Cigarette smoking associated with premature facial wrinkling: image analysis of facial skin replicas

Clinical Assessment, Diagnosis, and Management of Infraorbital Wrinkles and Pigmentation

Lower eyelid skin is unique and different from that of other areas. In addition to being an area of high exposure to the sun and elements, there are anatomic considerations and specific histologic characteristics that can cause the skin in this area to be more sensitive. These attributes can readily cause under-eye wrinkling and pigmentation. This review aims to present an updated overview of the current knowledge regarding the clinical characteristics, diagnosis, and management of wrinkles and pigmentation in this area. These disorders are usually caused by different factors, such as genetics, aging, sun exposure, lack of sleep, and stress.

The combination of cigarette smoke and solar rays causes effects similar to skin aging in a bilayer skin model

Skin aging is a multifactorial process influenced by internal and external factors. The contribution of different environmental factors has been well established individually in the last few years. On the one hand, man is rarely exposed to a single factor, and on the other hand, there is very little knowledge about how these extrinsic factors may interact with each other or even how the skin may react to chronic exposure. This study aimed to evaluate the effect on skin aging of a chronic co-exposure of tissue-engineered skin substitutes to cigarette smoke extract (CSE) and solar simulator light (SSL). Skin substitutes were reconstructed according to the self-assembly method and then exposed to CSE followed by irradiation with SSL simultaneously transmitting UVA1, visible light and infrared. When skin substitutes were chronically exposed to CSE and SSL, a significant decrease in procollagen I synthesis and the inhibition of Smad2 phosphorylation of the TGF-β signaling pathway were observed. A 6.7-fold increase in MMP-1 activity was also observed when CSE was combined with SSL, resulting in a decrease in collagen III and collagen IV protein expression. The secretory profile resulting from the toxic synergy was investigated and several alterations were observed, notably an increase in the quantities of pro-inflammatory cytokines. The results also revealed the activation of the ERK1/2 (3.4-fold) and JNK (3.3-fold) pathways. Taken together, the results showed that a synergy between the two environmental factors could provoke premature skin aging.

Toxic Interaction Between Solar Radiation and Cigarette Smoke on Primary Human Keratinocytes

Solar radiation and cigarette smoke are two environmental risk factors known to affect skin integrity. Although the toxic effects of these factors on skin have been widely studied separately, few studies have focused on their interaction. The objective of this study was to evaluate and understand the synergistic harmful effects of cigarette smoke and solar rays on human primary keratinocytes. The keratinocytes were exposed to cigarette smoke extract (CSE) and then irradiated with a solar simulator light (SSL). The viability, as determined by measuring metabolic activity of skin cells, and the levels of global reactive oxygen species (ROS) were evaluated after exposure to CSE and SSL. The combination of 3% CSE with 29 kJ m-2 UVA caused a decrease of 81% in cell viability, while with 10% to 20% CSE, the cell viability was null. This phototoxicity was accompanied by an increase in singlet oxygen but a decrease in type I ROS when CSE and SSL were combined in vitro. Surprisingly, an increase in the CSE's total antioxidant capacity was also observed. These results suggest a synergy between the two environmental factors in their effect on skin cells, and more precisely a phototoxicity causing a drastic decrease in cell viability.

Skin Aging Exposome in Skin of Color Populations: Review of the Literature

BACKGROUND

As life expectancy increases, the comorbidities related to aging require greater attention. Skin aging exposomes were only recently defined and need additional delineation, particularly in Skin of Color (SOC) populations.

OBJECTIVE

The primary objective is to shed the light and summarize the existing literature on skin aging exposome in SOC populations.

MATERIALS AND METHODS

We performed an extensive search in the PubMed and Google Scholar databases. We included peer-reviewed studies in SOC populations around the world regarding one or more of the skin aging exposome factors, and we grouped and organized the studies under each factor of the skin aging exposome.

RESULTS

Some environmental exposome factors are preventable or modifiable, for example, by applying broad-spectrum sunscreens with visible light protection, improving nutrition, and smoking cessation. Other factors such as air pollution will require more complex solutions. Our search revealed a paucity of references on skin aging exposome factors in SOC populations.

CONCLUSION

We identified the need for more dedicated studies in SOC populations to advance knowledge on skin aging exposome factors. This knowledge will provide a better understanding of approaches to minimize extrinsic skin aging in these populations.

Immunological Aspects of Skin Aging in Atopic Dermatitis

The cutaneous immune response is important for the regulation of skin aging well as for the development of immune-mediated skin diseases. Aging of the human skin undergoes immunosenescence with immunological alterations and can be affected by environmental stressors and internal factors, thus leading to various epidermal barrier abnormalities. The dysfunctional epidermal barrier, immune dysregulation, and skin dysbiosis in the advanced age, together with the genetic factors, facilitate the late onset of atopic dermatitis (AD) in the elderly, whose cases have recently been on the rise. Controversial to the healthy aged skin, where overproduction of many cytokines is found, the levels of Th2/Th22 related cytokines inversely correlated with age in the skin of older AD patients. As opposed to an endogenously aged skin, the expression of the terminal differentiation markers significantly increases with age in AD. Despite the atenuated barrier disturbances in older AD patients, the aged skin carries an impairment associated with the aging process, which reflects the persistence of AD. The chronicity of AD in older patients might not directly affect skin aging but does not allow spontaneous remission. Thus, adult- and elderly subtypes of AD are considered as a lifelong disease.

Human Skin Gloss Perception Based on Texture Statistics

We propose objective, image-based techniques for quantitative evaluation of facial skin gloss that is consistent with human judgments. We use polarization photography to obtain separate images of surface and subsurface reflections, and rely on psychophysical studies to uncover and separate the influence of the two components on skin gloss perception. We capture images of facial skin at two levels, macro-scale (whole face) and meso-scale (skin patch), before and after cleansing. To generate a broad range of skin appearances for each subject, we apply photometric image transformations to the surface and subsurface reflection images. We then use linear regression to link statistics of the surface and subsurface reflections to the perceived gloss obtained in our empirical studies. The focus of this paper is on within-subject gloss perception, that is, on visual differences among images of the same subject. Our analysis shows that the contrast of the surface reflection has a strong positive influence on skin gloss perception, while the darkness of the subsurface reflection (skin tone) has a weaker positive effect on perceived gloss. We show that a regression model based on the concatenation of statistics from the two reflection images can successfully predict relative gloss differences.

Elastic fibers during aging and disease

Elastic fibers are essential constituents of the extracellular matrix of higher vertebrates and endow several tissues and organs including lungs, skin and blood vessels with elasticity and resilience. During the human lifespan, elastic fibers are exposed to a variety of enzymatic, chemical and biophysical influences, and accumulate damage due to their low turnover. Aging of elastin and elastic fibers involves enzymatic degradation, oxidative damage, glycation, calcification, aspartic acid racemization, binding of lipids and lipid peroxidation products, carbamylation and mechanical fatigue. These processes can trigger an impairment or loss of elastic fiber function and are associated with severe pathologies. There are different inherited or acquired pathological conditions, which influence the structure and function of elastic fibers and microfibrils predominantly in the cardiorespiratory system and skin. Inherited elastic-fiber pathologies have a direct or indirect impact on elastic-fiber formation due to mutations in the fibrillin genes (fibrillinopathies), in the elastin gene (elastinopathies) or in genes encoding proteins that are associated with microfibrils or elastic fibers. Acquired elastic-fiber pathologies appear age-related or as a result of multiple factors impairing tissue homeostasis. This review gives an overview on the fate of elastic fibers over the human lifespan in health and disease.

Environmentally-Induced (Extrinsic) Skin Aging: Exposomal Factors and Underlying Mechanisms

As a barrier organ, the skin is an ideal model to study environmentally-induced (extrinsic) aging. In this review, we explain the development of extrinsic skin aging as a consequence of skin exposure to specific exposomal factors, their interaction with each other, and the modification of their effects on the skin by genetic factors. We also review the evidence that exposure to these exposomal factors causes extrinsic skin aging by mechanisms that critically involve the accumulation of macromolecular damage and the subsequent development of functionally altered and/or senescent fibroblasts in the dermal compartment of the skin.

E-Liquid Containing a Mixture of Coconut, Vanilla, and Cookie Flavors Causes Cellular Senescence and Dysregulated Repair in Pulmonary Fibroblasts: Implications on Premature Aging

Electronic cigarette (e-cig) usage has risen dramatically worldwide over the past decade. While they are touted as a safe alternative to cigarettes, recent studies indicate that high levels of nicotine and flavoring chemicals present in e-cigs may still cause adverse health effects. We hypothesized that an e-liquid containing a mixture of tobacco, coconut, vanilla, and cookie flavors would induce senescence and disrupt wound healing processes in pulmonary fibroblasts. To test this hypothesis, we exposed pulmonary fibroblasts (HFL-1) to e-liquid at varying doses and assessed cytotoxicity, inflammation, senescence, and myofibroblast differentiation. We found that e-liquid exposure caused cytotoxicity, which was accompanied by an increase in IL-8 release in the conditioned media. E-liquid exposure resulted in elevated senescence-associated beta-galactosidase (SA-β-gal) activity. Transforming growth factor-β1 (TGF-β1) induced myofibroblast differentiation was inhibited by e-liquid exposure, resulting in decreased α-smooth muscle actin and fibronectin protein levels. Together, our data suggest that an e-liquid containing a mixture of flavors induces inflammation, senescence and dysregulated wound healing responses.

A variety of processes that affect the perception of skin aging

The purpose of this paper is to discuss the most important factors affecting perceived age. Aging is an unavoidable and irreversible process, but perceived age is a modifiable psychosocial factor. Our exterior has become one of the determinants of our social position, the key to success in our professional and personal lives. Today, we see people through their appearance, we judge after the first impression. With the help of aesthetic medicine, we can change the perceived age, but we cannot stop aging. This article discusses factors affecting the perceived age, such as hair color, skin color, general appearance and environmental factors. Many cannot be avoided, but we can make changes in life to look younger and more well-groomed. Indeed, we can change our habits for the benefit of the whole body, not only for the skin.

Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know

Objectives

The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular.

Methods

English-language publications of human and animal studies categorizing subjects into smokers and nonsmokers were sourced from MEDLINE, The Cochrane Library, and SCOPUS. This review specifically focused on the risk, surgical treatment, and prevention of fracture complications in smokers.

Results

Smokers have an increased risk of fracture and experience more complications with delayed bone healing, even if they have already stopped smoking, because some adverse effects persist for a prolonged period. Some risks can be reduced during and after surgery by local and general prevention, and smoking cessation is an important factor in lessening this risk. However, if a patient wants to stop smoking at the time of a fracture, the cessation strategies in reducing tobacco use are not easy to implement. The patient should also be warned that using e-cigarettes or other tobaccos does not appear to reduce adverse effects on health.

Conclusion

The evidence reviewed in this study shows that smoking has a negative effect in terms of the risk and treatment of fractures.

Cite this article: J. Hernigou, F. Schuind. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res 2019;8:255–265. DOI: 10.1302/2046-3758.86.BJR-2018-0344.R1.

Vitamin D history part III: the "modern times"-new questions for orthopaedic practice: deficiency, cell therapy, osteomalacia, fractures, supplementation, infections

PURPOSE

The nutritional basis for rickets was described between 1880 and 1915, at the same period of discovery of other "vital substances" or vitamins. In contrast, rickets could also be prevented or cured by sunshine. But as the capacity to produce vitamin D depends on exposure to ultraviolet B rays (UVB) from sunlight or artificial sources, vitamin D became one of the most frequently used "drugs" in the twentieth century to compensate for insufficient exposure to UVB of humans. Furthermore, as the understanding of vitamin D metabolism grew during the twentieth century, other concerns than rickets occurred for the orthopaedic surgeon: In recent history, deficiency is explored as being an associated factor of different bone pathologies as fracture or prosthetic infection. The aim of this review is to analyze these new data on vitamin D.

MATERIALS AND METHODS

During the twentieth century, there were many concerns for the orthopaedic surgeon: sources and synthesis of vitamin D, regulation of the calcium deposition process for both children and adults, when vitamin D deficiency is observed, and what the best method of vitamin D supplementation is. As target genes regulated by vitamin D are not limited to those involved in mineral homeostasis, orthopedists recently discovered that vitamin D might prevent periprosthetic infection.

RESULTS

The primary source (80%) of vitamin D is dermal synthesis related to the sun. Dietary sources (20%) of vitamin D are fat fishe, beef, liver, and eggs. Vitamin D is produced industrially to be used in fortified foods and supplements. Maintenance of skeletal calcium balance is mediated through vitamin D receptors. Progenitor cells, chondrocytes, osteoblasts, and osteoclasts contain these receptors which explains the role of vitamin D in cell therapy, in the prevention of rickets and osteomalacia. Despite fortified foods, the prevalence of deficiency remains endemic in north latitudes. However, the definition of vitamin D insufficiency or deficiency remains controversial. Vitamin D has been evaluated in patients undergoing fractures and elective orthopaedic procedures Although supplementation may not be able to prevent or cure all the orthopaedic pathologies, oral supplementation is able to improve the vitamin D levels of deficient patients. These vitamin D level improvements might be associated with better functional and clinical outcomes after some surgical procedures and improvement of immunity to decrease the risk of infection in arthroplasties.

CONCLUSION

Vitamin D deficiency is frequent and concerns millions of people in the world. It is therefore normal to find hypovitaminosis in various orthopaedic populations including trauma and arthroplasties. However, we do not know exactly if this phenomenon only reflects the general prevalence of vitamin D deficiency or has an influence on the outcome of some pathologies on specific populations at risk. After the success of treatment of rickets, it is disappointing that we are still wondering in the twenty-first century whether supplementation of a substance synthetized millions of years ago by plankton and necessary for growth of all the animals may improve (or not) clinical and functional outcomes of a simple fracture in humans.

Use of Advanced Imaging Techniques for the Characterization of Oily Skin

Excessively oily skin leads to clinical signs that cause discomfort to patients, such as excessive shine, enlarged pores, acne, and an imbalance of the hydrolipidic layer. In this context, a constant demand for the research and development of products that prevent these features, has been noted in the field of cosmetics and dermatology. Thus, the objective of this study is to evaluate the cutaneous characteristics of oily skin due an excessive production of sebum through biophysical and skin imaging techniques. 19 participants with different skin types were selected and the following parameters were evaluated: pore count, determination of the number of sebaceous glands and amount of sebum in infundibulum, determination of cutaneous microrelief, count of comedones, evaluation of epidermis thickness, characterization of the cellular, and comedone size and its characteristics. These evaluations were done through biophysical and skin imaging techniques. The obtained results showed that different regions of the face presented different characteristics related to oiliness, quantity, and the appearance of pores and comedones. The malar region had a lower epidermis thickness and a larger number of large pores. Moreover, in this region excessive sebum production, which can be related to pores, not comedones, was noted. The nose region presented higher sebum content in the infundibulum and lower active sebaceous glands, showing a higher activity of sebaceous production in this region. The chin region presented a positive correlation between the sebum content, roughness parameter and the number of pores and comedones. As different skin properties are related and influence the appearance of undesirable clinical signs, we identified the need for a multifactorial approach for the effective treatment of oily skin. The rational development of multifunctional cosmetic products that promote the control of oily skin, that regulate the keratinization process, improve the microrelief and leads to a better epidermis and dermis structure, will not only improve oily skin conditions but will also allow for the reduction or disappearance of clinical signs that result from excessive oiliness, all of which causes concern and results in a relentless search for cosmetic and dermatological products that address the unaesthetic nature of these conditions.

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.

Use of chromatographic and electrophoretic tools for assaying elastase, collagenase, hyaluronidase, and tyrosinase activity

Elastase, collagenase, hyaluronidase and tyrosinase, are very interesting enzymes due to their direct implication in skin aging and as therapeutic hits. Different techniques can be used to study these enzymes and to evaluate the influence of effectors on their kinetics. Nowadays, analytical techniques have become frequently used tools for miniaturizing enzyme assays. The main intention of this article is to review chromatographic and electrophoretic tools that study the four enzymes above mentioned. More specifically, the use of high-performance liquid chromatography and capillary electrophoresis and their derivative techniques for monitoring these enzymes will be investigated. The advantages and limitations of these assays will also be discussed. The original use of microscale thermophoresis and thin layer chromatography in this domain will also be covered.

Histological study on the effect of nicotine on adult male guinea pig thin skin

Tobacco smoking has been identified as an important factor in premature skin aging to detect the histological changes occurred in adult male guinea pig thin skin under the influence of low and high doses of nicotine; which constitutes approximately 0.6%–3.0% of the dry weight of tobacco. Fifteen adult male pigmented guinea pigs were equally divided into three groups: group I, control; group IIA, low dose nicotine treated; 3 mg/kg subcutaneously for 4 weeks; and group IIB, high dose nicotine treated; 6 mg/kg subcutaneously for 4 weeks. Specimens from the back thin skin were processed for light and electron microscopy. Nicotine administration revealed flattened dermo-epidermal junction and reduced rete ridges formation. Collagen bundles were disorganized with increased spaces between them. A reduction in the amount of elastic fibers in the dermis were also observed compared to group I. Ultrastructurally, keratinocytes had hyperchromatic nuclei, intracytoplasmic vacuoles, disruption of desmosomal junctions, irregular tonofilaments distribution, and increased inter-cellular spaces. These changes were more pronounced with high dose nicotine administration. The epidermal thickness was reduced in low dose nicotine administration. But, high dose nicotine administration revealed increased epidermal thickness compared to the control group. Nicotine induced structural changes of adult male guinea pig thin skin. These changes were more pronounced with high dose nicotine administration.

Skin condition and its relationship to systemic inflammation in chronic obstructive pulmonary disease

Background

The systemic (extrapulmonary) effects and comorbidities of chronic obstructive pulmonary disease (COPD) contribute substantially to its burden. The supposed link between COPD and its systemic effects on distal organs could be due to the low-grade systemic inflammation. The aim of this study was to investigate whether the systemic inflammation may influence the skin condition in COPD patients.

Materials and methods

Forty patients with confirmed diagnosis of COPD and a control group consisting of 30 healthy smokers and 20 healthy never-smokers were studied. Transepidermal water loss, stratum corneum hydration, skin sebum content, melanin index, erythema index, and skin temperature were measured with worldwide-acknowledged biophysical measuring methods at the volar forearm of all participants using a multifunctional skin physiology monitor. Biomarkers of systemic inflammation, including high-sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), and tumor necrosis factor α (TNF-α), were measured in serum using commercially available enzyme-linked immunosorbent assays.

Results

There were significant differences between COPD patients and healthy never-smokers in skin temperature, melanin index, sebum content, and hydration level (P<0.05), but not for transepidermal water loss and erythema index. No significant difference was noted between COPD patients and smokers in any of the biophysical properties of the skin measured. The mean levels of hsCRP and IL-6 in serum were significantly higher in COPD patients and healthy smokers in comparison with healthy never-smokers. There were significant correlations between skin temperature and serum hsCRP (R=0.40; P=0.02) as well as skin temperature and serum IL-6 (R=0.49; P=0.005) in smokers. Stratum corneum hydration correlated significantly with serum TNF-α (R=0.37; P=0.01) in COPD patients.

Conclusion

Differences noted in several skin biophysical properties and biomarkers of systemic inflammation between COPD patients, smokers, and healthy never-smokers may suggest a possible link between smoking-driven, low-grade systemic inflammation, and the overall skin condition.

Comparison of two skin imaging analysis instruments: The VISIA® from Canfield vs the ANTERA 3D® CS from Miravex

BACKGROUND

The skin imaging analysis instruments are widely used to record and measure the surface and subsurface skin conditions. The main aim of this study is to reveal the differences and correlations in measuring wrinkle, skin texture, coloration/evenness, vascular features, and pore between two commercially available instruments.

METHODS

Twenty-eight subjects were enrolled in the study. A 2*2 cm cardboard was used to make sure the two instruments analyze the same area. Pictures were taken and analyzed by the VISIA^® from Canfield and the ANTERA 3D^® CS from Miravex, in sequence.

RESULTS

The spot, ultraviolet spot, brown spot, red area, texture values measured with VISIA^® were positively correlated with age, while the pore and wrinkle values showed no significance. The wrinkle, texture, melanin, hemoglobin, pore index, pore volume values measured with ANTERA 3D^® had a significantly positive correlation with age. The spot, brown spot values from VISIA^® were positively correlated with the melanin value from ANTERA 3D^® . Texture value measured with the two instruments revealed positive linear correlation. Strong correlation was found between the red area value from VISIA^® and the hemoglobin value from ANTERA 3D^® . Ultraviolet spot from VISIA^® showed no linear correlation with the melanin value from ANTERA 3D^® . Neither of the wrinkle and pore measured with the two instruments showed linear correlation.

CONCLUSIONS

ANTERA 3D^® relies on multidirectional illumination obtained by LEDs of different wavelengths from different directions which make it advanced at the qualitative evaluation of various dermatologic conditions. Compared with VISIA^® , ANTERA 3D^® is more sensitive in the assessment of wrinkle and it may also be available to evaluate the aging-related enlarged pore.

The skin aging exposome

The term "exposome" describes the totality of exposures to which an individual is subjected from conception to death. It includes both external and internal factors as well as the human body's response to these factors. Current exposome research aims to understand the effects all factors have on specific organs, yet today, the exposome of human skin has not received major attention and a corresponding definition is lacking. This review was compiled with the collaboration of European scientists, specialized in either environmental medicine or skin biology. A comprehensive review of the existing literature was performed using PubMed. The search was restricted to exposome factors and skin aging. Key review papers and all relevant, epidemiological, in vitro, ex vivo and clinical studies were analyzed to determine the key elements of the exposome influencing skin aging. Here we propose a definition of the skin aging exposome. It is based on a summary of the existing scientific evidence for the role of exposome factors in skin aging. We also identify future research needs which concern knowledge about the interaction of distinct exposomal factors with each other and the resulting net effects on skin aging and suggest some protective measures.

Cutaneous Effects of Smoking

Background:

Cigarette smoking is the single biggest preventable cause of death and disability in developed countries and is a significant public health concern. While known to be strongly associated with a number of cardiovascular and pulmonary diseases and cancers, smoking also leads to a variety of cutaneous manifestations.

Objective:

This article reviews the effects of cigarette smoking on the skin and its appendages.

Methods:

A literature review was based on a MEDLINE search (1966–2004) for English-language articles using the MeSH terms cutaneous, dermatology, tobacco, skin, and smoking. An additional search was subsequently undertaken for articles related to smoking and associated mucocutanous diseases, with the focus on pathogenesis and epidemiologic data. Articles presenting the highest level of evidence and latest reports were preferentially selected.

Results:

Smoking is strongly associated with numerous dermatologic conditions including poor wound healing, wrinkling and premature skin aging, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions. In addition, it has an impact on the skin lesions observed in diabetes, lupus, and AIDS. The evidence linking smoking and melanoma, eczema, and acne is inconclusive. Anecdotal data exist on the possible protective effects of smoking in oral/genital aphthosis of Behçet's disease, herpes labialis, pyoderma gangrenosum, acral melanoma, and Kaposi's sarcoma in AIDS patients.

Conclusions:

An appreciation of the adverse cutaneous consequences of smoking is important. Dermatologists can play an integral role in promoting smoking cessation by providing expert opinion and educating the public on the deleterious effects of smoking on the skin.

Multiple Roles for Elastic Fibers in the Skin

Dermal elastic fibers are believed to have a primary role in providing elastic stretch and recoil to the skin. Here we compare the structural arrangement of dermal elastic fibers of chick skin and different animal species. Most elastic fibers in chick skin are derived from cells that line the feather follicle and/or smooth muscle that connects the pterial and apterial muscle bundles to feather follicles. Elastic fibers in the dermis of animals with single, primary hair follicles are derived from cells lining the hair follicle or from the ends of the pili muscle, which anchors the muscle to the matrix or to the hair follicle. Each follicle is interconnected with elastic fibers. Follicles of animals with primary and secondary (wool) hair follicles are also interconnected by elastic fibers, yet only the elastic fibers derived from the primary follicle are connected to each primary follicle. Only the primary hair follicles are connected to the pili muscle. Human skin, but not the skin of other primates, is significantly different from other animals with respect to elastic fiber organization and probably cell of origin. The data suggest that the primary role for elastic fibers in animals, with the possible exception of humans, is movement and/or placement of feathers or hair.

Perception of Age, Attractiveness, and Tiredness After Isolated and Combined Facial Subunit Aging

BACKGROUND

Patients often seek help to redress aging that affects various regions of the face (subunits). The purpose of this study was to determine how aging of different facial subunits impacts perception of age, attractiveness, and tiredness.

METHOD

Frontal and lateral view facial photographs of a middle-aged woman were modified using imaging software to independently age different facial features. Sixty-six subjects were administered with a questionnaire, and presented with a baseline unmodified picture and others containing different individual or grouped aging of facial subunits. Test subjects were asked to estimate the age of the subject in the image and quantify (0-10 scale) how "tired" and "attractive" they appeared. Facial subunits were organized following rank assignment regarding impact on perception of age, attractiveness, and tiredness.

RESULTS

The correlation coefficient between age and attractiveness had a strong inverse relationship of approximately -0.95 in both lateral and frontal views. From most to least impact in age, the rank assignment for frontal view facial subunits was full facial aging, middle third, lower third, upper third, vertical lip rhytides, horizontal forehead rhytides, jowls, upper eyelid ptosis, loss of malar volume, lower lid fat herniation, deepening glabellar furrows, and deepening nasolabial folds. From most to least impact in age, the rank assignment for lateral view facial subunits was severe neck ptosis, jowls, moderate neck ptosis, vertical lip rhytides, crow's feet, lower lid fat herniation, loss of malar volume, and elongated earlobe.

CONCLUSION

This study provides a preliminary template for further research to determine which anatomical subunit will have the most substantial effect on an aged appearance, as well as on the perception of tiredness and attractiveness.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A new wrinkle on old skin: the role of elastic fibres in skin ageing

Cutaneous ageing is the result of two distinct, biological processes which may occur concurrently: (i) the passage of time, termed intrinsic ageing and (ii) environmental influences, termed extrinsic ageing. Intrinsic ageing of the skin is a slow process which causes changes in tissue structure and impairs function in the absence of additional biological, chemical and physical factors. The clinical features of intrinsically aged skin are not usually evident until old age when, although smooth and unblemished, the skin surface appears pale and is characterized by fine wrinkles with occasional exaggerated expression lines. Functionally, intrinsically aged skin is dry and less elastic than more youthful skin. In contrast, extrinsically aged skin is exemplified by deep, coarse wrinkles, mottled hyperpigmentation and a marked loss of elasticity and recoil. The two major environmental influences which induce extrinsic ageing are: (i) chronic exposure to solar ultraviolet (UV) irradiation (termed photoageing) and (ii) smoking. This review discusses the changes associated with the ageing process in the skin, with particular emphasis on the role played by the elastic fibre network in maintaining dermal function. The review concludes with a discussion of a short-term assay for independent assessment of the efficacy of anti-ageing cosmetic products using the elastic fibre component fibrillin-1 as a biomarker of extracellular matrix repair.

Smoking in relation to age in aesthetic facial surgery

BACKGROUND

Smoking is a major cause of premature facial aging. Skin aging in general, often accompanied by wrinkling and furrowing, plays a significant role in the decision to undergo aesthetic surgery. Smoking may therefore be related to the demand for cosmetic surgery. This study aimed to compare smoking habits with respect to a standard cosmetic procedure (blepharoplasty) in the general population and to evaluate whether the age at surgery differs between smokers and nonsmokers.

METHODS

A questionnaire was sent to 517 patients with valid reports describing dermatochalasis of the upper eyelid who subsequently underwent an upper-eyelid correction in 2004. Smoking habits, socioeconomic status, and medical history were evaluated. The patients were classified as smokers, ex-smokers with at least 1 year of smoking cessation, and never-smokers.

RESULTS

Of the 353 questionnaires (68.3 %) returned, 345 were eligible for statistical analysis. The smoking habits did not differ between the blepharoplasty group and the general population. However, the smokers underwent surgery an average of 3.7 years earlier than the ex-smokers (p=0.0007) and 3.5 years earlier than the never-smokers (p=0.006). No significant difference was observed between the ex-smokers and the never-smokers.

CONCLUSIONS

This is the first study to describe an association between smoking habits and an earlier need for upper-eyelid correction among ex- and never-smokers. The mechanism of skin restoration could result in a regenerative mechanism among ex-smokers, but further research is needed to support this hypothesis.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.

Cigarette Smoking and Facial Wrinkles: A Review of the Literature

Research studies indicate that smoking cigarettes is related to a premature development of facial wrinkles. Given that facial wrinkles may act as motivation for people to quit smoking, it is crucial that smoking cessation professionals be able to accurately inform clients about research concerning smoking and wrinkles. Therefore, the purpose of this article is to provide an updated overview of the literature which can be used by cessation clinicians as a practical reference on smoking and facial wrinkles. Databases were searched for peer-reviewed articles that study the association with smoking and wrinkles. In all, 17 articles were located and reviewed for research methods and results. Although facial wrinkles and smoking were measured inconsistently between studies, the overall literature indicates that those who smoke have a higher risk of developing premature facial wrinkles as compared to those who do not smoke. The implications of this review for smoking cessation professionals are described.

The determinants of periorbital skin ageing in participants of a melanoma case-control study in the U.K

BACKGROUND

Skin ageing is said to be caused by multiple factors. The relationship with sun exposure is of particular interest because the detrimental cutaneous effects of the sun may be a strong motivator to sun protection. We report a study of skin ageing in participants of an epidemiological study of melanoma.

OBJECTIVES

To determine the predictors of periorbital cutaneous ageing and whether it could be used as an objective marker of sun exposure.

METHODS

Photographs of the periorbital skin in 1341 participants were graded for wrinkles, degree of vascularity and blotchy pigmentation and the resultant data assessed in relation to reported sun exposure, sunscreen use, body mass index (BMI), smoking and the melanocortin 1 receptor (MC1R) gene status. Data were analysed using proportional odds regression.

RESULTS

Wrinkling was associated with age and heavy smoking. Use of higher sun-protection factor sunscreen was protective (P = 0·01). Age, male sex, MC1R variants ('r', P=0·01; 'R', P=0·02), higher reported daily sun exposure (P=0·02), increased BMI (P=0·01) and smoking (P=0·02) were risk factors for hypervascularity. Blotchy pigmentation was associated with age, male sex, higher education and higher weekday sun exposure (P=0·03). More frequent sunscreen use (P=0·02) and MC1R variants ('r', P=0·03; 'R', P=0·001) were protective.

CONCLUSIONS

Periorbital wrinkling is a poor biomarker of reported sun exposure. Vascularity is a better biomarker as is blotchy pigmentation, the latter in darker-skinned individuals. In summary, male sex, sun exposure, smoking, obesity and MC1R variants were associated with measures of cutaneous ageing. Sunscreen use showed some evidence of being protective.

Acne and smoking

BACKGROUND.: Post-adolescent acne is an inflammatory disorder, whose cause is unknown. Contrasting data are available on correlation between acne and smoking habit. OBJECTIVES.: To verify the frequency of clinically non-inflammatory (atypical) post-adolescent acne (APAA) among women, a possible correlation with cigarette smoking, possible differences in sebum composition in a group of female smokers with acne compared to healthy smokers and non-smokers. METHOD AND RESULTS.: 1046 randomly selected women (25-50-years-old) participated at the study. In 60 selected female subjects we analyzed sebum composition for alpha-tocopherol, squalene and squalene monohydroperoxide. We found a high prevalence of APAA among women (74.6%), a strong correlation with smoking habit (p < 0.0001), as well as an increase in the grade of sebum peroxidation (p < 0.05) with a reduction in vitamin E (p = 0.02), in the subjects with acne compared to the controls. CONCLUSIONS.: Clinical evidence and experimental data showed a straight correlation between smoking habit and post-pubertal acne in which the clinically non-inflammatory type-APAA-is the most frequent. In the more severe cases we could consider APAA as a new entity (smoker's acne).

The modified Fitzpatrick Wrinkle Scale: a clinical validated measurement tool for nasolabial wrinkle severity assessment

BACKGROUND

The number of existing wrinkle assessment scales makes it difficult to compare the efficacy of cosmetic techniques in rejuvenating photoaged skin. A single and simple assessment scale that reliably quantifies wrinkle depth is needed.

OBJECTIVE

The objective was to validate the Modified Fitzpatrick Wrinkle Scale (MFWS) as a nasolabial wrinkle severity assessment tool.

METHODS AND MATERIALS

The MFWS comprises three main classes, in which definitions are based on a set of reference photographs and descriptions, and three interclasses, in which definitions are based only on descriptions. Assessors were trained to apply this scale to volunteers and study patients by using photographs of nasolabial wrinkles either alone or with descriptions. Inter- and intraassessment reliability coefficients were calculated using weighted kappa statistics.

RESULTS

In patients, the combined intraassessor reliability from both sides of the face was 0.71 (95% confidence interval [CI], 0.68-0.74) when only photographs were used and 0.79 (95% CI, 0.76-0.82) when descriptions were added. Interassessor reliability for the photographs alone was 0.65 (95% CI, 0.62-0.68) and 0.74 (95% CI, 0.69-0.79) for photographs plus descriptions.

CONCLUSIONS

The MFWS is a reliable method for quantitative assessment of nasolabial skin folds, with good inter- and intraassessor reliability. Including descriptions with the photographs increased reliability.

Aging and induced senescence as factors in the pathogenesis of lung emphysema

Classically, the development of emphysema in chronic obstructive pulmonary disease is believed to involve inflammation induced by cigarette smoke and leukocyte activation, including oxidant-antioxidant and protease-antiprotease imbalances. While there is substantial evidence for this, additional aspects have been suggested by a number of clinical and experimental observations. Smokers exhibit signs of premature aging, particularly obvious in the skin. The link between aging and chronic disease is well-known, e.g., for the brain and musculoskeletal or cardiovascular system, as well as the clinical link between malnutrition and emphysema, and the experimental link to caloric restriction. Interestingly, this intervention also increases lifespan, in parallel with alterations in metabolism, oxidant burden and endocrine signaling. Of special interest is the observation that, even in the absence of an inflammatory environment, lung fibroblasts from patients with emphysema show persistent alterations, possibly based on epigenetic mechanisms. The importance of these mechanisms for cellular reprogramming and response patterns, individual risk profile and therapeutic options is becoming increasingly recognized. The same applies to cellular senescence. Recent findings from patients and experimental models open novel views into the arena of gene-environment interactions, including the role of systemic alterations, cellular stress, telomeres, CDK inhibitors such as p16, p21, pRb, PI3K, mTOR, FOXO transcription factors, histone modifications, and sirtuins. This article aims to outline this emerging picture and to stimulate the identification of challenging questions. Such insights also bear implications for the long-term course of the disease in relation to existing or future therapies and the exploration of potential lung regeneration.

Association between smoking and cutaneous ageing in a Brazilian population

OBJECTIVE

This study aims to determine the relationship between smoking and cutaneous ageing.

METHODS

A cross-sectional study was carried out on 301 subjects (191 women and 110 men, aged between 25 and 86 years), of which 165 were non-smokers and 136 were smokers and ex-smokers. The association between tabagism and cutaneous ageing was controlled for other variables (solar exposure, age, skin phototype, sex, sunscreen use, alcohol consumption, coffee consumption, sports participation, body mass index, and history of relatives with precocious ageing).

RESULTS

Analysis revealed that age, chronic solar exposure, skin phototype and tobacco load significantly contributed to the formation of facial wrinkles. The larger the tobacco load, the larger was the amount of facial wrinkling, with an odds ratio of 3.92 in 'heavy' smokers (> 40 packs/year) in relation to non-smokers.

CONCLUSION

The results of this study point to smoking as one of the main factors involved in facial wrinkling. The relationship between smoking and cutaneous ageing is an important element in educational campaigns against tabagism.

In contrast to lung fibroblasts--no signs of senescence in skin fibroblasts of patients with emphysema

Smoking is known to be linked to skin ageing and there is evidence for premature senescence of parenchymal lung fibroblasts in emphysema. To reveal whether the emphysema-related changes in cellular phenotype extend beyond the lung, we compared the proliferation characteristics of lung and skin fibroblasts between patients with and without emphysema. Parenchymal lung fibroblasts and skin fibroblasts from the upper torso (thus limiting sun exposure bias) were obtained from patients without, or with mild, or with moderate to severe emphysema undergoing lung surgery. We analysed proliferation rate, population doublings (PD), staining for senescence-associated beta-galactosidase (beta-gal) and gene expression of IGFBP-3 and IGFBP-rP1. Population doubling time of lung fibroblasts differed between control, mild, and moderate to severe emphysema (median (IQR) 29.7(10.0), 33.4(6.1), 44.4(21.2) h; p=0.012) and staining for beta-gal was elevated in moderate to severe emphysema. Compared to control subjects, skin fibroblasts from patients with emphysema did not differ with respect to proliferation rate, PD and beta-gal staining, and showed a lower abundance of mRNA for IGFBP-3 and -rP1 (p<0.05, each). These results suggest that the induction of a senescent fibroblast phenotype by cigarette smoke, as observed in emphysema, primarily occurs in the lung.

Effect of smoking on skin elastic fibres: morphometric and immunohistochemical analysis

BACKGROUND

It has been established during recent years that smoking is an independent risk factor for the development of premature facial wrinkling. The underlying mechanism is not well known, but elastic fibres of the dermis seem to be the major target of smoke components.

OBJECTIVES

To determine quantitative and qualitative changes of the dermal elastic tissue of non-sun-exposed skin induced by smoking, as well as the possible mechanisms responsible for them.

METHODS

Sixty-nine patients were recruited (20 nonsmokers, 19 former smokers and 30 smokers). Using static morphometry and immunohistochemistry and lectin staining we analysed elastic fibres of the dermis and their major components, elastin and microfibrillar component.

RESULTS

Significantly higher values for the number of elastic fibres mm(-2) and the percentage of the area filled by them in the reticular dermis were found in smokers. Cumulative tobacco dose showed statistically significant correlations with both morphological parameters (Spearman's rank correlation coefficient). Immunohistochemistry demonstrated that the two main components of elastic fibres were altered in smokers. Plasma protease inhibitors and lectin staining were negative in all the samples.

CONCLUSIONS

Smoking is an independent risk factor for the increase of elastic fibres in the reticular dermis of nonexposed skin, and it acts on their two main structural components, elastin and microfibrillar component. This increase in the area of elastic fibres in smokers is not due to newly synthesized elastic material, but to their degradation, as occurs in solar elastosis and which acts in an additive manner.

Smoking related COPD and facial wrinkling: is there a common susceptibility?

BACKGROUND

Cigarette smoking causes accelerated facial wrinkling and predisposes to chronic obstructive pulmonary disease (COPD). However, it has long been recognised that there is a subgroup of susceptible smokers who are at increased risk of developing airflow obstruction. We have tested the hypothesis that there is a common susceptibility for the development of COPD and facial wrinkling in cigarette smokers.

METHODS

One hundred and forty nine current and ex-smokers were recruited from a family based study of COPD genetics, 68 (45.6%) of whom fulfilled the definition of COPD. 124 (83.2%) had no or minor facial wrinkling (Daniell <IV) and 25 (16.8%) were wrinkled (Daniell score >/=IV). Generalised estimating equations were used to adjust for familial correlations between related individuals and the potential confounding effects of age and pack years smoked.

RESULTS

Forced expiratory volume in 1 second (FEV(1)) was significantly lower in those with wrinkles than in those without (mean difference in FEV(1) % predicted -13.7%, 95% CI -27.5 to 0.0, p = 0.05) and facial wrinkling was associated with a substantially increased risk of COPD (adjusted OR 5.0, 95% CI 1.3 to 18.5, p<0.02). The Daniell score correlated with the extent of emphysema on the CT scan (p<0.05) and facial wrinkling was also associated with a greater risk of more extensive emphysema (adjusted OR 3.0, 95% CI 1.0 to 9.3, p = 0.05).

CONCLUSION

Facial wrinkling is associated with COPD in smokers, and both disease processes may share a common susceptibility. Facial wrinkling in smokers may therefore be a biomarker of susceptibility to COPD.

Facial assessments: identifying the suitable pathway to facial rejuvenation

OBJECTIVES

There are now numerous ways in which a patient can rejuvenate their facial appearance, including various types of expensive, invasive, surgical procedures, and an ever increasing gamut of products that can be inserted or injected beneath the skin to restore a youthful look to the face. The importance of facial assessments in identifying the most suitable treatment option is discussed here.

RESULTS

Before a patient commits to any one of these corrective options, it is the responsibility of the physician to conduct a thorough assessment of the patient's face. All of the facial characteristics should be examined closely: underlying bone and musculature, shape, proportion, and features including folds, wrinkles, fine lines, volume deficits and changes in pigmentation. The degree of ptosis in the facial tissues should be assessed by light palpation. Following assessment of the face, digital photographs should be taken of the patient's full face and profile, allowing the physician to indicate areas, on a visual display, that need correction and there are now computer programs which can 'morph' the features of a facial photograph, providing an approximation of the post-treatment result. Shape and proportion are neglected facets in the assessment of the face prior to corrective treatment. A treatment or technique which rejuvenates a 'thin' face may not work so successfully on a 'round' face and vice versa. Most importantly, the physician should aim to understand the patient's objective and subjective perceptions of their face and ascertain the results that are desired by the patient before evaluating what can be achieved. Appropriate corrective options can then be discussed in detail, highlighting the risks, side effects, costs, invasiveness, logistics and anticipated outcomes of each.

CONCLUSION

A comprehensive assessment of the patient's face allows the physician to formulate a regimen of treatments that will reach or exceed the expectations of the patient.

The impact of body weight on smoking cessation in German adults

OBJECTIVE

To assess the relevance of pre-existing body weight for successful smoking cessation among women and men.

METHODS

We carried out a retrospective cohort analysis among 4270 ever smoking participants of a general health screening examination in Germany recruited from July 2000 to June 2002 aged 50 to 74, who provided lifetime histories of both body weight and smoking.

RESULTS

In the extended Cox model, the relative cessation rate (RCR) increased significantly with increasing body mass index (BMI) among both genders (test for trend: P < 0.01 for women and P < 0.0001 for men). In women, this effect was mainly due to a lower cessation rate in low-weight (BMI <20) smokers (adjusted RCR = 0.76, 95% confidence interval (CI) 0.62-0.95), whereas in men, the effect was mainly due to a higher cessation rate among overweight and obese smokers (adjusted RCR = 1.26, 95% CI 1.11-1.35, and 1.38, 95% CI 1.17-1.63, respectively) compared to normal-weight smokers.

CONCLUSIONS

While in men, overweight and obesity are associated with increased smoking cessation, possibly related to increased health concerns, in women, low weight is associated with decreased smoking cessation, possibly related to increased fear of weight gain.

Relationships between lung function, smoking and morphology of dermal elastic fibres

OBJECTIVE

To investigate the relationship between lung function and dermal elastic fibres in non-smokers and smokers with and without chronic obstructive pulmonary disease (COPD).

METHOD

A cross-sectional study was performed with lung function as the outcome [forced expiratory volume in the first second (FEV1)%, FEV1/forced vital capacity (FVC)% and residual volume (RV)/total lung capacity (TLC)%] and smoking (pack-years) and morphology of dermal elastic fibres (fibres/mm(2) and percentage histologic field filled with them) as independent variables, with assessment of the associations between these variables by univariate and multivariate testing.

RESULTS

Sixty outpatients reporting chronic cough and/or phle\gm were enrolled (16 non-smokers/44 smokers; COPD: 26, 43.3%). Both lung function and elastic fibres in the reticular dermis (fibres/mm(2)r(s) = 0.36, percentage of the histologic field filled by elastic fibres r(s) = 0.48, P < or = 0.01) correlated with cumulative smoking (Spearman's rank correlation coefficient). Lung function parameters correlated with percentage of the histologic field filled by elastic fibres (FEV1%: r = -0.43; FEV1/FVC%: r = -0.36 and RV/TLC%: r = 0.43; P < or = 0.01, Pearson correlation coefficient), and COPD was significantly related to this morphologic parameter (odds ratio 1.26, 95% confidence interval 1.06-1.48; P = 0.006), associations that depended mainly on cumulative smoking.

CONCLUSION

Lung function impairment with an obstructive pattern is associated with morphologic abnormalities in the reticular dermis appearing in the histologic section as an increase in the percentage of the field filled by elastic fibres. This relationship depends on cumulative smoking and suggests a common effect of smoking on the elastic fibres in both lung and skin.

Cutaneous Effects of Smoking

BACKGROUND

Cigarette smoking is the single biggest preventable cause of death and disability in developed countries and is a significant public health concern. While known to be strongly associated with a number of cardiovascular and pulmonary diseases and cancers, smoking also leads to a variety of cutaneous manifestations.

OBJECTIVE

This article reviews the effects of cigarette smoking on the skin and its appendages.

METHODS

A literature review was based on a MEDLINE search (1966-2004) for English-language articles using the MeSH terms cutaneous, dermatology, tobacco, skin, and smoking. An additional search was subsequently undertaken for articles related to smoking and associated mucocutanous diseases, with the focus on pathogenesis and epidemiologic data. Articles presenting the highest level of evidence and latest reports were preferentially selected.

RESULTS

Smoking is strongly associated with numerous dermatologic conditions including poor wound healing, wrinkling and premature skin aging, squamous cell carcinoma, psoriasis, hidradenitis suppurativa, hair loss, oral cancers, and other oral conditions. In addition, it has an impact on the skin lesions observed in diabetes, lupus, and AIDS. The evidence linking smoking and melanoma, eczema, and acne is inconclusive. Anecdotal data exist on the possible protective effects of smoking in oral/genital aphthosis of Behçet's disease, herpes labialis, pyoderma gangrenosum, acral melanoma, and Kaposi's sarcoma in AIDS patients.

CONCLUSIONS

An appreciation of the adverse cutaneous consequences of smoking is important. Dermatologists can play an integral role in promoting smoking cessation by providing expert opinion and educating the public on the deleterious effects of smoking on the skin.

Identification of Benzene Metabolites in Dermal Fibroblasts as Nonphenolic: Regulation of Cell Viability, Apoptosis, Lipid Peroxidation and Expression of Matrix Metalloproteinase 1 and Elastin by Benzene Metabolites

The skin is exposed to benzene and its derivatives, prevalent environmental chemicals. They may impair the structural integrity of the skin by increased expression of matrix metalloproteinase 1 (MMP-1; degrades structural collagen) and elastin, synthesized primarily by the dermal fibroblasts. We examined the metabolism of benzene in dermal fibroblasts and identified the benzene metabolites as toluene, benzaldehyde, aniline and benzoic acid. These metabolites were not toxic to the cells with regard to cell viability, apoptosis and lipid peroxidation, unlike the phenolic benzene metabolites (hydroquinone, t-butyl hydroquinone and phenol) or hydrogen peroxide. Toluene and phenol, which compose cigarette smoke, and benzaldehyde stimulated MMP-1 and/or elastin expression. In summary, the dermal fibroblasts metabolize benzene to nonphenolic metabolites that are less toxic to the cellular components than the phenolic benzene derivatives. Toluene, benzaldehyde and phenol can directly cause facial wrinkling and impaired structural integrity by upregulating MMP-1 and/or elastin.

Skin ageing and wrinkles: clinical and photographic scoring

Sunlight induces clinical, histological and physiological changes in the skin that are known as photoageing. As the population ages, prevention and treatment of photoageing is a growing challenge because of its association with skin cancer as well as for cosmetic reasons. Therefore, it is of interest to assess the degrees of photoageing by developing valid and comprehensive grading systems. Several different methods have been proposed. These include descriptive grading scales, visual analogue scales and photographic grading scales. The merits and inconveniences of these different approaches are discussed.