lift peels) very effectively lift the topmost layer of skin by dissolving the "glue" (desmosomes) which binds it to the underlying epidermis, triggering a "burst" of cell division which accelerates skin cell production and shedding. Its developer., Douglas Kligman, M.D., Ph.D.(who is the son of Albert Kligman, M.D., Ph.D., the founder of Retin-A!), developed it for the cosmetic treatment of sun-damaged skin, hyperpigmentation (including melasma, "liver" or "age" spots, and freckles), superficial lines, and "weathered" or rough skin. These peels are often more intense than the glycolic acid peels.

Both types of peels are in-office procedures that are used in conjuction with a home skin-care program. Results obtained with chemical peels are part of a process and NOT a "quick fix." Although you may notice some benefit from one peel, it takes a series of peels in addition to consistent at-home therapy to yield significant results.

In general, a series of 6-10 glycolic acid peels is performed at regular intervals (depending upon your skin type and the condition or conditions being addressed) which can vary from once weekly to once every third week.

Salicylic acid (Beta-Lift) peels are generally performed in a similar series; however, the briefest time between these peels is two weeks, and some people with especially sensitive skin may need to wait up to four weeks between peels.

If you are currently taking or have taken Accutane within the past six months, you are not a candidate for chemical peels at this time. Patients with healing wounds from recent surgery, patients with active herpes simplex (fever blisters or cold sores) on their face, patients who have had radiation therapy to their face (or area which they wish to have peeled), or patients who have had cryotherapy in the past month should not have a chemical peel. A tendency toward hypertrophic or keloidal scarring may also make you not a good candidate for a peel. It is essential that you use very effective photoprotection after a peel; thus, if you are unwilling or unable to do so, you should not have a chemical peel.

Please let me know if you wish to discuss any of these products or procedures to learn if they would be of benefit to you.