Psychologic aspects of aging and the skin

Strategies to make human skin models based on cellular senescence for ageing research

Human skin ageing is closely related to the ageing of the whole organism, and it's a continuous multisided process that is influenced not only by genetic and physiological factors but also by the cumulative impact of environmental factors. Currently, there is a scientific community need for developing skin models representing ageing processes to (i) enhance understanding on the mechanisms of ageing, (ii) discover new drugs for the treatment of age-related diseases, and (iii) develop effective dermo-cosmetics. Bioengineers worldwide are trying to reproduce skin ageing in the laboratory aiming to better comprehend and mitigate the senescence process. This review provides details on the main ageing molecular mechanisms and procedures to obtain in vitro aged skin models.

Father figure: Study of the age progression process from old pictures and its value in forensic sciences

The application of age progression to the search for missing persons demonstrates its usefulness in being able to reconstruct the aged face based on the current age of a person who has been missing for many years. Age progression takes into account facial physiognomic elements and their changes over time. Based on these premises, the present study aims to investigate the evolution of somatic features, from childhood to adulthood, of one of the authors' father using photos at different ages of him. Sixteen photos were collected depicting an individual of Italian origin between the age of 1 and 72. The photos were processed in Adobe© Photoshop software to graphically highlight the shape development of individual physiognomic elements. The shape of the face, eyebrows, eyes, nose, mouth, and cheeks were analysed in detail using a morphological approach. The ageing processes that occurred in this case were discussed on the basis of the literature. The present study demonstrates the in-depth analysis of the dynamics of facial growth in a single case. Nonetheless, aging is different for each individual, so further studies are necessary to observe facial development on as many subjects as possible.

Predicting the evolution of clinical skin aging in a multi-ethnic population: Developing causal Bayesian networks using dermatological expertise

INTRODUCTION

Software to predict the impact of aging on physical appearance is increasingly popular. But it does not consider the complex interplay of factors that contribute to skin aging.

OBJECTIVES

To predict the +15-year progression of clinical signs of skin aging by developing Causal Bayesian Belief Networks (CBBNs) using expert knowledge from dermatologists.

MATERIAL AND METHODS

Structures and conditional probability distributions were elicited worldwide from dermatologists with experience of at least 15 years in aesthetics. CBBN models were built for all phototypes and for ages ranging from 18 to 65 years, focusing on wrinkles, pigmentary heterogeneity and facial ptosis. Models were also evaluated by a group of independent dermatologists ensuring the quality of prediction of the cumulative effects of extrinsic and intrinsic skin aging factors, especially the distribution of scores for clinical signs 15 years after the initial assessment.

RESULTS

For easiness, only models on African skins are presented in this paper. The forehead wrinkle evolution model has been detailed. Specific atlas and extrinsic factors of facial aging were used for this skin type. But the prediction method has been validated for all phototypes, and for all clinical signs of facial aging.

CONCLUSION

This method proposes a skin aging model that predicts the aging process for each clinical sign, considering endogenous and exogenous factors. It simulates aging curves according to lifestyle. It can be used as a preventive tool and could be coupled with a generative AI algorithm to visualize aging and, potentially, other skin conditions, using appropriate images.

Difference between the biologic and chronologic age as an individualized indicator for the skincare intensity selection: skin cell profile and age difference studies

Background

The present research addresses the issue of skin aging and corresponding skin treatment individualization. Particular research question was on the development of a simplified criterion supporting patient-specific decisions about the necessity and intensity of skin treatment. Basing on published results and a wide pool of our own experimental data, a hypothesis is formulated that a difference between biologic and chronologic age can be used as a powerful indicator of skin aging.

Methods

In the present paper, we report the results of studies with 80 volunteers between 15 and 65 years of age linking skin cell profile parameters to biologic and chronologic age. Biologic age was calculated using the empirical expressions based on the forced vital lung capacity, systolic blood pressure, urea concentration, and blood cholesterol level. Epidermis and derma cellular structures were studied using skin biopsy samples taken from the gluteal region.

Results

The present study supports the conclusion that biologic and chronologic age difference is changing in the progress of life. Our studies are showing that time point when calculated biologic age becomes equal to the chronologic one reflecting the onset of specific changes in the age dependencies of experimentally measured skin cell profile parameters. Thus, it is feasible that a difference between chronologic and individually assessed biologic age indeed reflects the process of skin aging.

Conclusions

With all reservations to the relatively small number of study participants, it seems feasible that a difference between biologic and chronologic age can be used as an indicator of skin aging. Additional research linking blood immune profile and skin topography to the difference of biologic and chronologic age (reported in the following paper) provides further support for the formulated hypotheses. So, a difference between calculated biologic age and chronologic age can be used as an individualized criterion supporting decisions on skin treatment strategies. Further research involving larger numbers of participants aimed at optimizing the expressions for calculating biologic age could lead to reliable and easily available express criterion supporting the decision for the individualized skin treatment.

The Psychological Impacts of Upper Facial Lines: A Qualitative, Patient-Centered Study

Background

The 11-item Facial Line Outcomes (FLO-11) questionnaire is content validated for measuring the negative psychological impacts of crow’s feet lines (CFL).

Objectives

The aims of this study were to determine psychological impacts of forehead lines (FHL) alone and upper facial lines (UFL: FHL + CFL + glabellar lines [GL]) and to assess adequacy of FLO-11 to measure these impacts.

Methods

Participants aged at least 18 years participated in concept elicitation and cognitive interviews to identify and define psychological impacts of UFL. They completed the FLO-11 questionnaire to assess its ability to measure psychological impacts of facial lines and its comprehensiveness in doing so.

Results

Forty interviews were completed by 29 participants. Twenty participants each provided interviews for FHL and for UFL. The most commonly reported psychological impacts for FHL and UFL, respectively, were feeling unattractive (85%, 80%), looking less attractive than desired (85%, 70%), feeling bothered (80%, 70%), feeling good/bad about appearance (80%, 70%), looking older than actual age (75%, 65%), and feeling stressed (70%, 70%). For FHL, 70% of participants also reported looking older than desired as a psychological impact. More than 50% of participants agreed that all 11 FLO-11 items measured a psychological impact for FHL. More than 50% reported that 9 of 11 items measured a psychological impact for UFL. The majority of participants (FHL, 65%; UFL, 60%) reported that the FLO-11 questionnaire is comprehensive in measuring psychological impacts of facial lines.

Conclusions

FHL and UFL have psychological impacts on patients, and FLO-11 is a content valid, comprehensive instrument for measuring them.

OnabotulinumtoxinA treatment of moderate to severe glabellar lines in Chinese subjects after laser therapy: A prospective, open-label, noncomparative study

INTRODUCTION

This study evaluated safety and efficacy of onabotulinumtoxinA for moderate to severe glabellar lines (GL) following laser therapy in Chinese subjects.

MATERIALS AND METHODS

Subjects (n = 173) were followed for 120 days following a single onabotulinumtoxinA (20 U) treatment for GL after recent laser therapy. Subjects completed validated patient-reported outcomes, including Facial Lines Outcome 11-item (FLO-11) Questionnaire and Facial Lines Satisfaction Questionnaire (FLSQ). Physicians and subjects assessed GL severity at maximum frown and at rest using the Facial Wrinkle Scale with Asian Photonumeric Guide (FWS-A).

RESULTS

Mean total FLO-11 scores increased from 47.7 (baseline) to 75.9 (day 120) (p < 0.0001), with mean improvement of at least two grades for most items maintained to day 120. Most subjects were mostly or very satisfied, per the FLSQ. Percentages of subjects with at least one-grade improvement in FWS-A (responders) at maximum frown per subjects and physicians were 93.1% and 97.1%, respectively, at day 30, and 72.3% and 81.5% at day 120 (all, p < 0.0001). More than 70% were FWS-A responders at day 120. All adverse events were mild or moderate; none were related to onabotulinumtoxinA.

CONCLUSIONS

A single onabotulinumtoxinA (20 U) treatment following laser therapy was safe and effective in correcting GL for up to 120 days.

The impact of upper facial lines and psychological impact of crow's feet lines: content validation of the Facial Line Outcomes (FLO-11) Questionnaire

BACKGROUND

Treatments for upper facial lines (UFL), the most visible sign of aging, are of interest to patients and clinicians alike. Patient-reported outcomes (PROs) are valuable in evaluating the impact of such treatments; however, regulatory recommendations have stipulated that the patient perspective be central in developing these assessments.

OBJECTIVES

(1) To evaluate the content validity of the Facial Lines Outcomes Questionnaire, a PRO instrument developed to assess upper facial line impacts, according to the regulatory guidance of the United States Food and Drug Administration and (2) assess whether it adequately measures the psychological impacts associated with crow's feet lines (CFL) (lateral canthal lines) from the patient perspective.

METHODS

Two patient groups participated in face-to-face qualitative interviews. One group included patients with UFL (Group 1, n = 25 interviews), and the other included patients specifically with CFL (Group 2, n = 41 interviews). Each interview consisted of a concept elicitation and cognitive debriefing phase.

RESULTS

Interviews with both groups elicited all key concepts of the instrument, including "bothered by facial lines"; "looking older"; "looking less attractive"; and looking "tired," "stressed," or "angry." Most Group 2 patients (n = 35, 85%) agreed that the instrument adequately assessed the psychological impacts associated with CFL. During cognitive debriefing, the majority of patients in both groups agreed the instrument was understandable, comprehensive, and easy to complete.

CONCLUSIONS

The Facial Line Outcomes Questionnaire is an appropriate and valid tool to assess the impact of UFL and the psychological impacts associated with CFL.

Older people and skin: challenging perceptions

In this article we set out to challenge perceptions about older people and skin. We examine current portrayals of older people and skin, both in the media and in the nursing literature. We describe the ‘normal’ process of skin ageing and highlight the importance of maintaining skin integrity and effective barrier function for health and wellbeing, particularly in older people. One element of maintaining skin integrity is ensuring that personal hygiene and emollient needs are met. Effective skin hygiene and emollient care will reduce the risk of breakdown, with all its burdensome and costly consequences. We therefore offer a summary of the current evidence base for skin-hygiene practice. We make a case for nurses considering skin health from a wider societal and human perspective, and identify opportunities to enhance nursing practice through skin-care advice and health education for all older people.

[Dermatology, cosmetic and well-being]

BACKGROUND

To the extent that they help improve our appearance, cosmetics can affect how we relate to ourselves and to others, and as such can improve quality of life. Such benefits may be objectively demonstrated using validated methods and quality-of-life scales.

GOAL

The aim of this review is to assess the effects of cosmetics on well-being in various situations based on studies using objective measurement methods.

METHOD

Literature review.

RESULTS

In pathological settings, the use of cosmetics can significantly improve the quality of life and well-being of patients, resulting in better acceptance of their disease and better therapeutic compliance. The use of cosmetics has also been shown to exert positive effects on self-esteem and social relations. A growing body of studies also demonstrates the beneficial effects of cosmetics on well-being under normal physiological conditions.

DISCUSSION

Today, the effects and benefits of cosmetics can be measured objectively using quality-of-life scales, allowing initiation of actions for the rediscovery of well-being and self-esteem.

Podophyllin reaction mimicking Bowen's disease in a patient with delusions of verrucosis

A 40-year-old woman presented with a delusion of warts on the forehead, for which she was applying podophyllin toxin. A skin biopsy was taken, which showed prominent mitotic figures in the basal and suprabasal layers of the epidermis and apoptotic keratinocytes. Histopathologically Bowen's disease was suspected, but was discounted after clinicopathological correlation was obtained and showed absence of epidermal atypia or disorganization. This case demonstrates the histological resemblance of podophyllin reaction to Bowen's disease. Differentiation of self-inflicted from organic skin disease may be difficult, especially where histopathological findings are confounded by cutaneous application of toxins.

Skin and psyche--from the surface to the depth of the inner world

About 30% of dermatology patients have signs or symptoms of psychological problems. Dermatologists should be familiar with the basics needed to identify, advise and treat these patients. Because of the complex interaction between skin and psyche, it is difficult to distinguish whether the primary problem is the skin or the psyche. Sometimes the clinical picture is a consequence of interactions between them and other factors. The interactions between skin and psyche are well known in history, art and literature--perhaps better known today because the marked emphasis on such images in our modern multimedia society. Aging is increasingly perceived as an illness and not as a physiological process. Through globalization, many different cultural approaches to the skin have entered in our daily life and influence our communication. This article considers the most important dermatoses which often show primary or secondary interaction with the psyche.

Psychocutaneous syndromes: a call for revised nomenclature

We propose abandoning three outdated, pejorative diagnostic terms: 'trichotillomania', 'delusions of parasitosis', and 'neurotic excoriation'. These insensitive terms are offensive to patients and become a barrier to treatment. We suggest the following alternative patient-centred nomenclature: 'neuromechanical alopecia', 'pseudoparasitic dysaesthesia', and (simply) 'excoriation'. We briefly review clinical and historical aspects of these disorders.

[Plastic surgical body form correction. Part II: Face-lift, periorbital surgery, and breast augmentation and reduction]

The demand for a younger appearance is increasing as the average age of the population increases. Extensive anatomic studies in recent years have improved for facial and breast reconstruction the understanding of anatomic structures and the basis of the aging process. Numerous new surgical techniques have resulted. This understanding of the anatomy of aging and the diversity of surgical methods have made the attainment of naturally young facial appearance more easily possible, in which repositioning of the tissue plays a more important role than lifting. In the past, plastic surgery of the eyelids aimed primarily at hiding the aging process, not at true anatomic restoration. Modern techniques in this field aim more toward redistribution of fatty tissues and the anatomic restoration of aging structures. In this way long-term results are stabilized and secondary stigmata can be avoided. New concepts have also been established in breast surgery that allow more natural results, particularly in augmentation. Although no single method may be designated as superior, there still exists an optimal technique suited to every patient's anatomy and personal wishes.

Elderly skin and its rejuvenation: products and procedures for the aging skin

In the last few decades, there has been a substantial increase in the population of people over 60 years of age. Most of them maintain a good general health and physical activity and fitness. For these individuals there is a good number of dermatologic procedures, medications, and cosmetics that can be prescribed to improve the aspect of skin aging, providing an improvement in their self-esteem and quality of life as a result of their better look. We will discuss the mechanisms of skin aging, and the procedures and substances used to minimize its deleterious effects, such as sunscreens, estrogens, chemical peels, toxin botulinum, fillers and surgical procedures, among others. The use of makeup and the adverse reactions to cosmetics will also be mentioned.

Trigeminal trophic syndrome

Ulceration of the nose may be inadvertently induced by the patient. Although trigeminal trophic syndrome is an uncommon cause of chronic ulcers, healthcare providers should consider the possibility of this disorder when encountering a patient with nasal ulcerations. Trigeminal trophic syndrome most commonly occurs in older women following therapy for trigeminal neuralgia. The ulcers usually involve the nasal ala and paranasal areas. The clinical vignette of a man with a self-induced nasal ulcer secondary to trigeminal trophic syndrome, which was initially suspected to be skin cancer, is presented. Since nasal ulcerations can be secondary to other conditions, a lesional biopsy should be performed to exclude other diagnoses when trigeminal trophic syndrome is entertained. In addition to trigeminal trophic syndrome, the differential diagnosis of conditions that can cause nasal ulcers include factitial disorders with self-induced ulcerations (such as dermatitis artifacta and neurotic excoriations), granulomatous conditions, infectious diseases, malignancy, and pyoderma gangrenosum. Treatment of trigeminal trophic syndrome requires prevention of digital manipulation of the lesion-either by occluding contact with the ulcer, initiating psychotropic medication, or both. Psychiatric and/or pharmacologic intervention should be considered to reduce or resolve further habitual self-inflicted injury before surgical intervention.

Dissociative identity disorder presenting as dermatitis artefacta

Dermatitis artefacta is a rare psychiatric condition characterized by rubbing of skin blisters and denial of self-infliction. Dissociation may be comorbid with self-injurious behavior. A background of emotional disturbances during formative years and in later life often results in feelings of isolation and insecurity, which can lead to dissociation as a primary defense mechanism used to overcome traumatic events. In this case report, we describe a female patient with dermatitis artefacta associated with dissociative identity disorder. The patient was a 14-year-old girl. Multiple large, deep ulcerations with unnatural shapes were seen on her left forearm. The ulcerations were thought to be self-inflicted. Psychiatric examination revealed that she had a different identity, and inflicted the lesions when this was assumed. This case leads us to suggest that patients with dermatitis artefacta might have comorbid dissociative experiences, which cannot be identified easily.

Changes associated with the aging face

The demand for facial plastic surgery has increased dramatically in recent years as persons from all socioeconomic levels and age groups have become interested in facial rejuvenation. As the population ages, the demand for esthetic surgery in the elderly will increase at an even greater rate. Before the surgeon begins to learn specific techniques in facial plastic surgery, he or she should have a thorough understanding of the anatomy of the aging face. Safe and effective esthetic surgery is possible only when the anatomic changes associated with the aging face are appreciated by the surgeon and patient.

Psychosocial Aspects Of Aging Skin

Many older individuals use products and procedures to conceal or delay the signs of aging. For most, this provides a helpful ego boost, but some suffer from pathologies such as eating disorders and body dysmorphic disorder. The impact of aging skin may include social anxiety and social isolation. Poor self-image is associated with chronic illness and fewer preventive health behaviors, such as exercise. Aged appearance, especially in women, is also associated with workplace discrimination. Patients should therefore be offered treatments for aging skin, ensured that society's negative views not be unnecessarily reinforced, and maintain a realistic treatment expectations.

Dermatitis artefacta: unusual appearance in an older woman

Dermatitis artefacta is a rare and difficult condition for diagnosis and treatment, with the highest incidence of onset in late adolescence to early adult life. Most patients are young women who have a personality disorder; borderline features are common and the patient's denial of psychological distress makes management and treatment difficult. Patients use a variety of means to cause the skin changes. Clinical presentation of the skin lesions does not conform to those of known dermatoses and are located on easily reached parts of the skin. We report an unusual case of a 72-year-old woman with symmetrical changes under the breasts and in the right inguinal region. The lesions were composed partly of haemorrhagic round lesions and partly of scars. A skin biopsy was taken and consultations with the psychiatrist, internist and the patient's family led to the diagnosis of self-induced dermatitis. The skin lesions were covered by occlusion techniques and the lesions improved very rapidly. The patient was discharged from the hospital under psychiatric and family care.

Spectrum of acute allergic diseases in an emergency department: an evaluation of one years' experience

OBJECTIVE

There is limited available literature on the incidence of allergic diseases in ED. The objective of this study was to investigate the clinical records of patients admitted to the ED with a suspected allergic reaction.

METHODS

A 1 year retrospective study was carried out and data were collected from the patients' computerized medical reports.

RESULTS

A total of 324 patients were admitted for an allergic event. Of those, 165 patients (50.9%) were female and their mean age was 55 +/- 18.5 years. Diagnoses included: asthma in 100 patients (30.9%); hymenoptera allergy in 78 patients (24.1%); food allergy in 31 patients (9.5%); drug allergy in 25 patients (7.7%); and allergic conjunctivitis in 12 patients (3.7%). No diagnosis was found in the medical records of 78 patients (24.1%). Anaphylactic shock was observed in 12 patients (3.7%) with a diagnosis of food allergy (six cases), drug allergy (three cases) and hymenoptera allergy (three cases). Ninety patients (27.7%) were hospitalized in the following units: 38 in allergy unit (42.2%); 20 in intensive care unit (22.2%); 10 in pulmonary unit (11.1%); eight in the dermatology unit (8.9%); six in the internal medicine unit (6.7%); and eight in other units (8.9%). Overall, 42 patients (12.9%) were evaluated by an allergologist after ED discharge with positive allergy results in 28 cases (66.6%).

CONCLUSIONS

Acute allergic diseases are not rare in ED, representing 1% of the annual visits in our series. A low rate of allergologist referral was observed. Emergency physicians must work closely with allergologists to ensure a better evaluation, long-term care and preventive management of patients with allergic diseases admitted to the ED.

Dermatitis artefacta in pediatric patients: experience at the national institute of pediatrics

Dermatitis artefacta is a factitious disorder in which there is deliberate conscious production of skin lesions. There are only a few reports that evaluate instances of dermatitis artefacta in the pediatric population. The aim of this retrospective study was to assess the characteristics of patients with this disorder who were seen at the National Institute of Pediatrics in Mexico City. The records of all patients diagnosed with dermatitis artefacta from January 1980 to December 1999 were analyzed. There were 29 patients (25 females, 4 males). The upper limbs and the face were the most commonly involved areas. Superficial erosions were the most frequent initial event, and residual lesions consisted of scars and crusts. Time taken to diagnosis was on average 10 months. Half of the patients were lost to follow-up. No correlation was found between the length of time from the disease onset to diagnosis, the type of lesions, and the clinical outcome. Twelve patients had an associated systemic disorder. The possible association with chronic disease has not been sufficiently stressed and demonstrates the importance of providing psychological support for these patients. Psychiatric diagnoses were anxiety, depression, and personality disorder. No correlation was found between the psychiatric diagnosis and the outcome of dermatitis artefacta. A young age at presentation, which has been considered important as a favorable prognostic sign, could not be demonstrated in our patients.

Social implications of hyperfunctional facial lines

The face is the focus of human interactions, and facial appearance profoundly affects self-esteem. Facial appearance is not only a compilation of the dimensions of the primary morphologic features but is also a direct result of the emotional expressions exhibited on the face. Facial expressions are central in the communication of emotions, as well as in signaling characteristics such as age. The repeated expression of emotions produces hyperfunctional facial lines, and the presence of these lines when the face is at repose may give an erroneous impression of emotions or personality characteristics. These lines are also perceived as a sign of aging. Treatment of hyperfunctional facial lines is beneficial for patients who believe that their faces are not communicating their emotions properly, who want to delay the outward appearance of aging, or who simply want to look their best.

Artefactual skin disease in children and adolescents

As in adults, artefactual skin disease in children and adolescents has heterogenous presentations with multifactorial aetiology. We report a series of 32 young patients aged 8-16 years. There were 24 females and 8 males. In over half of the cases the lesions were on the head and neck. The types of lesions encountered included physical injury producing grazing, erosions and deep ulcers, chemical and thermal burns, hair cutting and shaving and skin painting. We discuss the approach that we believe should be taken with these patients, emphasizing the role of dermatology-psychiatry liaison in their management. Of great importance is the avoidance of confrontation of the patient but the clear exposition of the nature of the problem to the parents. The major aim should be to have the family accept the need for expert psychiatric assistance.

Elder care and the dermatologic surgeon

BACKGROUND

The elderly are an increasing percentage of the population and dermatologic surgeons will be caring for more senior citizens.

OBJECTIVE

Understanding issues in geriatric care will help both surgeons and patients have productive and rewarding encounters.

METHODS

Approaches to the care of elders are detailed in this article. Surgical tips for the senior patient are prescribed.

RESULTS

Older patients need more time and may need special assistance. Multiplicity of disease increases with age. A third-party interview can be helpful in gathering information. The elderly have sensory loss and benefit from extra attention, follow-up telephone calls, and therapeutic touch. Written handouts and instructions printed in large type are excellent. Dermatologic care should be kept as simple as possible with surgical closures designed to require minimal attention. Be cognizant of the social services available for the elderly and watch for dermatologic signs of internal disease. A skin care program for the elderly is helpful and cosmetic procedures are of interest to seniors.

CONCLUSIONS

Dermatologic surgeons can provide excellent care to elders. An understanding of gerontologic issues and surgical tips can help the dermatologic surgeon care for the older patient.

Demographics and psychological implications for the aging population

The aging of skin is more than a decline in physiologic functions. Aging skin is associated with regressive anatomical changes such as looseness, roughness, wrinkles, and dyspigmentations (age spots) which adversely affect appearance. Unattractive aged persons tend to have less confidence, have low self-esteem, and are in fact less healthy than those who have aged well. Physicians must educate the public to follow life-styles that prevent a prematurely aged appearance. Additionally, resources which make it possible to remarkably correct the various deteriorations of the photo damaged face are now available. Patients should be told that these interventions are not simply an expression of vanity, but add to self-esteem and improved social relations.