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The ageing of the skin

Introductory

As the medical world improves its skills, people are growing older. It is estimated that 20% of the population in the developed nations of the world, will be aged 65 years or older in the beginning of the 21^st century. The generation of 85 years and older, are already the fastest growing segment of these societies.

The problem of aging does not only have a socio-economic side, but the social status of the elderly is also involved. This is affected by the excessive individualism of a society that is becoming increasingly materialistic. Self-esteem has a strong incentive in the way others see us – as a result dematology and cosmetology have special roles to play.

With this assignment, we take a look into the skin, its functions, the chronological and external factors that have an influence on the aging processes of the skin, its prevention measures and remedies for aging skin.

What is the skin and its functions.

The skin is the largest organ of the body covering an area of approximately 1,2 – 2 square meters. Its main function is to protect our internal organs from the environment.

The skin covering our body is about 0.6mm thick, while the facial skin is much thinner, only 0.12 mm, and the thinnest of all is found on the lips - that is why they are so prone to cracking and splitting in cold weather. Skin is a living organ that constantly renews itself, shedding dead cells all the time and generating new ones.

Skin consists of three main layers, namely the:

Epidermis (outside layer)

Dermis (middle layer)

Subcutaneous layer (deepest layer, directly upon the muscles and

organs)

The Epidermis consist of 5 layers with the outer layer continually being shed as new cells are formed. New cells reproduce by mitosis every 21-40 days depending on age and skin condition. These new live cells form the bottom layer of the epdidermis, called the stratum germinativum. They gradually move upwards through the layers of the surface, then flatten out, die and harden due to the production of a substance called Keratin. The two top layers of the epidermis together forms the horny layer. The basal layer of the epidermis contains living cells that produce melanin – the pigment that gives skin and hair their colour. The epidermis is the protective layer of the body.

The Hydro-lipidic film.

Found on the surface of the stratum corneum (outside layer of the epidermis) is the hydro-lipidic film, also named acid mantle. Consisting of lipids from the epidermis, sebum secreted from the sebaceous glands (body’s natural body oil) and sweat secreted from the sweat glands (body’s natural water) and natural perspiration. This slightly acidic film – pH between 4,5 and 5,5 – ads as natural protection against the environment and helps to maintain a good hydration level, also fighting against infections.

The Dermis is the middle layer just beneath the epidermis. This layer supports all other structures, nourishes and lubricates the skin and provides its elasticity. Within this layer are found various structures, like sebaceous glands, sudoriferous glands and hair follicles. It also contains blood vessels that supply the skin of oxygen and nutrients.

This layer consists out of tough bundles of protein fibers giving the skin its firmness and strength. Fibroblasts manufacture the collagen fibres in the skin which is responsible for firmness. They also manufacture elastin fibres that provide elasticity or stretch to the skin.

The sudoriferous glands help to regulate the body temperature, while the sebaceous glands produce an oily secretion called sebum, which is the skin’s natural lubricant. Overactive sebaceous glands however, cause an oily skin and underactive sebaceous glands result in a dry skin.

The dermis also contains pain receptors, pressure and touch receptors, heat and cold receptors - which keeps you in touch with the outer world and helps to protect against dangers.

The subcutaneous layer - this is the deepest layer of the skin and its foundation. It is found underneath the dermis. This layer is made up of fatty tissue known as lipids, which cushions the internal organs against shock and acts as an insulator and source of energy when required. The fatty layer separates the skin from the underlying muscles. Take a look at a sketch of a sectional view of the skin and its layers in Figure 1.

Figure 1. A sectional view of the skin (Avroy Shlain Beauty & Product Manual, 2004)

Main functions of the skin.

The skin acts as a thermostat, retaining heat or cooling the body down with sweat.

It offers protection from harmful substances and organisms.

It acts as a waste disposal. Certain waste is expelled from the body 24 hours a day through the skin.

It helps to communicate with the outside world, through a sense of touch, pressure, pain or cold through the nerve sensors in the dermis.

The sebum lubricates and insulates the skin, preventing natural moisture loss.

The skin’s fat cells act as an energy storage facility, as well as protecting the body’s muscles and organs.

Different factors that influence the aging of skin.

Biological (Intrinsic/Chronological) aging. Time.

Aging over time is the result of a slow, gradual, genetically programmed process and the aggression the skin is subject to daily.

The skin passes through 2 major stages in the life of an individual. From birth up to the age of 20 the skin matures.

After 20 the skin embarks on a long period of aging, causing its appearance to slowly and imperceptibly change. The first signs of aging are seen in the facial area. All those funny faces, smiles, squinting, pursing of the lips and frowning finally leave their mark on the skin. These are the origin of the tiny expression lines caused by tension in the facial muscles, which draw on the deepest parts of the dermis and over time form deep wrinkles.

The first facial areas affected are the eye corners where “crow’s feet” appear. They start at the outer corner of the eye as fine lines, then gradually spread out in a fan, deepening with time, to form a network of wrinkles. See figure 2.

Figure 2. The appearance of “crow’s feet” under a microscope at different ages. (Lévêque & Agache, 1993) p.188

Loss of elasticity.

The wrinkles spread little by little over the whole face, the neck and other parts of the body. The loss of elasticity of the dermis is not only seen in the appearance of wrinkles but the facial skin begins to sag.

Looseness of the skin also becomes visible on the skin of the neck and arms. Gravity inevitably influences the downward pull on the skin and sagging is common around the eye area, jaw line and neck.

The loss in elasticity also means a loss in blood vessel support, resulting in purple bruising patches.

Collagen and elastin.

The quality of collagen and elastin fibres increasingly becomes poorer and less elastic. Deep changes occur in the dermis as renewal of the dermal protein is very slow. Proteins with a long half-life – collagen and elastin - are subject to modification on contact with glucose. This substance reacts spontaneously to produce advanced glycation end products. The glycation unfortunately modifies the properties of the proteins. They are more resistant to proteolysis, preventing their renewal. The fibroblast population diminishes by half between the ages of 20 and 80.

The fibroblasts which have ensured a balance between the synthesis and matuaration of both the collagen and elastin fibres, and their breakdown, tip this equilibrium towards the breakdown of collagen and elastin fibres.

Flaccidity, no longer being able to counteract the effects of the contraction of the underlying muscles, all results in the appearance of wrinkles. The vascularisation of the dermis is reduced and the skin changes colour – gradually losing its rosy tint and becoming pale or yellowish. Fewer nutrients are therefore being supplied. The dermo-epidermal junction becomes flatter since the papillae are less numerous. The surface for exchange with the epidermis is reduced. The glycosaminoglycans of the dermis decrease. These sugar based molecules trap water in the dermis, and their diminution causes a reduction in the dermal and epidermal hydration.

Figure 3 Breakdown of collagen fibres (Avroy Shlain Beauty & Product Manual, 2004)

Although the alteration in the dermis is the most deeply altered during the age process, the other 2 layers are not spared modification. The skin’s vital functions slow down and the skin’s condition deteriorates.

Epidermal layer.

The stratum corneum (top horny layer of the epidermis) loses its capacity to retain moisture as keratinocyte renewal is slower, and the skin dehydrates.

The epidermal thickness is reduced and the thickness of the horny layer increases.

The boundary between dermis and epidermis flattens and falls in.

Dermal layer.

Loss of dermal thickness approaches 20% in elderly individuals, and may account for the paper-thin, sometimes nearly transparent quality of their skin. The remaining dermis is relatively acellular and avascular. The marked reduction in the vascular network surrounding hair bulbs, eccrine, apocrine and sebaceous glands may be responsible for their gradual atrophy and fibrosis with age. Age-related changes in hair color, density and distribution are widely recognized. Approximately half the population by age 50, has at least 50% grey body hair with an even higher proportion of depigmented scalp hair, virtually everyone has some degree of greying. Greying is due to progressive and eventually total loss of melanocytes from the hair bulb. Epidermal melanocytes do not decrease as rapidly as those in hair, because they are comparatively inactive throughout their life span.

Compromised thermo-regulation, which predisposes the elderly to hypothermia and possibly heat stroke, may be due in part to reduced vasodilation or vasoconstriction of dermal arterioles, partly due to decreased eccrine sweat production, and in part to loss of subcutaneous fat, all of which occur with advancing age.

The hypodermis is thinner and the skin collapses.

Figure 4 An example of mature skin.

(Avroy Shlain Beauty & Product Manual, 2004)

Figure 5. An example of dehydrated skin

(Avroy Shlain Beauty & Product Manual, 2004)

Diseases and wound healing.

With age, Langerhans cells, derived from bone marrow, and responsible for recognizing foreign antigens, are believed to decline with approxiamately 50%, therefore immunity is reduced – meaning greater susceptibility to infections. Many elderly people have pigmented spots and sores on their hands and arms. The melanocytes in the stratum germinativum of the epidermis are less active, but the melanosomes are larger than before. They accumulate in certain areas - forming pigmented spots.

When tanning, the skin often assumes a darker, more mahogany brown hue, rather than the golden tan of youth. Infections often starts to attack the skin. The process of healing slows and becomes less efficient in old age.

Skin cancer is not a part of aging, but many older people develop raised watery bumps with rough edges called seborrhoeic warts or keratoses. They vary in color from creamy-yellow to black and are often found on the neck, face and temples.

Sebaceous and Sudoriferous glands.

The skin surface becomes less smooth and loses its natural glow. The complexion becomes dull. The hydro-lipidic film deteriorates as production of sebum and sweat slows down. Therefore the skin surface becomes increasingly dry.

Figure 6. Altered hydro-lipidic film (Avroy Shlain Beauty & Product Manual, 2004)

Sebaceous glands do not diminish with age. In some men they can enlarge that leads to a thickened pitted nose. People who had greasy skin at a younger age, often have individual sebaceous glands that increase in size and present as small yellow pustules with a central indentation. They have no connection to cancer or a malignant disease. People generally sweat less with age.

External factors adding to aging.

1. Genetical - family history.

Factors that inevitably affect your skin, are genetics and aging. It is therefore important to make a habit of looking after your skin with a sensible skin-care routine from a young age.

2. Stress.

3. Hormones.

4. Neglect.

Poor or no skin care helps along the way to early aging of the skin.

5. Incorrect cosmetic preparations.

Using too harsh cleaning products can dry out the skin.

6. Diet.

Too much, too little, too rich, too little water intake.

7. Lifestyle.

Smoking and alcohol. Excessive alcohol intake, smoking exposure to long hours of air-conditioning, central heating, all takes its toll in the dehydration of the skin, that lead to lines eventually.

Short hours, and lack of sleep, not only has its part in premature aging, but also leads to stress and anxiety which again takes its toll in the aging of the skin.

8. State of health and medication.

Illness and depression.

Acne medication, contraceptives.

9. Environmental factors.

Wind, pollution, climate, sun.

Free radicals. The body naturally produces highly reactive substances, known as free radicals. Their production is kept balanced, thanks to various free radical scavengers – enzymes and anti-oxidants, such as vitamin E and C. However, subjected to stress, pollution and exposure to the ultraviolet rays of the sun, the skin’s natural system of control is not efficient enough. These excess free radicals damage the cells and prematurely age the skin.

Photoaging is not he same as true aging, and happily is mainly preventable. Photoaging defines a clinical condition characterized by cutaneous aging exacerbated by exposure to ultraviolet light. Photoaged skin shows increased wrinkling, thickness and laxity; its color acquires a yellow hue with areas of brown pigmentation. Photoaging has a different pathogenic impact on skin structures than intrinsic aging, and the dermal alterations in photoaged areas of the face and hands are different from those of protected skin of aged individuals. Different factors influence skin thickness during the aging process. As a whole, it seems that skin becomes thinner with intrinsic aging. On the other hand, sun damaged skin (extrinsic aging) becomes thicker. As elastin is lost, the fiber architecture gradually disappears, leaving only tangles of microfibrils. Thus, the dominant change in photoaging is hyperplasia of the elastic tissue, ending in complete disorganization. See figure 7. Thickened skin on the upper lip caused by photoaging, skin thinning on the cheeks (intrinsic aging)

Figure 7. A 66 year old female. Different types of aging are seen on the upper lip (thick peau citréine skin) and cheek (thin atrophic skin with telangiectasias) (Lévêque & Agache, 1993)

Sun damage is the major villain of visible signs of pre-mature aging. Dark and uneven pigmentation marks, loss of elasticity and lack of firmness are all caused by exposure to sunrays. An outdoor lifestyle can increase sun damage if there is no special protection taken against the rays, like protective sun creams and clothing. It is now appreciated that people who avoid the sun, or take special sun protection, can have smooth, unblemished skin even into old age, showing then only laxity and deepening of expression lines. In contrast, photoaged skin displays a telangiectatic, leathery, dry, nodular, yellow surface with a variety of benign, premalignant and malignant neoplasms, deep wrinkles, accentuated skin furrows, sags and bags. Many of these disfigurements reflect profound structural changes in the dermis.

Recent research has shown that ultra violet rays induce the release of enzymes which contribute to the destruction of collagen and elastin fibres. It also generates the production of free radicals which attack the lipids and membranes of the cells.

The UVA rays penetrate the stratum corneum and 80% of these rays reach the dermis. This lead to deep modifications of the elastin and collagen of the dermis, which is responsible for premature aging. UVA rays allow tanning without burning.

UVB rays. 10% of these rays reach the upper dermis. They are partly stopped by the stratum corneum and consequently lead to deep modifications of the epidermal tissue.

UVC rays are usually blocked out by the ozone layer, but with that being damaged, are now penetrating right down into the hypodermis, causing an increase in skin cancer.

In most individuals, sun damage is indeed responsible for the majority of clinically evident age-associated cutaneous changes, but unlike intrinsic aging, is readily preventable.

Psychological aspects of skin disorder in the elderly.

The traditional neglect of the skin is well-nigh unforgivable and has cruel consequences for the well being of the elderly. The great majority of persons over 70 have at least one, often even two or three skin conditions which would benefit from the attentions of a knowledgeable doctor. These diseases do not kill, but they are persistent pestilences which spoil the quality of life for the unfortunate bearer. The cutaneous stigmata of old age – yellowing and mottled pigmentation, leathery roughness, deep wrinkles, sags and bags, excoriations - are unsightly and unpleasant. They are also frightening and repellent, not only to the ravaged bearer, but to all onlookers, especially the calloused young. The elderly themselves expect to have trouble with their skin and do not realize that many of their problems are treatable or preventable. Having skin that no one “loves to touch” is a sad matter. The need to be touched, fondled, caressed, rubbed and massaged does not end in infancy. One can only guess what happens when an old person becomes nontactile, literally forced out of contact and deprived of the pleasurable sensations nice skin long provided.

The sociologic aspects of skin, what might be called “social skin” need much greater emphasis. The skin is an organ of communication; it sends varied messages. Depending on care and adornment, it can communicate status, age, health, sex, wealth, etc.

The core of the problem is that disfigurements are unattractive, displeasing and disturbing, especially in the elderly. However, much more than esthetics is involved in the aversive behavior of the young to the elderly. Can it be that the facial portrait of the elderly person is disturbing, because it reminds us of our own coming physical decrepitude and eventual demise? The prospect of looking old, even more than being old, is unnerving. Much better to keep the elderly out of sight in nursing homes and retirement communities. In this sense, the first wrinkle is an unnerving experience. A face full of them, an emotional disaster. There is a good deal of truth in the saying that beauty is skin deep. We love to look at smooth, unblemished skin, associated with health and youth. Because physical appearance, especially of the face, is a powerful factor in human transactions, facial cutaneous deterioration is of considerable consequence. Those who are good looking gain many social advantages, whereas the unattractive suffer throughout their lives. People automatically assume that the physically attractive are also attractive in many important social attributes, for example the good looking are judged to have more favorable personalities, to be more outgoing, and kinder etc.

There is some evidence to suggest that facial appearance provides a reliable index of mental and physical well-being. Some people seem to age much faster than others. Research concerned with the relationship between chronological and biological age shows that age in years is not a good predictor of physiological well-being. In a major study by Borkan and Norris, it was found that those who looked old for their chronological age were in fact older by physiological criteria. They used more than a dozen tests of various body organs, like heart, lung, kidney, to obtain objective values of physiological competence in more than a 1,000 similarly aged elderly men. The health of those who looked much younger than their stated age was indeed superior on practically every measure. Moreover, in follow-up studies it was found that the good-looking men actually lived longer. Appearance may be a more powerful predictor of physiological well-being than expected. It appears that good looks contributes to good health and longevity. The skin is a convenient organ to study and faithfully records its history. In studying questionnaires being answered by attractive and unattractive elderly, it appears that the attractive aged perceived themselves far more positively by a number of important dimensions. They thought they were in better health and had a better overall feeling of well-being. They were emotionally more cheerful and better adjusted, which enabled them to have a more positive outlook on life. The latter finding is very important in view of the high frequency of depression in the aged. All this says unequivocally, that the positive attributes associated with beauty in youth and adult life extend as well as to the aged.

An enormous range of services are available to overcome the sizable handicaps that accrue form loss of good looks in the elderly, whether or not the deterioration is self-induced. As in the case of photoaging. Tumors and excrescences can be destroyed or removed in a dozen different inexpensive ways with splendid cosmetic results. Soft tissue defects, such as wrinkles and scars, can be inflated with silicone or collagen. Pigmented lesions can be bleached out with liquid nitrogen. Baggy skin can be corrected by face-lifting. etc. The greater problem is educational: to convince the elderly that the eradication of appearance-detracting lesions is worthwhile, not simply for vanity’s sake, but for the sake of physical and mental health. Caring for appearance establishes positive behavior patterns that enhance good health and caring for self and others. It was found that cosmetic therapy as method of treatment to improve mental health is particularly beneficial for those suffering from depression and those simply needing a psychological boost. It is also appropriate for the aged with skin disorders and disfigurements that need camouflaging, e.g. pigmented lesions, scarring diseases, and aging skin. Also use of skin care cosmetics such as moisturizers, cleansers and body lotions can encourage self-care and help to generate feelings of nurturance, relaxation, and general well-being in the elderly. Aged men and women stand to gain considerably by learning more about effective use of anti-aging cosmetics.

Prevention Strategies towards skin aging.

It is the skin more than any other organ which most clearly reveals the cumulative losses which time prints on the visage of the high and low alike.

The skin, in order to remain healthy and attractive, needs to be protected, hydrated and nourished, whatever its age.

Protection against the ultra violet rays of the sun.

By protecting the skin from daily exposure to sunlight, light and free radicals, it is possible to delay the appearance and cause of wrinkles. Daily application of a minimum of a Sun protection factor 15 or a total sun block of 30, specifically formulated for the face, is necessary. This protection is ensured by appropriate ultra violet ray filtering and reflecting agents introduced into the formulas.

Working against the loss of firmness.

In consequence of the injurious effect of light on the skin’s surface, various changes take place. The collagen and elastin fibres, which are mainly responsible for the firmness of the skin, deteriorate both in quantity and quality. Therefore, the skin not only loses its firmness, but also its elasticity and facial contours become less defined. This make it important to help avoid the breakdown of the elastin and collgen fibres and reinforce the skin’s tissues by employing specific active ingredients able to slow down the loss of elasticity and firmness.

Stimulate cellular activity.

In daytime the skin’s primary mission is to protect itself against a host of external aggressions. At night, the kin needs nourishment to concentrate on repair and regenerating functions. It is very important to support the renewal process, which reaches its highest level at night. It is thus the best time to provide the skin with nourishment to help regenerate and repair the cells during sleep.

Confining dehydration.

To limit dehydration, the skin must be supplied with moisturizing agents, such as glycerol, natural moisturizing factor, like amino-acids and glucids. It must be able to integrate water in the upper epidermal layers and retain it there throughout the day. To be hydrated, the epidermis also needs lipids and nutritive elements including essential fatty acids and ceramides, which help maintain it as an effective barrier.

Extreme dryness, flakiness, hardening and roughness are all signs of extensive dehydration. Help is provided by the direct application of essential fatty acids (found in vegetable oils) to strengthen and improve the state of the stratum corneum. If the skin is well nourished, it is also better protected against dehydration.

Protection from within.

The biggest part of our bodies are made up of water. To retain this balance, and also to cleanse the body of toxic substances, 2 liters of water should be drunk daily. A good multi-vitamin and anti-oxidant should also be taken daily.

Conclusion.

Cosmetic programs to improve the psychological and social well-being of not only elderly people, but of every body, are worthy of more serious attention. Cosmetic make over treatments deserve the status of a therapeutic modality.

Long-term training in effective cosmetic use should be introduced as a vehicle for self-care and a way to help the aged to take a more positive attitude and to enhance their self-image. Improved appearance of the elderly would help to lessen ageism and improve their social standing.

References.

The Avroy Shlain Beauty & Product Manual. 2004: Avroy Shlain Cosmetics

Balin, Arthur K. & Kligman,Albert M.; Aging and the skin.1989; Raven

Press Ltd., U.S.A.

Gilchrest, Barbara A.; Skin and aging processes. 1984; CRC Press, Inc.,

Florida.

Lévêque, Jean-Luc & Agache, Pierre G., Aging Skin. Properties and

Functional Changes. 1993. Marcel Dekker, Inc., New York.

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