3 YOUR SKIN, YOUR AGE, YOUR BEAUTY
In some ways, beauty really is skin-deep, and no part of your body shows aging quite as obviously and dramatically as your skin. Skin issues of all kinds plague many of my patients, especially issues that cause people to look older. It’s usually the first thing people ask me about, and yet I find that most people don’t understand how skin is constructed, how it ages, why it ages, and what they can do about it.
Maybe you are desperate to look younger and you will try just about anything, or maybe you don’t like your wrinkles and you’d rather not get any more of them, but you don’t think there’s much you can do if you don’t want plastic surgery. Fortunately, you are wrong. You do not have to be at the mercy of your skin. There are many tricks, techniques, products, and procedures that target everything from wrinkles to age spots to sagging jowls and nasolabial folds, and you won’t have to go under the knife to try them. I’ve seen noticeable, often dramatic differences in the skin quality and appearance of my patients. I’ve seen them appear to grow younger before my eyes. This can be you. Are you ready to look younger than you do right now?
SKIN BASICS
You’ve got about twenty square feet of skin on your body, and it has a big job to do. It keeps dirt and pathogens out of your insides, and it excretes oil through tiny holes called pores to keep your skin protected and moisturized. Your skin can even soak up medicine and other substances, like the hormones in a birth control patch or the nicotine in a nicotine patch. The skin is technically your largest organ, even though it doesn’t look like an organ. It’s also more complex than it appears.
UNDERSTANDING SKIN ANATOMY
Skin contains three layers:
The Epidermis
Your epidermis is showing! This is the fancy name for your skin, specifically the outer layer of skin that you see. Because it is the layer visible to the world (and in the mirror), this is where your efforts at skin care will show up most dramatically.
Depending on what’s going on with your epidermis, your skin can look plump, moist, and youthful or thin, dry, and wrinkled. The very top layer of the epidermis is mostly dead skin cells, and the bottom layer is the basal cells, which divide. As the new basal cells divide, they move up toward the surface, and eventually die and slough off. All day we are sloughing dead skin cells, leaving them in our mattresses, on our clothing, and even, if you haven’t bathed in a few days, as a ring around the tub! This constant turnover slows down as you get older, and also with exposure to sun and environmental toxins. This causes the layer of older dead cells to clump and build up, causing you to look flaky, dull, rough, and, frankly, older. This is why exfoliating treatments make you look younger—they get rid of the top layer of the oldest dead skin cells and expose the younger, newer cells.
The other thing the epidermis contains is melanocytes. These are the cells that create melanin, which is the pigment that gives your skin its unique color. Melanin protects you from sun damage, darkening to be more protective when you are exposed to the sun. Yes, a suntan is really your body’s reaction to shield you from the damaging rays. As you age, the melanocytes can become more irregular in their production of pigment, which causes age spots and melasma (a condition in which sun exposure or hormone changes cause dark patches of skin on the face). Even though the epidermis turns all its skin cells over every six to eight weeks, you don’t get a newborn-baby face every two months, unfortunately. The mechanisms that create the new cells age and get damaged, and the age spots and flaky patches you have can remain or keep coming back. However, don’t be discouraged. The lifestyle measures and treatment that I’ll soon introduce to you can drastically improve your skin’s look, color, plumpness, and even tone.
The Dermis
The dermis is a thicker layer beneath the epidermis. You don’t see this layer, but it’s pretty busy under there. The dermis contains strong connective tissue to give the thinner epidermis support. It’s mostly made out of collagen, elastin, and hyaluronic acid.
Collagen is what most of the skin is made out of, which is why you see all those skin-care products that contain collagen. Collagen fibers are strong protein fibers that are organized in parallel bands. They are like the bricks of your skin that are held together by elastin, which is like the mortar. We have the most collagen when we are children. Collagen production slows down in the teen years, holds constant through our twenties and thirties, and then starts to decline, which is one major reason why you will start to notice signs of aging in your thirties. The quality of your collagen determines how tight your skin looks and feels. When it becomes weakened, or those parallel bands of collagen become frayed and damaged by aging, sun exposure, and other trauma, your skin will begin to look more wrinkled, saggy, and old.
Elastin is what gives skin its elastic nature. When you pull on your skin, it bounces back to its original position. Hyaluronic acid is a sugar that binds water and attracts moisture. This is what makes your skin look moist and plump. The main reason young skin looks so young is because it’s plumped up with lots of collagen, elastin, and hyaluronic acid, and the reason faces look older as they age is because all of these components decrease with age. Skin gets less plump and juicy, and so it looks thinner, drier, saggier, and more wrinkled. This is why many skin-care products also contain elastin and hyaluronic acid. So, do skin-care products containing the three main elements of skin—collagen, elastin, and hyaluronic acid—actually restore these to your skin? That depends on the delivery system. I’ll talk more about this later in this chapter and in the next chapter.
The dermis also contains a few other things: fibroblasts that produce collagen and elastin, hair follicles, sweat glands, and sebaceous glands, which produce an oily-ish, waxy substance called sebum for skin lubrication. Overactive sebaceous glands can cause acne, because they are producing too much sebum, which bacteria can feed on, causing pimples.
The Hypodermis
This is the deepest layer of skin, and the fattest layer. In fact, it contains fat and connective tissue, and it overlays your muscle and bone. It also contains fibroblasts and macrophages, but its primary purpose is for fat storage. This is where our dreaded cellulite lives. We’ll talk more about cellulite and what you can do about it in chapter 8.
AGING AND YOUR SKIN
Why does aging change your skin, and why oh why can’t it just stay the same as it was when you were young, before you ever had a pimple, before you were exposed to pollution or thought tanning was a great idea? The reason is that life quite literally happens to you, and your skin is the primary barrier between you and the world. It is your shield, and it gets battered by time and life experience. Women typically begin to show the first signs of aging in their mid-twenties, while men begin to show the first signs about five years later, only because they have thicker skin. Their shields are a bit thicker, but aging happens to us all eventually.
Aging happens due to two different kinds of influences: intrinsic and extrinsic. You can’t do much about intrinsic aging. It is caused by your genetics, such as a propensity to stay looking younger longer or to get wrinkles at a younger age. One celebrity who appears to have inherited a slow intrinsic aging process is Kate Hudson. Her mom, Goldie Hawn, didn’t seem to age for decades, and now Kate looks as if she’s following in her footsteps. Intrinsic aging is also caused by your ethnicity. Different ethnic skin types withstand aging better or worse than others. Dr. Travis Stork, host of the syndicated show The Doctors, once asked me how my skin was so smooth and wrinkle free. I answered him honestly that it was a combination of TV makeup and my ethnicity!
Intrinsic aging can also be caused by certain disease conditions, which can prematurely age your skin. An extreme example of this is the genetic disorder progeria, or the anti–Benjamin Button syndrome, where the affected person’s body ages incredibly quickly. You can’t change your genetics, your ethnicity, or arguably your disease state. However, you can definitely do something about extrinsic aging.
Extrinsic aging is caused by factors that you can control, and it is the main focus of this book. Fortunately, extrinsic aging is a major part of aging, so while you can’t turn the clock back forever, you can definitely slow it down pretty significantly. There are four major factors that cause extrinsic aging:
1. Sun damage. Excess ultraviolet radiation is the absolute worst thing you can expose your skin to if you want to keep it looking young. You probably already know that ultraviolet radiation increases your risk of skin cancer. However, it also has a striking effect on aging. All you have to do to determine whether ultraviolet light has already aged you beyond how you would age without exposure is to compare the skin on a part of your body that gets a lot of sun, like your face or your arms, with parts of your body that get almost no sun, like your butt cheeks. Check out your butt cheeks. (I won’t look.) Notice how nice and smooth they are? They don’t have age spots or wrinkles, and while they might have a few cellulite dimples or not be the exact size or shape you would prefer, the skin itself is looking pretty good, wouldn’t you say? Imagine how young you would look if your facial skin and the skin on your hands and forearms looked like the skin on your butt. Clearly, being called a butt-face is really a compliment!
2. Smoking. Smoking is second only to UV radiation in its aging effects on the skin. Smoking constricts the blood vessels, which decreases blood supply to your skin. It also dehydrates your skin, increases free-radical damage, and has been linked to an increased risk of skin cancer.5 One study showed that the risk of developing severe wrinkles was three times higher in smokers than in nonsmokers.6 Another demonstrated that heavy smokers were 4.7 times more likely to be wrinkled than nonsmokers.7 That’s reason enough to throw that pack of cigarettes in the trash!
3. Eating poorly. You know it’s not healthy for your insides, but did you know that poor dietary choices can make visible differences in your skin? Sugar in particular is a skin wrecker, as it causes aging by increasing inflammation and glycation. Eating the right kinds of fats can actually help you look younger, however. I’ll talk much more about eating for younger skin in chapter 5.
4. Drinking too much alcohol. Excessive alcohol consumption is bad for you in all kinds of ways, and one of those ways is by aging your skin prematurely. Alcohol dehydrates your skin and causes some people to have a flushing reaction. Repeated flushing can result in a ruddy complexion, and I don’t mean that healthy glow you get when you’ve been on a hike. I mean the kind caused by tiny broken blood vessels that show up as splotchy red patches all over your face. It’s not pretty. Too much alcohol can also keep you from other healthy habits, like eating well, and can encourage other unhealthy habits, like smoking. Sit out on the beach in the sun with a cigarette and a cocktail, and you’ve got a recipe for overnight aging.
The effects that these four factors have on skin aren’t just about dehydration and blood vessel constriction or swelling. They’re also about free radicals. In fact, a significant amount of aging in the body is caused by free radicals, and you have the power to greatly minimize these effects.
Free radicals are damaged oxygen molecules that are missing at least one electron. To remedy the problem, they attach to healthy cells and steal their electrons, damaging the cells or causing them to malfunction. This can cause all sorts of problems, from cell structure damage to DNA damage. Free radicals are by-products of the body’s various processes, like digestion, and they should be present in amounts the body can easily handle. However, when you add in extrinsic factors like UV exposure, smoking, a poor diet, alcohol, and the effects of toxins like pollution, pesticides, automobile exhaust, and environmental chemicals, and especially when you have more than one of these operating on the body at one time, free radicals can become too numerous.
FREE RADICALS
NEUTRALIZING FREE RADICALS
When this happens, the body enters a state of oxidative stress, where it cannot fend off all the free-radical damage on its own. Free radicals then begin to cause visible damage. One type is a breakdown in collagen and elastin, making the skin looser, more wrinkled, and thinner. As we age, collagen production slows down, so we don’t replace the collagen that gets broken down as quickly. Eventually, we hardly replace it at all.
This is why the best antiaging treatments address free radicals in their formulations. First on the list: antioxidants. Antioxidants fight free radicals by neutralizing them. They donate an extra electron to the free radical, essentially stopping it from scavenging electrons from other cells. Your body naturally produces antioxidants, but if you add more through diet (see chapter 5) and the right skin-care products, you can help your body immensely. Antioxidants are like the cavalry sweeping in to fight off the free-radical onslaught. See the next chapter for more specific information about antioxidant products.
ANTIAGING ATTACK
Now that you know what’s happening to age your skin, let’s get down to business and attack aging where it starts: on your face, in the form of wrinkles, fine lines, and age spots. In the next chapter, we’ll talk more about lifestyle issues, specifically diet, but first I want to focus on the products, procedures, and even natural therapies that I have seen make a real difference in the appearance of my patients’ skin. I’ll also clue you in to which products, techniques, and procedures probably won’t do what they claim, so you can save your time and money for the strategies that really work.
Forehead Wrinkles
Little kids have smooth foreheads because they haven’t spent years raising their eyebrows and scrunching up their foreheads. Forehead wrinkles primarily consist of two types: the horizontal lines across the forehead that you get when you raise your eyebrows, which are caused by the contraction of the frontalis muscles; and the little vertical lines between your eyebrows, called the 11 sign, which are caused when you furrow your brows to make that stern expression while scolding your kids or the dog. The 11 sign is, hands down, the most common cosmetic complaint I see in my office. Of all the patients who come in to look younger, at least 60 percent of them complain about their 11 signs. As far as aging, it’s endemic! If you are one of the few (very few!) who are over forty and don’t have an 11 sign, be very thankful. For the rest: After years of creasing your forehead horizontally and vertically, those creases are going to stick.
These are also called dynamic lines, because they are caused by muscle movement. The best way to treat dynamic lines like forehead wrinkles and the 11 sign is to stop the muscles from contracting and making these wrinkles. Here are my recommendations:
Botox: There is no question that Botox is the most effective way to reduce wrinkles in the forehead and between the eyebrows. In fact, it’s FDA-approved for treatment of lines between the eyebrows. However, people worry about Botox. They connect it with a lot of scary things: frozen foreheads, drooping mouths, perma-smiles, and even death from black-market Botox. I hate to say it, but many of these problems have occurred. Those fears have a basis, but they needn’t be a problem for you if you choose the right doctor.
I admit Botox sounds scary when you know what it really is. Botox is the trade name for botulinum toxin, a neurotoxin created by the bacterium Clostridium botulinum. Botulinum toxin is one of the most dangerous poisons in the world, and small to moderate amounts that are injected or inhaled can kill a person. So how is it that Botox is now the number one cosmetic treatment in the world, with nearly 4 million Americans undergoing Botox injections in 2014, according to the American Society for Aesthetic Plastic Surgery? The difference is in dosage. While a small amount of botulinum toxin can kill you, the minuscule amounts used in Botox injections will not harm you at all. They will paralyze only the immediate area where the toxin is injected, and that’s good news for you (and bad news for your wrinkles). Botulinum toxin was first used to effectively treat spastic muscle disorders of the eyes and eyelids, otherwise known as strabismus and blepharospasm. Botulinum toxin, when used in minute amounts, was found to be very effective at relaxing these spastic muscles, thereby improving the disorders. This led two enterprising dermatologists from Canada, Drs. J. A. and J. D. Carruthers (a married couple), to wonder: If it’s good enough to weaken muscles in the eyes and eyelids, why can’t it be good enough to weaken the muscles of the face that cause wrinkles?
They decided to test the botulinum toxin’s effects on the wrinkle-causing muscles in the face, and they discovered that when the tiniest quantities of botulinum toxin were injected into the muscles that caused wrinkles in the glabella (that is, the vertical frown lines between the eyebrows and above the nose, otherwise known as the “11 sign”), they caused the muscles to weaken, resulting in a temporary smoothing of wrinkles. And voila! Botox was born.
Now Botox is one of the favorite and most effective antiaging treatments available. It is used in minute quantities and is injected into the muscles that create these wrinkles. Within a week or two, these muscles weaken and even become temporarily paralyzed. This causes the muscles and the wrinkles to relax and look smoother. Botox typically wears off within three to four months, after which time it needs to be repeated. Otherwise, the wrinkles return like they were before. You can also try one of Botox’s competitors, such as Dysport. Results with Dysport are very similar to results with Botox.
People worry about Botox because they know it is a toxin. It even sounds a little scary to those who aren’t familiar with it. However, Botox is extremely safe, and in the hands of a board-certified plastic surgeon or dermatologist, you are extremely likely to have excellent results. Prior to Botox, plastic surgeons and dermatologists used lasers and chemical peels to improve forehead wrinkles. The results were minimal at best, since the wrinkles are caused by muscles, and these treatments affect only the skin on top of the muscles.
If you’re considering Botox but are nervous that the treatment might make you look like a mannequin, a Disney cartoon, or even worse, a Real Housewife of Beverly Hills, then start small. Try treating either your crow’s-feet or the 11 sign. If your doctor treats one of these areas conservatively, it’s very unlikely you will look strange or “done.” Give yourself a couple of weeks after the treatment to get used to the results. If you’re happy with them (which almost everyone is), then return to treat another area (or two). Just be careful when getting your forehead Botoxed. When Botox is improperly injected into the forehead, it can cause the dreaded “frozen forehead” appearance where your eyebrows don’t move. Or, even worse, you can get Frozen Forehead’s horrible cousin, Evil Eyebrow. This is when your brows become overly arched, making you look like the cartoon version of Sleeping Beauty’s wicked Maleficent.
Before we finish covering Botox, here is a question: What do Botox treatments have in common with smoking cigarettes and drinking booze?
They’re addictive.
No, not in the unhealthy way that the body becomes chemically addicted to the toxins nicotine and alcohol. Millions of people are “addicted” to the way Botox smooths their lines, reduces their wrinkles, and relaxes their stern expressions. Once you see how a conservative amount of Botox can make you look, you may become addicted, too. We have many return clients.
No-Scrunch Zone: If Botox just isn’t for you, there is another way. It takes a little more effort, but it can make a difference. It is possible to train your muscles to stop contracting so much, thereby smoothing the wrinkles of your forehead naturally. I work on this myself—unless I’m modeling these wrinkles for my patients, I try not to scrunch my forehead or between my eyebrows as much as possible.
It can be tricky to isolate small muscles in the face or elsewhere, but with a little concentration and practice, you can learn to do it. Remember when you first learned to raise your eyebrows, flare your nostrils, or wiggle your ears? That’s facial muscle control. In acting classes, they teach the minute control of facial muscles to help actors master various expressions. If they can do it, so can you. However, it’s not easy, so here are some tricks that can help you with your facial muscle training:
Put tape over your forehead during the evening and while you sleep. This essentially keeps the skin smooth, and if you try to scrunch your face, you will feel the tape and be reminded not to do it. Some people even scrunch their foreheads while they sleep, so putting tape on your forehead while you sleep can help prevent this from happening.
There is a commercially available product that works in a way similar to the tape. Frownies are patches you wear over your wrinkles that actually splint the wrinkle and prevent your skin from contracting and creasing, or at least call your attention to it so it feels uncomfortable when you do it. The makers claim that Frownies will train your muscles at night to prevent them from contracting during the day. It makes sense in theory and would probably be helpful for those willing to put in the effort to also be more aware of their facial wrinkling habits.
I wish I could tell you that there was a magic cream that would eliminate forehead creases without any other effort, but like the lasers and chemical peels doctors used to try, creams really affect only the skin and do not impact the muscle underneath. Because the muscle is the issue with this particular type of wrinkling, the muscle has to be the point of treatment.
Fine Lines
If you’ve had a thirtieth birthday, you’ve probably had this experience: You wake up, you look in the mirror, and there they are. You hadn’t really noticed them before, because you were in your twenties. Now that you are thirty, you see them, and they are only going to get worse: those fine lines forming on your face. Fine lines add a subtle age to your face, even if they are not obvious creases. The difference between a young face and a middle-aged face is largely about fine lines. Fine lines are caused by a combination of factors, including sun damage, environmental toxins, dry skin, loss of collagen and elastin, and skin-muscle interactions. They are the inevitable result of aging and life in the world, and there are no surgical treatments that will erase them. However, there are some nonsurgical treatments that can make them look much less noticeable, and even eliminate some or most of them, depending on how many you have.
I once had a patient drive five hours to see me for a consultation on a facelift. Immediately upon my entrance into the exam room, she pulled out a large wad of bills and said, “I’ve been saving for years for my facelift. Just tell me where and when you can do it.” I asked her what was bothering her about her face and what specifically she wanted to improve. She pointed to fine lines under her eyes, around her mouth, and on the sides of her face. I informed her that no facelift, no actual surgery, can remove fine lines. There is nothing I can do with a scalpel to get rid of them! We started her on the right skin-care products and signed her up for a series of chemical peels. Then I instructed her to use the rest of the money she’d saved (several thousand dollars) on a dream vacation instead. A week of pure relaxation is another excellent way to make your face look younger, because it melts away stress, which makes you crease your face into wrinkles. This is hard to do while lying on a beach under an umbrella with a fruity drink!
But back to those fine lines. Remember the structure of the skin: The epidermis is the top layer that generates skin cells. They move up toward the surface, die, and eventually fall off. As these cells build up, fine lines can become more noticeable, because dry, flaky skin shows off fine lines. This is why one of the best treatments for fine lines is exfoliation, or removal of the upper layers of the skin. This can cause the skin to look smoother and reduce the appearance of fine lines, because you will be sloughing off the dry dead cells and revealing the younger cells beneath. You can do this at home, but there are more aggressive ways of exfoliating in a medical setting.
CO2 Lasers: The most aggressive way of doing this is with the old-fashioned CO2 laser. The problem with this laser is that it is ablative, meaning it literally burns off the entire upper layer of skin. This leaves people not only feeling like burn patients but sporting redness and even oozing. The procedure is painful and the recovery time is significant.
The newer CO2 treatments are fractional, meaning instead of burning all the skin, they burn only a fraction of the skin. That may still sound harsh, but the fractional lasers are now the standard of care for aggressive treatment of fine lines and wrinkles. These lasers come in many different brands and names, such as Fraxel, Active FX, and Deep FX, to name a few. The downtime also varies, with some aggressive treatments necessitating a week or more to recover from them.
Sometimes, depending on how aggressive the laser is, you may need a sedative or light anesthetic to be able to tolerate the actual treatment. These laser treatments can be quite costly (in the thousands of dollars), as you are typically paying for the doctor’s time in addition to the cost of leasing the laser. Fractional lasers typically cost a plastic surgeon upward of $100,000 to purchase, and the cost is therefore passed on to the patient (you).
Chemical Peels: Chemical peels are another procedure you’ve probably heard about. They are another way to effectively exfoliate the skin. Chemical peels come in many different types and strengths. In general, however, the more aggressive the peel, the better the results, but the longer the recovery time.
Chemical peels are typically more affordable than laser treatments because the cost of the supplies needed to perform a chemical peel can be as low as $10. Compared to the cost of purchasing and operating a laser, this is a significant difference that should be passed on to you. For that reason alone, chemical peels can be considered a cost-effective alternative to fractional laser treatments. Still, aggressive chemical peels can easily cost in the upper hundreds of dollars.
The most aggressive and effective chemical peel, the phenol peel, must be done under the care of a vigilant plastic surgeon or dermatologist, because the acid can create cardiac arrhythmias if overapplied. Call me a scaredy-cat, but because of the potential heart issues, I’m afraid to perform these. Not surprisingly, like the old ablative CO2 lasers, the phenol peel is gradually going out of favor, as doctors and patients are opting for less aggressive treatments to exfoliate the skin.
In my office, I perform quite a few moderate-depth chemical peels. Although not as strong or as effective as the deeper phenol peel, these are more easily tolerated, are safer, and can get nice results, especially if repeated. My current favorite is the ZO Controlled Depth Peel, which uses a blue dye to create a more even, effective peel. Patients peel for a week afterward, but the recovery is completely painless. The only downside to the ZO Controlled Depth Peel is that you leave the office looking like a Smurf.
Many people undergo so-called lunchtime peels, which can have absolutely no downtime or pain. These are weaker versions of standard chemical peels, and they are great for smoothing the skin and creating some mild tightening. The results are temporary, and the peels should be repeated approximately every month to maintain their results. The lunchtime peels rarely cost more than $200, depending on the location. If these are available to you, they are a good maintenance option.
At-Home Laser Treatment: If you’re more of the DIY ilk and you want to do your beauty treatments at home, there are some good options. I like a product called Silk’n FaceFX. This is an at-home, do-it-yourself laser that improves the look of fine lines, skin texture, and wrinkles. It takes about fifteen to twenty minutes, and you use it three times per week. The results are proven. A study showed that after eight weeks of treatment, 91 percent of users had an improvement in skin texture, and 69 percent had a reduction in fine lines and wrinkles. This is a good option for a budget-conscious person or someone who doesn’t live within driving distance of a dermatologist, plastic surgeon, or med spa that provides chemical peel or laser services. It costs about $299, but I’ve seen advertised specials online for less, so keep an eye out.
Tretinoin (Retin-A): For a real long-term difference in fine lines, there is no better treatment than prescription-strength tretinoin, otherwise known as Retin-A. Tretinoin is scientifically proven to reduce fine lines via exfoliation and also a thickening of the dermal and epidermal layers. Results aren’t immediate, however. You may see some results within two weeks, but it usually takes six to eight weeks to see any real change in fine lines. You will see a difference eventually, however, and a tube of tretinoin costs $40 to $50 with discount coupons you can find online, so it’s an inexpensive option. Tretinoin is actually used as a precursor to chemical peels to prepare the skin for the peel. I tell patients that if they like what the tretinoin does for their skin, the peel will take that to the next level. Tretinoin is also an excellent remedy for acne. (See the next chapter for more information about tretinoin.) Some people are sensitive to tretinoin, but others tolerate it quite well.
Alpha-Hydroxy Acid (AHA): This product can also help with fine lines, especially when combined with tretinoin. These are fruit acids, glycolic acids, and lactic acids that exfoliate the skin, removing the upper layer of dead skin cells and indirectly stimulating new cell growth. AHAs are derived from natural sources, but be careful when combining these two exfoliating treatments, as they can be very powerful. AHAs are another good treatment for acne. See the next chapter for more detailed information about AHAs. As with Retin-A, some people are sensitive to AHAs to varying degrees, but some have great results and very little if any irritation.
Peter Thomas Roth’s Un-Wrinkle Peel Pads: You can do a mild chemical peel at home. These handy pads contain a potent combination of alpha-, beta-, and even gamma-hydroxy acids to exfoliate and tighten the skin. But that’s not it! This product also contains antiaging amino acids. Apply these pads once a day for great results within just a few treatments. You can purchase these online or at Sephora stores.
Dimethicone: If you’re looking for an immediate change, then a powerful moisturizer can be very effective to fill in fine lines and smooth your skin. As we age, our skin dehydrates more easily, resulting in dry, wrinkled skin. Moisturizers can reverse this phenomenon and create an immediate change. Look for a moisturizer that contains hyaluronic acid, glycerin, and/or dimethicone. Dimethicone is a type of topical silicone that can immediately plump out fine lines. Dimethicone is one of the main ingredients in L’Oréal’s RevitaLift, which is an inexpensive, easy-to-find, and effective temporary skin smoother.
Beauty Secret
Currently my favorite moisturizing skin-care line is from Teoxane Cosmeceuticals. Their Swiss-made serums and creams list Resilient Hyaluronic Acid as a prime ingredient. Hyaluronic acid, you may remember, is a naturally occurring moisturizer of our skin. It’s also the prime ingredient in injectable wrinkle fillers like Juvederm, Restylane, and Voluma. Teoxane products are the closest thing we have to skin fillers in a tube. The products rehydrate the skin so well that it looks as if your wrinkles are literally filled in. I recently started my mom on these products (they’ve only recently become available in the United States), and she loves them. Teoxane is especially good for women whose skin is dry due to menopause and/or living in drier climates. I consider Teoxane products an 
.
Fruit Acids from Your Own Kitchen: If you like your beauty natural style, there are some interesting treatments you can whip up in your own kitchen that use vitamins, alpha-hydroxy acids, and other skin-boosting, beauty-enhancing ingredients:
Bananas are full of vitamins A, B, and E. Mash up half a ripe banana, then apply the mash to your face. Leave it on for thirty minutes, then wash it off with warm water. Your face will feel cleaner and tighter.
For the ultimate natural DIY chemical peel, combine 3 tablespoons apple juice, 2 tablespoons milk, and 1 egg white. Mix everything together and apply to your face. Let it sit for fifteen minutes, then wash off with warm water. The malic acid in the apple juice and the lactic acid in the milk act as gentle exfoliants, while the albumin in the egg white has a shrink-wrap effect on the face: tightening the skin, shrinking pores, and making your face look firmer and smoother. Who knew you could get a chemical peel from apple juice?
Insider Tip
One way to disguise fine lines is through the skilled application of primer, foundation, powder, highlighter, and bronzer. You may need only one or a few of these products, or maybe you will choose to use them all, but how you put them on can make the difference between hiding fine lines and accentuating them. Here are some tips:
Try using primer before applying makeup. This can cover blemishes and fill in fine lines before you’ve even applied your makeup. You can also try applying primer to your neck and chest. It can reduce the appearance of aging by covering up wrinkles and sun spots without a heavily made-up look.
Go light and sheer with your foundation, especially as you age. Thick, heavy foundation accentuates wrinkles and creases rather than hiding them.
Pay attention to detail. Meticulously blend so you don’t have makeup lines along your jaw or covering blemishes. Foundation and concealer brushes are great tools for creating a flawless look.
Mineral foundation that comes in a powder goes on like a liquid and can actually protect your skin, because the titanium dioxide or zinc oxide minerals shield you from sun damage. They are also less likely to cause acne. If you find that the powder looks dry on your skin, try “setting” the makeup with a spray of Thermal Spring Water by La Roche-Posay. This can give it a less powdery look. If this doesn’t work, then it might be best to switch back to a creamy foundation.
Match your foundation color to the color of your skin at your jawline.
Update your powder if you haven’t done so in a while. The newer powders are reflective and brightening rather than drying and cakey.
The strategic use of a highlighter can give a lifting effect to the face. Apply highlighter to areas you want to accentuate, like cheekbones, the bridge of your nose, and just under your eyebrows, to give the impression of a brow lift. Fill in the parts you want to recede with bronzer, just slightly darker than your natural skin color. Blend it all really well so there are no separation lines.
Use highlighter and bronzer to provide a lift to the cheeks.
ACNE
It’s so unfair. You’re dealing with fine lines at the same time you’re dealing with acne! It’s true—over 25 percent of women in their forties and 15 percent of women older than fifty battle adult acne, and this is the kind of acne that doesn’t make you look like a teenager. Nope, this kind of acne tends to be cystic. Instead of that frecklelike spread of teenage redness, you get those big, pus-filled suckers in the least attractive places—smack in the middle of your chin or forehead, or around your mouth, or around the sides of your nose. You also might get blackheads—those ugly black dots caused by your pores getting clogged with oxidized (darkened) sebum. Blackheads don’t get red and puffy like pimples do, but they aren’t pretty, either.
FORMATION OF ACNE
Adult acne can be caused by stress, heredity, hormone fluctuations, and even some medications, but the best treatments are, fortunately, those you can do at home. For the most effective acne eradication, try this four-step process:
1. Unclog your pores to prevent pimples and clear out blackheads.
2. Kill bacteria causing these skin infections and reduce excess oil.
3. Increase cell turnover to get younger, fresher skin faster.
4. Know how to manhandle pimples.
Here’s what I recommend:
Step One: Unclog Pores
Salicylic acid is the key to unclogging pores. Use a salicylic acid–based cleanser with a strength of 1 to 2% twice a day, morning and evening. This will help scour your pores, reduce blackhead formation, and help prevent pimples from forming. Salicylic acid is a beta-hydroxy acid that comes from trees, and it is lipid soluble, so it penetrates the oily sebum plugging your pores. If you want to get serious and intimidate your acne into total submission, you can even get a salicylic acid peel in a plastic surgeon’s or dermatologist’s office every few weeks. This can make a big difference in keeping both blackheads and pimples at bay.
Caution!
Do not use any product containing salicylic acid if you are pregnant. Although the only proven dangers are through the oral administration of salicylic acid, most doctors recommended avoiding the topical form, too, just in case. Avoid all products containing any of the following:
Salicylic acid
Beta-hydroxy acid (BHA)
Another neat trick for blackheads is pore strips, like Bioré Deep Cleansing Pore Strips, which work to remove the sebum from pores. Pull these strips off your nose and witness hundreds of tiny piles of sebum that have been pulled right out. No more blackheads! Be very careful to pull the strips off gently if you are taking tretinoin, however. This makes your skin more delicate, and pulling the strips off roughly could inflame or even injure your skin.
Bioré strips too pricey for you? Here’s a DIY trick: Apply a thin layer of Elmer’s Glue to the skin affected by blackheads. Let it dry, then gently peel it off. The blackheads come right along with it! If that’s too weird for you, you could also mix 2 teaspoons of unflavored gelatin with 2 teaspoons of milk. Warm it in the microwave for ten seconds, allow it to cool slightly, then apply it to your nose while still warm and sticky. Once it firms up, pull it off, along with the blackheads. You can do this once a week for best results. (Although these DIY treatments work, you may find the Bioré strips work better.)
Step Two: Kill Bacteria and Reduce Excess Oil
Pimples are caused by clogged pores that get infected with accumulated bacteria called P. acnes. Pus builds up and you have the dreaded whitehead. The best way to tackle bacteria is with a cleanser containing benzoyl peroxide. This kills P. acnes and is also anti-inflammatory, so it helps to reduce redness. Ten percent benzoyl peroxide cream (in addition to a benzoyl peroxide–based cleanser) can mop up excess oil quite effectively.
If you are prone to both pimples and blackheads, try alternating cleansers every other day: one with salicylic acid and one with benzoyl peroxide.
Step Three: Increase Cell Turnover
One of the best antiaging creams also happens to be one of the most effective ways to treat acne by causing more efficient cell turnover, which helps pores unclog naturally. I’m talking about tretinoin. Tretinoin is a prescription medication, but most doctors will prescribe it for problematic adult acne. Adapalene (also known as Differin) is another prescription cream that works similarly to tretinoin, but it can also come premixed with benzoyl peroxide under the trade name Epiduo. If you don’t want to get a prescription, then consider adding a retinol-based cream to your antiacne regimen. Just make sure it isn’t too thick so it doesn’t clog your pores.
Step Four: Know How to Manhandle Pimples
Because adult acne tends to be cystic, it’s also important to know how to handle those big ones when they come in (right before you need to look fabulous, of course). I have a few tricks for this. Some of them you can do at home, and some you can do at the doctor’s office.
Ask your doctor to inject your pimple with cortisone. This is especially effective for those really deep, cystic pimples. It will speed up the healing—the pimple should disappear within two to three days.
Try the Tanda Zap. This is a device you use at home that treats pimples with blue light to kill bacteria and warmth to increase blood supply, as well as vibration to clear pores. This handy device can zap a pimple within twenty-four hours if you start using it when the pimple first appears. It retails for just $39.99, which I think is a good deal for a tool you can use over and over again.
A spot of toothpaste (use only the kind that is all white in color) can dry out a pimple within a few hours. Dab it on before you go to bed, and wake up with a zit that is just a shadow of its former self.
One simple method for reducing the inflammation of a pimple is to apply a Band-Aid over it. Studies show that a covered wound heals better than one that is open to the air. Therefore, I’ve found that covering a pimple with a Band-Aid, even if just overnight, can reduce the redness and inflammation, causing it to heal and disappear faster. This trick can be combined with any of the treatments above for maximal effect.
Oral zinc supplements can be helpful for some people with acne, due to zinc’s anti-inflammatory effect. One study showed that taking 30 mg of zinc per day was effective in reducing acne, although it was less effective than the antibiotic minocycline.8 There are several commercially available formulations of zinc made specifically for acne. Most of these contain a slightly higher dose of 50 mg per day. Studies also show that combining zinc supplements with oral antibiotics may aid in preventing antibiotic resistance.9
Don’t throw away that banana peel! Rub it on your face instead. Cut off a small piece, about one inch square, and rub the inside of the peel onto areas where you have acne until the inside of the peel turns brown. Allow the banana residue to dry on your face and leave it on for thirty minutes while you do something else. Wash it off with warm water and repeat two or three times per day. (Save the peel in an airtight bag in the refrigerator.) The reason this helps with acne is that banana peels contain fatty acids and antioxidants that soothe skin. For this reason, banana peels are also good for other skin issues like eczema and psoriasis. Just be sure to consult with your dermatologist if you want to try this for a more serious skin disorder.
Although banana peels can do nice things for your skin, I do recommend a visit to a dermatologist if you have severe acne, such as full-face acne with cystic areas. The humble banana can do only so much.
If the above topical treatments don’t improve your acne, then you probably need a visit to the dermatologist. The combination of prescribed oral antibiotics (like doxycycline) with benzoyl peroxide or a retinoid like tretinoin (see Step Three) may be needed to effectively attack chronic adult acne. Not only does doxycycline kill P. acnes, but it also acts as a general anti-inflammatory to reduce the appearance of new lesions. It doesn’t work immediately, but many people find their acne lesions becoming less and less common after a month or two of treatment.
AGE SPOTS, SUN SPOTS, LIVER SPOTS, AND MELASMA
Besides wrinkles and fine lines and the indignity of adult acne, the biggest sign of aging on the face is age spots, sometimes called sun spots or liver spots. A variation of this is a condition called melasma, in which dark patches develop on the face, usually related to sun exposure.
Sun spots are darkened spots on the face. They can also appear on the chest, arms, hands, or anywhere else you get regular sun exposure. They have a variety of appearances, from light to dark, flat to elevated, freckle-sized to large. Sometimes many spots can clump together, making the appearance of a large blotch of pigment. These spots also have a variety of names, including freckles, age spots, liver spots (although they have nothing to do with the liver—they are called this because they can be liver colored), and solar lentigines. In most cases, sun spots are the result of UV radiation, which causes the melanocytes in your skin to produce melanin in an attempt to protect the skin from the radiation. In general, these spots do not disappear spontaneously. The only way to get rid of them is to do something to them.
Melasma is a slightly different but similar problem. It’s caused by hereditary factors and hormones (it can occur during pregnancy) as well as sun exposure. Instead of cute little freckles or charming moles, melasma involves large, dark patches on the face that occur on sun-exposed areas like the cheeks and forehead. The longer you have a melasma patch without treating it, the harder it is to fade. New spots can fade quickly with over-the-counter creams (I discuss these just a little bit later in the chapter), but older spots are more stubborn and may require medical treatment.
Here are some general therapies that can make a real difference in the appearance of age spots, sun spots, liver spots, and melasma.
Intense Pulsed Light Therapy (IPL): The best treatment for age spots, and an , is a procedure called intense pulsed light therapy (IPL). This is also sometimes called a FotoFacial. IPL treatments target dark spots and destroy them with pulsed light, which causes the spots to turn slightly darker and eventually slough off. IPL treatments are generally painless and require no downtime or recovery. They can be used to treat sun spots on all parts of the body, including the face, chest, and hands. This procedure is performed across the country in plastic surgery and dermatology offices. It typically costs several hundred dollars per treatment, and four to six treatments are usually required for optimal results.
Chemical peels can also be very effective at removing sun spots. I prefer IPL treatments over chemical peels, however, since the lighter, lunchtime chemical peels are usually not aggressive enough to remove sun spots. Most of the time, more aggressive peels are needed, and these come with significant peeling and downtime. Most of my patients would rather spend a little more to have a FotoFacial and avoid having to take the time to peel.
For melasma, especially stubborn patches, the best medical treatment is to combine creams (see the next section) with IPL and chemical peels and/or laser treatments. Chemical peels will treat only superficial melasma unless the peel is quite intense. IPL and laser treatments are better at treating melasma spots that have deeper pigment, because these treatments pass through the upper layers of the skin.
Ultimate 3-in-1 Antiaging Face Cream: There is a topical treatment for pigment issues that you can use at home. I consider it one of my because it is quite powerful: the Ultimate 3-in-1 Antiaging Face Cream. This isn’t a specific product you can buy, but a method of combining three different products in a way that is very effective. This is my favorite way to treat pigmentation on the face and is, in my opinion, probably the best available cream combination for treating melasma.
This special concoction combines two of the most effective antiaging creams: tretinoin, the only scientifically proven cream to tighten skin, reduce fine lines, and even reverse early precancerous skin lesions; and 4% (or more) hydroquinone, the most powerful pigment-reducing cream, available in the prescription strength of 4%. Combining these two creams can result in better penetration and the maximal effectiveness in reducing age spots and sun damage.
The third component of this combination is a steroid to reduce the common skin reaction to tretinoin: redness, itching, and flaking. I recommend a very small amount of hydrocortisone cream 0.5%. This is typically not enough to create the severe thinning that can occur with higher-potency steroid creams.
Because you cannot buy this combination of creams—they are prescription strength and not made by any manufacturers—you will need to ask your plastic surgeon or dermatologist to have it made by their compound pharmacy.
Apply it every other night at first, increasing to every night as tolerated. Once your skin looks better, decrease or discontinue its use, since it’s not a good idea to apply the hydrocortisone or hydroquinone to your skin indefinitely. Make sure to consult with a board-certified dermatologist or plastic surgeon prior to starting this treatment, to confirm that it is right for you and your skin issues.
Licorice Root: Licorice root is an all-natural product that some skin-lightening creams contain, or you can use the extract itself. Purchase licorice root extract drops in your local health-food store or online, and apply the liquid with a cotton swab directly to brown spots every morning and every evening. You should see fading in about two months.
DIY Sunspot-Lightening Mask: You can make this mask at home from ingredients you probably already have in your kitchen. Combine 1 tablespoon each of soy milk, honey, and lemon juice in a small bowl. Apply to your face, and let it sit for twenty to thirty minutes. Wash it off with warm water. Repeat two to three times per week, and you should notice sun spots fading after eight to ten weeks. All for just pennies! This works because the citric acid in lemon juice is a natural skin lightener, soy milk has enzymes that can inhibit the production of melanin in the skin (and is also full of vitamins A and E, which are both good for aging skin), and honey is what I call the jack-of-all-trades for at-home skin care. It has natural antibacterial properties, so it can help reduce acne; it also soothes irritated skin, moisturizes dry skin, and tightens the skin. It’s a great ingredient to add to most at-home skin-care regimens.
Beauty Secret
Makeup can also help to hide age spots pretty effectively. Find a yellow-based concealer that is two shades lighter than your normal skin color. Thicker concealers like Dermablend usually work well.
Apply the concealer with your finger or a brush.
Pat your foundation over the areas. Be careful if you rub the foundation, as it can cause the concealer to smudge.
Apply powder over the foundation to set it.
Now that you have some good, targeted information on how to tackle the most pressing aging issues on the part of you that faces the world every day, let’s get into prevention and routine maintenance of your skin. In the next chapter, I’ll take you through a routine you can customize for your own needs, lifestyle, and budget.