Photoaging and cosmeceutical solutions in sun-overexposed countries: The experience of Australia and Brazil

Skin aging is the result of physiological changes determined by genetically driven processes and intrinsic factors, and exacerbated by a combination of multiple environmental factors, the main one being sun exposure. The effects of photoaging are particularly apparent on the face, where the appearance of aging signs can have a significant impact on the emotions conveyed and well-being. Photoprotection and facial skin care for managing photoaging signs are thus of particular importance for both physical and mental health. Countries, like Australia and Brazil, where the level of sun exposure is high and the populations have predominantly outdoor lifestyles, are particularly aware of the harms of photoaging and have implemented several measures to help reduce the risk of skin cancer in their populations. However, sun-seeking behaviours are difficult to change, and it takes time before interventions provide perceptible results. Australia still has some of the highest skin cancer incidence and mortality rates in the world. Solutions that target individuals can also be used for minimizing the clinical signs of facial aging and for improving skin quality, with the ultimate aim being not only to improve the appearance of the skin but also to mitigate the occurrence of pre-malignant and malignant lesions. This review summarizes the features of facial skin photoaging in photo-exposed populations, based on evidence gained from studies of Australian individuals, and discusses the various available solutions for skin photoaging, in particular those that are most popular in Brazil, which is a country with many years of experience in managing photoaged skin.

Antioxidants in Photoaging: From Molecular Insights to Clinical Applications

Photoaging (PA) is considered a silent disease affecting millions of people globally and is defined as skin damage due to prolonged exposure to ultraviolet radiation (UVR) from the sun. Physiologically, the skin is in a state of renewal and synthesis of components of the extracellular matrix (ECM). However, exposure to UVR affects the production of the ECM, and the functioning and response of skin cells to UVR begins to change, thus expressing clinical and phenotypic characteristics of PA. The primary mechanisms involved in PA are direct damage to the DNA of skin cells, increases in oxidative stress, the activation of cell signaling pathways responsible for the loss of skin integrity, and cytotoxicity. The medical and scientific community has been researching new therapeutic tools that counteract PA, considering that the damage caused by UVR exceeds the antioxidant defense mechanisms of the skin. Thus, in recent years, certain nutraceuticals and phytochemicals have been found to exhibit potential antioxidant and photoprotective effects. Therefore, the main objective of this review is to elucidate the molecular bases of PA and the latest pharmaceutical industry findings on antioxidant treatment against the progression of PA.

Molecular basis of skin photoaging and therapeutic interventions by plant-derived natural product ingredients: A comprehensive review

Skin areas exposed to ultraviolet radiation (UV) from sunlight are more prone to photoaging than unexposed areas evidenced by several signs which include skin dryness, irregular pigmentation, lentigines, hyperpigmentation, wrinkling, and decreased elasticity. Plant-based natural product ingredients with therapeutic potential against skin photoaging are gaining more attention. This article aims the reviewing the research work done in exploring the cellular and molecular mechanisms involved in UV-induced skin photoaging, followed by summarizing the mechanistic insights involved in its therapeutics by natural product-based ingredients. In the mechanistic section of the convoluted procedure of photoaging, we described the effect of UV radiation (UVR) on different cellular macromolecules (direct damage) and subsequently, the deleterious consequences of UVR-generated reactive oxygen species (indirect damage) and signaling pathways activated or inhibited by UV induced ROS generation in various cellular pathologies of skin photoaging like inflammation, extracellular matrix degradation, apoptosis, mitochondrial dysfunction, and immune suppression. We also discussed the effect of UV radiation on the adipose tissue, and transient receptor potential cation channel V of photoaging skin. In the past few decades, mechanistic studies performed in this area have deciphered various therapeutic targets, opening avenues for different available therapeutic options against this pathological condition. So the remaining portion of the review deals with various natural product-based therapeutic agents available against skin photodamage.

A Subjective and Objective Assessment of Combined Methods of Applying Chemical Peels and Microneedling in Antiaging Treatments

Combined methods of applying chemical peels and antioxidants could be an option for skin rejuvenation with no down-time. The penetration of active substances can be enhanced by microneedle mesotherapy. The study was conducted on a group of 20 female volunteers, aged 40-65 years. All volunteers received a series of eight treatments performed every seven days. The whole face was first treated with azelaic acid; following this, the right side received a 40% solution of vitamin C and the left side 10% vitamin C with microneedling. Hydration and skin elasticity were markedly improved, with better results observed on the microneedling side. Melanin and erythema index decreased. No significant side effects were seen. The combination of active ingredients and delivery techniques have great potential to enhance the effectiveness of cosmetic preparations, probably by multidirectional ways of action. In our study, we demonstrated that both 20% azelaic acid + 40% vitamin C treatment and 20% azelaic acid + 10% vitamin C + microneedle mesotherapy efficiently improved the assessed parameters of aging skin. However, the use of microneedling mesotherapy as a means of direct delivery of active compound to the dermis enhanced the effectiveness of the studied preparation.

Epidemiological survey of the quantity and anatomical position of facial pigmented spots in relation to age in 454 Japanese women

Facial pigmented spots are one of the phenotypes of skin aging, but no quantitative analysis of spot features such as color intensity, size, anatomical position, and number on the cheek has yet been performed. In the current study, we conducted an epidemiological survey of 454 Japanese women in their 20s to 70s and analyzed age-related changes and site differences of facial pigmented spots. Using image analysis of high-resolution digital facial photographs, 4912 individual pigmented spots were quantified according to color, size, anatomical position, and total number on the cheek. As a result of color analysis, the color intensity of individual pigmented spots increased with aging, significantly so between ages 30s and 50s. The age-related increase in melanin index of facial spots was confirmed in all sites but did not significantly differ between facial subregions. Regarding the size of pigmented spots, the frequency of large spots increased with age, and large spots were detected in all facial sites. The total number of pigmented spots on the entire cheek increased with aging, significantly so between the 20s and 40s. The number of pigmented spots tended to increase from the region near the canthi to the lower cheeks. The number of spots was markedly increased in the buccal regions compared with the infraorbital and zygomatic regions. The data and methodology presented in the current study can link the state of facial pigmentation with the various factors involved in the histological development of pigmented spots, opening new possibilities in the fields of skin pharmacology and dermatology.

The effect of on-site application density on the UV protection efficacy of sunscreens

BACKGROUND

Sun protection factor (SPF) and UVA protection factor (UVAPF) are performance indicators consumers recognize for UV protective cosmetics such as sunscreens. However, on-site application density affects actual UV protection, despite these indicators. To understand actual UV protection better, a more reliable manner is needed to verify application density for further discussion of photoprotection efficacy regarding public health.

OBJECTIVES

To estimate the UV protective efficacy of sunscreen in actual use based on the application density of UV protective cosmetics and the analysis of UV protective effect modulated by application density.

METHOD

The subjects applied the SPF-labeled sunscreens as usual. We measured the application amount and area including any amount on their hands to calculate the average application density on the face. Also, sunscreens were applied at densities of 0.5, 1.0, and 2.0 mg/cm² . The SPF values were measured at each application site to evaluate the effect of application density on photoprotection efficacy.

RESULT

We established a method of measuring application density utilizing three-dimensional photograph analysis. The median application density of the sunscreen applied in actual use was 1.33 mg/cm² . The measured SPF values decreased in association with the decreased application density of sunscreens. Based on the estimate assuming the first-order correlation, the SPF value required to get the protective effect equivalent to a sunscreen with SPF 15, 30, or 50 at 2 mg/cm² was calculated to be 23.8, 47.5, and 79.2, respectively, with the application density of 1.33 mg/cm² .

CONCLUSION

We demonstrated a reasonable procedure for estimating the photoprotection efficacy of sunscreens on the face. A suggestion was made to consider the application density for further discussion of photoprotection among consumers, especially for the long term with respect to public health.

Managing Skin Ageing as a Modifiable Disorder—The Clinical Application of Nourella® Dual Approach Comprising a Nano-Encapsulated Retinoid, Retilex-A® and a Skin Proteoglycan Replacement Therapy, Vercilex®

Skin ageing is a progressive, but modifiable, multi-factorial disorder that involves all the skin’s tissues. Due to its wide range of physiological and psychosocial complications, skin ageing requires rigorous clinical attention. In this review, we aim to encourage clinicians to consider skin ageing as a disorder and suggest a novel, dual approach to its clinical treatment. Topical retinoids and per-oral proteoglycans are promising, non-invasive, therapeutic modalities. To overcome the low bioavailability of conventional free retinoids, Nourella® cream with Retilex-A® (Pharma Medico, Aarhus, Denmark) was developed using a proprietary nano-encapsulation technology. The nano-encapsulation is a sophisticated ‘permeation/penetration enhancer’ that optimises topical drug delivery by increasing the surface availability and net absorption ratio. Treatment adherence is also improved by minimising skin irritation. Interventional evidence suggests the greater efficacy of Retilex-A® in improving skin thickness and elasticity compared with conventional free forms. It is also reported that the rejuvenating efficacy of Retilex-A® and tretinoin are comparable. Another skin anti-ageing approach is proteoglycan replacement therapy (PRT) with Vercilex®. Vercilex® in Nourella® tablet form has the potential to ameliorate proteoglycan dysmetabolism in aged skin by activating skin cells and improving collagen/elastin turnover. Replicated clinical trials evidenced that PRT can significantly enhance the density, elasticity and thickness of both intrinsically aged and photoaged skin. Evidently, Vercilex® and Retilex-A® share a range of bioactivities that underlie their synergistic activity, as observed in a clinical trial. Dual therapy with Nourella® tablets and cream produced greater effects on skin characteristics than monotherapy with each of the two treatments. In conclusion, Nourella® cream and tablets are safe and effective treatments for skin ageing; however, combining the two in a ‘dual skin rejuvenation system’ significantly improves treatment outcomes.

Skin aging risk factors: A nationwide population study in Mongolia risk factors of skin aging

The world population is aging and no country is immune to the consequences. We are not aware of any country-specific skin aging risk factors data for the Mongolian people. Thus, we aimed to study the risk factors associated with skin aging in the Mongolian population. A population-based cross-sectional study of 2720 study participants 18 years of age and older was performed evaluating the severity of skin aging based on cutaneous microtopography. Questionnaire data and skin physiological measurements were obtained. The odds ratios for skin aging grades associated with risk factors were estimated using ordinal logistic regression. Study participant’s mean age was 45 years, ranging from 18 to 87. After adjustment for known risk factors, skin aging was associated with demographic risk factors such as increasing age (aOR = 1.19, 95% CI 1.18–1.20), living in an urban area (aOR = 1.31, 95% CI 1.12–1.55) and lifestyle factors including being a smoker (aOR = 1.32, 95% CI 1.09–1.61), having a higher body mass index (aOR = 1.04, 95% CI 1.02–1.06) and higher levels of sun exposure time (aOR = 1.03, 95% CI 1.00–1.06) were significantly associated with higher skin aging grades. Having dry (aOR = 1.94, 95% CI 1.45–2.59) and combination skin (aOR = 1.62, 95% CI 1.22–2.16) types were also independent risk factors associated with skin aging. Having very low skin surface moisture at the T-zone (aOR = 2.10, 95% CI 1.42–3.11) was significantly related to skin aging. Older age, urban living and toxic working conditions were independent demographic risk factors related to skin aging. Smoking, higher BMI, greater levels of sun exposure were significant lifestyle risk factors. Having a skin type other than normal was a physiologic risk factor for skin aging.

Defining skin aging and its risk factors: a systematic review and meta-analysis

Skin aging has been defined to encompass both intrinsic and extrinsic aging, with extrinsic aging effected by environmental influences and overlaying the effects of chronological aging. The risk factors of skin aging have been studied previously, using methods of quantifying skin aging. However, these studies have yet to be reviewed. To better understand skin aging risk factors and collate the available data, we aimed to conduct a systematic review and meta-analysis. We conducted our systematic review in compliance with Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guidelines. Embase, PubMed and Web of Science databases were searched in October 2020 using specific search strategies. Where odds ratios were reported, meta-analyses were conducted using the random effects model. Otherwise, significant factors were reported in this review. We identified seven notable risk factors for various skin aging phenotypes: age, gender, ethnicity, air pollution, nutrition, smoking, sun exposure. This review's results will guide future works, such as those aiming to examine the interaction between genetic and environmental influences.

Subbrow Blepharoplasty in Caucasians

SUMMARY

Subbrow blepharoplasty is widely used in Asian patient populations to preserve the natural upper lid crease while addressing dermatochalasis with lateral hooding. The authors describe the first use of this technique in Caucasians with dermatochalasis and lateral hooding. This is a retrospective case series of Caucasian patients who underwent subbrow blepharoplasty for moderate to severe dermatochalasis with lateral hooding. Patients were included when the skin excess of the upper lid was noted predominantly as a lateral hooding over the lateral half of the upper lid. A modified subbrow blepharoplasty technique was used and will be described in detail. Fifty patients underwent the procedure from January of 2017 to June of 2018, 18 female and 32 male patients. The average age of the patients was 71.4 years (range, 59 to 84 years). Minimum patient follow-up was 3 months. An internal browpexy and a periosteal fixation were combined with subbrow blepharoplasty for 22 patients (14 men and eight women). Patient satisfaction with the result of the procedure and incision line were assessed. All 50 patients were satisfied with the surgical results. No patients noted any issues with the incision. No patients complained of incision problems, but the surgeon noted two patients with redness in the scar at 3 months that improved over a 12-month follow-up. Subbrow blepharoplasty may be an alternative to the classic upper lid blepharoplasty in older Caucasian patients, as it can address moderate to severe dermatochalasis with lateral hooding.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

High variability in anatomic patterns of cutaneous photodamage: a population-based study

BACKGROUND

Skin cancer is strongly associated with photodamaged skin, but body sites are often referred to as 'exposed' or 'unexposed' to sun without recognizing extent of site-specific variation.

OBJECTIVES

To assess whole-body patterns of photodamage in an Australian population.

METHODS

A random sample of adult residents of Queensland underwent imaging across 10 body sites. Photodamage was graded from images using an ordinal photonumeric scale. We used cluster analysis to identify whole-body photodamage patterns and prevalence proportion ratios (PPRs) to assess associated factors.

RESULTS

Of 190 adults (median age 52; 58% males), 58% showed severe or moderate-to-severe photodamage on most body sites. A higher proportion of woman had severe photodamage on the arms (upper: P = 0.002, lower: P = 0.034). A higher proportion of men had moderate or severe photodamage on the lower back (P = 0.004). We identified four photodamage patterns: 'severe general' (n = 24, 13%), 'moderate-severe general' (n = 86, 45%), 'moderate-severe v-neck' (n = 40, 21%) and 'mild-moderate upper body' (n = 12, 6%). All participants with 'severe-general' photodamage were >50 years and more likely to have past skin cancer (PPR: 2.54, 95% CI: 1.44-4.49) than those with 'moderate-severe v-neck' photodamage. Those with 'moderate-severe general' photodamage showed similar associations and were more likely female (PPR: 1.33, 95% CI: 1.04-1.69). Past or current smoking was associated with having higher levels of photodamage, with no smokers in those with 'mild-moderate upper body' photodamage.

CONCLUSIONS

Moderate-to-severe photodamage across much of the body is common in Queensland adults and associated with age, sex, past skin cancer and smoking. Assuming a universal pattern of site-specific sun exposure could lead to spurious correlations, while accurate and objective assessment of site-specific photodamage can add to understanding of the development of sun-associated skin cancers, in particular site-specific skin carcinogenesis. Additionally, degree of site-specific photodamage has the potential to assist skin cancer screening.

Genetics of facial telangiectasia in the Rotterdam Study: a genome-wide association study and candidate gene approach

BACKGROUND

The severity of facial telangiectasia or red veins is associated with many lifestyle factors. However, the genetic predisposition remains unclear.

OBJECTIVES

We performed a genome-wide association study (GWAS) on facial telangiectasia in the Rotterdam Study (RS) and tested for replication in two independent cohorts. Additionally, a candidate gene approach with known pigmentation genes was performed.

METHODS

Facial telangiectasia were extracted from standardized facial photographs (collected from 2010-2013) of 2842 northwestern European participants (median age 66.9, 56.8% female) from the RS. Our GWAS top hits (P-value <10^-6 ) were tested for replication in 460 elderly women of the SALIA cohort and in 576 additional men and women of the RS. Associations of top single nucleotide polymorphisms (SNPs) with expression quantitative trait loci (eQTL) in various tissues were reviewed (GTEx database) alongside phenotype associations in the UK biobank database. SNP-based associations between known pigmentation genes and facial telangiectasia were tested. Conditional analysis on skin colour was additionally performed.

RESULTS

Our most significant GWAS signal was rs4417318 (P-value 5.38*10^-7 ), an intergenic SNP on chromosome 12 mapping to the SLC16A7 gene. Other suggestive SNPs tagged genes ZNF211, ZSCAN4, ICOS and KCNN3; SNP eQTLs and phenotype associations tagged links to the vascular system. However, the top signals did not pass significance in the two replication cohorts. The pigmentation genes KIAA0930, SLCA45A2 and MC1R, were significantly associated with telangiectasia in a candidate gene approach but not independently of skin colour.

CONCLUSION

In this GWAS on telangiectasia in a northwestern European population, no genome-wide significant SNPs were found, although suggestive signals indicate genes involved in the vascular system might be involved in telangiectasia. Significantly associated pigmentation genes underline the link between skin colour and telangiectasia.

The systemic influence of chronic smoking on skin structure and mechanical function

One of the major functions of human skin is to provide protection from the environment. Although we cannot entirely avoid, for example, sun exposure, it is likely that exposure to other environmental factors could affect cutaneous function. A number of studies have identified smoking as one such factor that leads to both facial wrinkle formation and a decline in skin function. In addition to the direct physical effects of tobacco smoke on skin, its inhalation has additional profound systemic effects for the smoker. The adverse effects on the respiratory and cardiovascular systems from smoking are well known. Central to the pathological changes associated with smoking is the elastic fibre, a key component of the extracellular matrices of lungs. In this study we examined the systemic effect of chronic smoking (>40 cigarettes/day; >5 years) on the histology of the cutaneous elastic fibre system, the nanostructure and mechanics of one of its key components, the fibrillin-rich microfibril, and the micromechanical stiffness of the dermis and epidermis. We show that photoprotected skin of chronic smokers exhibits significant remodelling of the elastic fibre network (both elastin and fibrillin-rich microfibrils) as compared to the skin of age- and sex-matched non-smokers. This remodelling is not associated with increased gelatinase activity (as identified by in situ zymography). Histological remodelling is accompanied by significant ultrastructural changes to extracted fibrillin-rich microfibrils. Finally, using scanning acoustic microscopy, we demonstrated that chronic smoking significantly increases the stiffness of both the dermis and the epidermis. Taken together, these data suggest an unappreciated systemic effect of chronic inhalation of tobacco smoke on the cutaneous elastic fibre network. Such changes may in part underlie the skin wrinkling and loss of skin elasticity associated with smoking. © 2020 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

Galactose-Induced Skin Aging: The Role of Oxidative Stress

Skin aging has been associated with a higher dietary intake of carbohydrates, particularly glucose and galactose. In fact, the carbohydrates are capable of damaging the skin's vital components through nonenzymatic glycation, the covalent attachment of sugar to a protein, and subsequent production of advanced glycation end products (AGEs). This review is focused on the role of D-galactose in the development of skin aging and its relation to oxidative stress. The interest in this problem was dictated by recent findings that used in vitro and in vivo models. The review highlights the recent advances in the underlying molecular mechanisms of D-galactose-mediated cell senescence and cytotoxicity. We have also proposed the possible impact of galactosemia on skin aging and its clinical relevance. The understanding of molecular mechanisms of skin aging mediated by D-galactose can help dermatologists optimize methods for prevention and treatment of skin senescence and aging-related skin diseases.

Quantitative evaluation of rejuvenation treatment of nasolabial fold wrinkles by regression model and 3D photography

OBJECTIVE

With the application of 3D photography, our study aimed to quantify parameters of static nasolabial fold wrinkles and establish mathematic regression model between parameters of wrinkles and age, further to quantitatively evaluate the effect of rejuvenation treatment in terms of age.

METHODS

From October 2016 to May 2018, 433 Chinese female volunteers, aged 25-60 years old, were enrolled in this study. Antera 3D camera was used to collect four parameters of static nasolabial fold wrinkles on the left and right sides of the volunteers, including overall size, average depth (mm), average width (mm), and maximum depth (mm). For those presented a linear relationship with age, univariate linear regression fitting was performed, followed by residual analysis, goodness of fit test, and significance test.

RESULTS

The results of univariate linear regression fitting showed there was a clear linear relationship between the maximum depth, average depth, overall size of nasolabial fold wrinkles and age, and the regression equations were established. The significance test of regression coefficients showed P values were less than .0001.

CONCLUSIONS

With application of the regression model between parameters of nasolabial fold wrinkles and age, the effect of rejuvenation treatment can be quantitatively evaluated in terms of age, which has certain reference and promotion value.

Atrophic and hypertrophic photoaging: Clinical, histologic, and molecular features of 2 distinct phenotypes of photoaged skin

BACKGROUND

Exposure to the sun causes premature skin aging, known as photoaging. Clinical features of photoaging vary widely among individuals. In one form, skin appears thin with telangiectasia, and in another form, skin appears thickened with coarse wrinkles. Etiologic, clinical, and therapeutic distinctions among different forms of photoaging remain largely unknown.

OBJECTIVE

To characterize the clinical, histologic, and molecular features of hypertrophic and atrophic photoaging.

METHODS

In total, 53 individuals were clinically classified as having primarily atrophic or hypertrophic photoaging or neither (controls). Participants' demographic and sun exposure-related lifestyle data were captured by questionnaire. Fifteen clinical features of participants were qualitatively or quantitively scored. Facial biopsies were analyzed for gene expression and histologic characteristics.

RESULTS

Actinic and seborrheic keratosis, telangiectasia, and prior incidence of skin cancers were statistically significantly greater and photoaging scale severity, coarse wrinkles, thickness, and sallowness were significantly reduced in atrophic versus hypertrophic groups. Histology also revealed significantly less elastotic material in atrophic photoaging. Gene expression of matrix metalloproteinases and collagens did not differ between the 2 forms of photoaging.

LIMITATIONS

The study was not designed to identify other possible subtypes of photoaging.

CONCLUSION

Systematic, categorical, and quantitative clinical and histologic assessments distinguish atrophic and hypertrophic photoaging.

Photoaging and actinic keratosis in Danish outdoor and indoor workers

BACKGROUND

The risk of photoaging and actinic keratosis caused by work related solar ultraviolet radiation exposure has not previously been investigated in Nordic countries. The objectives of this study were to describe the occurrence of photoaging, actinic keratosis, and keratinocyte cancer in a population of Danish outdoor and indoor workers, and investigate the association between these clinical findings and semi-objective measures of work related solar ultraviolet radiation exposure in the same population.

METHODS

A clinical cross-sectional study of the occurrence of facial wrinkles, actinic keratosis, keratinocyte cancer, and melanocytic nevi in a population of Danish outdoor and indoor workers and associations with semi-objective measures of work related solar ultraviolet radiation exposure based on a combination of dosimetry and self-report.

RESULTS

Work related solar ultraviolet radiation exposure was significantly positively associated with occurrence of facial wrinkles (α = 0.05). Actinic keratosis was associated to status as outdoor worker (OR = 4.272, CI [1.045-17.471]) and age (P < 0.001, CI [1.077-1.262]) and twice as common in outdoor workers (10.3% CI [0.05, 0.15]) compared to indoor workers (5.1% CI [0.00, 0.10]). Only two cases of keratinocyte cancer were diagnosed (<1%). Older age was negatively associated with occurrence of melanocytic nevi.

CONCLUSION

Outdoor work in Denmark is associated with increased occurrence of facial wrinkles and actinic keratosis from solar ultraviolet radiation exposure, thus justifying sun safety at Danish workplaces from a clinical perspective.

The effects of amniotic membrane stem cell-conditioned medium on photoaging

Background: Photoaging is a complex biologic process that affects various layers of the skin with the major damage seen in the connective tissue of the dermis. Although rarely fatal, photoaging can significantly contribute to a loss of quality of life; therefore, it deserves attention. Researchers are continually searching for new compounds to develop rejuvenation therapies. Nowadays, the stem cell population has been discovered, and it shows capability to rejuvenate the skin. Material and methods: This was an analytic experimental research conducted on a total of 48 women who were randomized into two groups: 24 women received amniotic membrane stem cell-conditioned medium (AMSC-CM) and the other 24 women received normal saline (NS). We applied the drug for three times with an interval of 2 weeks. Microneedling was used to enhance epidermal penetration. We evaluated the progression of photoaging on Weeks 0, 4, and 8, as well as the side effects. Results: The improvement in photoaging after treatment showed significant better effects with the AMSC-CM than with NS (p < .05). There were minimal transient side effects in either of the study groups. Conclusion: AMSC-CM has the capability to improve clinical photoaging and is a promising option for rejuvenation therapy.

A risk model for the prediction of skin tears in aged care residents: A prospective cohort study

The objective of this study was to construct a predictive model to identify aged care residents at risk of future skin tears. Extensive data about individual characteristics, skin characteristics, and skin properties were gathered from 173 participants at baseline and at 6 months. A predictive model, developed using multivariable logistic regression, identified five variables that significantly predicted the risk of skin tear at 6 months. These included: a history of skin tears in the previous 12 months (OR 3.82 [1.64-8.90], P = 0.002), purpura ≤20 mm in size (OR 3.64 [1.42-9.35], P = 0.007), a history of falls in the previous 3 months (OR 3.37 [1.54-7.41], P = 0.002), clinical manifestations of elastosis (OR 3.19 [1.38-7.38], P = 0.007), and male gender (OR 3.08 [1.22-7.77], P = 0.017). The predictive model yielded an area under the receiver operating characteristic curve of 0.854 with an 81.7% sensitivity and an 81.4% specificity. This predictive model could inform a simple but promising bedside tool for identifying older individuals at risk of skin tears.

Relationship between cumulative ultraviolet exposure and cognitive function in a rural elderly Chinese population

OBJECTIVES

Some researchers have focused on the relationship between vitamin D and cognition, but the conclusions are inconsistent. We estimated cumulative UV exposure could be used to represent the individual's long-term vitamin D status and investigated its association with global cognitive function in elderly Chinese.

METHODS

A total of 641 participants aged 60 years and over were recruited in a rural area of Shenyang, China. All were interviewed to obtain data regarding sociodemographic characteristics and time spent outdoors. Cognitive function was evaluated using the Montreal Cognitive Assessment-Beijing version (MoCA-BJ). Images of skin from UV-exposed (dorsal hand) and UV-protected (inner forearm) sites from each individual were graded by the Beagley-Gibson system. Differences in skin-grade between the 2 sites were used to indicate cumulative UV exposure level. Subjects were grouped in tertiles based on skin-grade differences (<1.75, 1.75-2.74, and ≥ 2.75), representing low, medium, and high UV exposure levels, respectively. The MoCA-BJ score was classified in tertiles as low (<19), middle (19-22), and high (≥23) levels of cognition. Associations between cognitive function and UV exposure were analyzed using ordinal regression.

RESULTS

Skin-grade differences were associated with self-reported time spent outdoors. After adjustment for age, gender, education, BMI, whether living alone, income, diet, hypertension, and diabetes, a high UV exposure level was associated with better cognitive function (odds ratio = 0.643, 95% confidence interval = 0.427-0.969).

CONCLUSIONS

Greater cumulative UV exposure appears to be associated with better cognitive function in elderly adults.

Comparison of self-reported signs of facial ageing among Caucasian women in Australia versus those in the USA, the UK and Canada

Background/Objectives

Australians are more exposed to higher solar UV radiation levels that accelerate signs of facial ageing than individuals who live in temperate northern countries. The severity and course of self‐reported facial ageing among fair‐skinned Australian women were compared with those living in Canada, the UK and the USA.

Methods

Women voluntarily recruited into a proprietary opt‐in survey panel completed an internet‐based questionnaire about their facial ageing. Participants aged 18–75 years compared their features against photonumeric rating scales depicting degrees of severity for forehead, crow's feet and glabellar lines, tear troughs, midface volume loss, nasolabial folds, oral commissures and perioral lines. Data from Caucasian and Asian women with Fitzpatrick skin types I–III were analysed by linear regression for the impact of country (Australia versus Canada, the UK and the USA) on ageing severity for each feature, after controlling for age and race.

Results

Among 1472 women, Australians reported higher rates of change and significantly more severe facial lines (P ≤ 0.040) and volume‐related features like tear troughs and nasolabial folds (P ≤ 0.03) than women from the other countries. More Australians also reported moderate to severe ageing for all features one to two decades earlier than US women.

Conclusions

Australian women reported more severe signs of facial ageing sooner than other women and volume‐related changes up to 20 years earlier than those in the USA, which may suggest that environmental factors also impact volume‐related ageing. These findings have implications for managing their facial aesthetic concerns.

Lifestyle and Physiological Factors Associated with Facial Wrinkling in Men and Women

Facial wrinkling is one of the most notable signs of skin aging. Men and women show different wrinkling patterns yet the lifestyle and physiological factors underlying these sex-specific patterns are relatively unknown. Here, we investigated sex-specific determinants for facial wrinkles. Wrinkle area was quantified digitally using facial photographs of 3,831 northwestern Europeans (51-98 years, 58% female). Effect estimates from multivariable linear regressions are presented as the percentage difference in the mean value of wrinkle area per unit increase of a determinant (%Δ). Wrinkle area was higher in men (median 4.5%, interquartile range: 2.9-6.3) than in women (3.6%, interquartile range: 2.2-5.6). Age was the strongest determinant, and current smoking (men: 15.5%Δ; women: 30.9%Δ) and lower body mass index (men: 1.7%Δ; women: 1.8%Δ) were also statistically significantly associated with increased wrinkling. Pale skin color showed a protective effect (men: -21.0%Δ; women: -28.5%Δ) and, in men, sunburn tendency was associated with less wrinkling. In women, low educational levels and alcohol use were associated with more wrinkling, whereas female pattern hair loss and a higher free androgen index were associated with less wrinkling. In summary, we validated known and identified additional determinants for wrinkling. Skin aging-reducing strategies should incorporate the sex differences found in this study.

Comparison of ultraviolet A light protection standards in the United States and European Union through in vitro measurements of commercially available sunscreens

BACKGROUND

The importance of adequate ultraviolet A light (UVA) protection has become apparent in recent years. The United States and Europe have different standards for assessing UVA protection in sunscreen products.

OBJECTIVE

We sought to measure the in vitro critical wavelength (CW) and UVA protection factor (PF) of commercially available US sunscreen products and see if they meet standards set by the United States and the European Union.

METHODS

Twenty sunscreen products with sun protection factors ranging from 15 to 100+ were analyzed. Two in vitro UVA protection tests were conducted in accordance with the 2011 US Food and Drug Administration final rule and the 2012 International Organization for Standardization method for sunscreen effectiveness testing.

RESULTS

The CW of the tested sunscreens ranged from 367 to 382 nm, and the UVA PF of the products ranged from 6.1 to 32. Nineteen of 20 sunscreens (95%) met the US requirement of CW >370 nm. Eleven of 20 sunscreens (55%) met the EU desired ratio of UVA PF/SPF > 1:3.

LIMITATIONS

The study only evaluated a small number of sunscreen products.

CONCLUSION

The majority of tested sunscreens offered adequate UVA protection according to US Food and Drug Administration guidelines for broad-spectrum status, but almost half of the sunscreens tested did not pass standards set in the European Union.

Skin microtopography as a measure of photoaging and risk of squamous cell carcinoma of the skin in a US population

BACKGROUND

Skin microtopography as a measure of photoaging is a noninvasive approach to measuring chronic ultraviolet radiation exposure and reflects the degree of dermal elastosis in populations of European descent in the subtropics. Less is known about the utility of this approach in populations at different latitudes, and whether it relates to skin cancer risk.

METHODS

A population-based case-control study of 342 squamous cell carcinoma (SCC) cases and 331 age- and gender-matched controls were evaluated for histologic evidence of solar damage and severity of photoaging based on microtopography on a six-grade scale. Odds ratios (OR) for SCC associated with degree of photoaging were estimated using logistic regression analysis adjusted for potentially confounding factors.

RESULTS

After adjustment for known risk factors, SCC was associated with increasing photoaging grade (OR = 1.7, 95% CI = 0.9-3.0 for severe photoaging; OR = 2.8, 95% CI = 1.6-5.0 for very severe photoaging). Associations remained among those with actinic keratosis (OR = 3.4, 95% CI = 0.9-12.4 for severe photoaging, OR = 5.7, 95% CI = 1.7-19.6 for very severe photoaging).

LIMITATIONS

There was limited statistical power, particularly for subgroup analyses.

CONCLUSION

Our findings provide further evidence of microtopography as an independent, objective indicator of risk of SCC.

The effects of continuous application of sunscreen on photoaged skin in Japanese elderly people - the relationship with the usage

Since photoaging of skin is caused by chronic sun exposure, it is well-recognized that regular sunscreen use can help prevent photoaging of skin in fair-skinned people. Therefore, application of sunscreen is recommended for the prevention of photoaging in many countries. However, the relationship between UV exposure and photoaging has rarely been investigated in clinical studies in Japan. In addition, there have been almost no long-term interventional studies in Japanese people. We have previously conducted a study where Japanese actinic keratosis patients were instructed to continuously apply sunscreen. The results indicated that long-term application of sunscreen is effective in suppressing actinic keratosis progression and generation. In the present study, we investigated the effects of sunscreen on photoaged skin in 14 elderly Japanese people. Skin conditions such as water content, transepidermal water loss, the number of spots, wrinkles, and skin color tone uniformity were measured and compared before and after the study. A statistically significant difference was observed only in skin surface hydration. There were large inter-individual differences in amount of sunscreen used throughout the study. The changes in the number of spots and skin color tone uniformity during the 18 months showed good correlation with amount of sunscreen being used. These results suggest an increase in the number of spots and deterioration in skin color tone uniformity in the 18-month non-sunscreen application period, and that such skin conditions improved with increasing use of sunscreen. In this study, we suggested an inhibitory effect on photoaging symptoms such as spots and skin color tone non-uniformity, by application of the appropriate amount of sunscreen over a long period of time in Japanese people, similar to Caucasians.

A prospective study of measured body size and height and risk of keratinocyte cancers and melanoma

BACKGROUND

The potential influence of measured body weight and height on keratinocyte skin cancer risk has scarcely been studied. Some evidence indicates melanoma risk increases as self-reported height increases, but an association with body mass index (BMI) is less certain.

METHODS

We measured body weight and height of 1171 Australian men and women in a community-based skin cancer study in Queensland and prospectively examined the association of BMI, body surface area (BSA) and height and incidence of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma while accounting for skin phenotype, sun exposure, clinical/cutaneous signs of chronic photodamage and other risk factors.

RESULTS

During 16 years of follow-up, 334 and 188 participants newly developed BCC and SCC, respectively; 28 participants were diagnosed with primary melanoma. BMI and BSA were unrelated to skin cancer incidence. After full adjustment, height was significantly associated with SCC development in men (relative risk (RR)=1.66; 95% confidence interval (CI)=1.11-2.48, for ≥175cm vs ≤171cm, Ptrend=0.017), and BCC in women (Ptrend=0.043). Melanoma in men, was similarly positively associated with height (RR per 5cm increment=1.55; 95%CI 0.97-2.47, P=0.067) though not significantly.

CONCLUSION

This study shows that after adjusting for sun exposure tall stature may be a risk factor for the most common types of skin cancer BCC, SCC, and melanoma, while body mass and surface area appear unrelated to risk.

Sunscreens: a review of health benefits, regulations, and controversies

Ultraviolet radiation plays a major role in the development of nonmelanoma and melanoma skin cancers. Photoprotection by sunscreens has been shown to prevent the development of actinic keratosis, squamous cell carcinoma, melanoma, and photoaging. However, these benefits are only derived if the users apply sunscreen appropriately and practice other sun protection measures. This review discusses the health benefits provided by sunscreen use, updates the latest regulatory landscape on sunscreen, and addresses the controversies and limitations associated with sunscreen use.

Biobanking across the phenome - at the center of chronic disease research

Background

Recognized public health relevant risk factors such as obesity, physical inactivity, smoking or air pollution are common to many non-communicable diseases (NCDs). NCDs cluster and co-morbidities increase in parallel to age. Pleiotropic genes and genetic variants have been identified by genome-wide association studies (GWAS) linking NCD entities hitherto thought to be distant in etiology. These different lines of evidence suggest that NCD disease mechanisms are in part shared.

Discussion

Identification of common exogenous and endogenous risk patterns may promote efficient prevention, an urgent need in the light of the global NCD epidemic. The prerequisite to investigate causal risk patterns including biologic, genetic and environmental factors across different NCDs are well characterized cohorts with associated biobanks. Prospectively collected data and biospecimen from subjects of various age, sociodemographic, and cultural groups, both healthy and affected by one or more NCD, are essential for exploring biologic mechanisms and susceptibilities interlinking different environmental and lifestyle exposures, co-morbidities, as well as cellular senescence and aging. A paradigm shift in the research activities can currently be observed, moving from focused investigations on the effect of a single risk factor on an isolated health outcome to a more comprehensive assessment of risk patterns and a broader phenome approach. Though important methodological and analytical challenges need to be resolved, the ongoing international efforts to establish large-scale population-based biobank cohorts are a critical basis for moving NCD disease etiology forward.

Summary

Future epidemiologic and public health research should aim at sustaining a comprehensive systems view on health and disease. The political and public discussions about the utilitarian aspect of investing in and contributing to cohort and biobank research are essential and are indirectly linked to the achievement of public health programs effectively addressing the global NCD epidemic.

Smoking during pregnancy is associated with a decreased incidence of obstetric anal sphincter injuries in nulliparous women

Background

Smoking is a modifiable lifestyle factor that has been shown to be associated with adverse perinatal outcomes and to have adverse health and dose-dependent connective tissue effects. The objective of this study was to examine whether smoking during pregnancy was associated with the incidence of obstetric anal sphincter injuries (OASIS) among six birthweight groups in singleton vaginal deliveries, considering nulliparous and multiparous women separately between 1997 and 2007 in Finland.

Methodology

A retrospective population-based register study. Populations included women with spontaneous singleton vaginal deliveries, consisting of all 213,059 nulliparous and all 288,391 multiparous women. Incidence of OASIS (n = 2,787) between smoking status groups was adjusted using logistic regression analyses.

Principal Findings

Of the nulliparous women, 13.1% were smokers, 3.6% had given up smoking during the first trimester of their pregnancy and 81.1% were non-smokers. Among these groups 0.7%, 0.9% and 1.1%, respectively suffered OASIS (p≤0.001). Nulliparous women who smoked had a 28% (95% CI 16–38%, p≤0.001) lower risk of OASIS compared to non-smokers, when adjusting for background variables. In multiparous women, the overall frequencies of OASIS were much lower (0.0–0.2%). A similar inverse relationship between OASIS rates and smoking was significant in pooled univariate analysis of multiparous women, but multivariate analysis revealed statistically insignificant results between non-smokers and smokers.

Conclusions

Nulliparous women who were smokers had a 28% lower incidence of OASIS. However, smoking during pregnancy cannot be recommended since it has shown to be associated with other adverse pregnancy outcomes and adverse health effects. The observed association warrants clinical repetition studies and, if confirmed, also in vitro studies focusing on connective tissue properties at a molecular and cellular level.

Prospective study of physical activity and risk of squamous cell carcinoma of the skin

BACKGROUND

The relationship between physical activity and risk of cutaneous squamous cell carcinoma (SCC) is unknown and difficult to investigate due to confounding by sun exposure. We prospectively examined the association of recreational and occupational physical activity and incidence of SCC accounting for photoaging and other risk factors.

METHODS

We used available information on physical activity from the Australian population-based Nambour Skin Cancer Study comprising 1,171 adults aged 25-75 years at baseline (1992). In sex-stratified analyses (person-based and tumor-based) we estimated the associations between type of activity and incidence of SCC prospectively to 2007.

RESULTS

During 16 years of follow-up, 98 men and 90 women newly developed SCC. We found no significant association between recreational activity measures and SCC after controlling for potential confounding factors including indicators of sun exposure. In men, the observed risk pattern was however suggestive of elevated risk with increasing total hours of recreational activity (compared to inactive men, RR (95%CI) 0.89 (0.54, 1.46) for ≤ 1.5 hrs/wk; 1.29 (0.82, 2.04) for ≤ 4.0 hrs/wk; 1.33 (0.86, 2.05) > 4.0 hrs/wk), while among women, higher level of occupational activity (standing and manual versus sedentary work activities) was associated with a reduced incidence of SCC tumors (P trend = 0.03).

CONCLUSIONS

Despite some suggestion that recreational activity in men and occupational activity in women are related to occurrence of SCC, there is no firm support for a role of physical activity in the development of cutaneous SCC.

Childhood exposure to ultraviolet radiation and harmful skin effects: epidemiological evidence

We review the general amount and patterns of exposure to solar ultraviolet (UV) radiation that children and teenagers experience and the spectrum of UV-related skin damage that can occur as a result. Data about the amount of solar UV received by children and teenagers are relatively few but suggest that around 40-50% of total UV to age 60 occurs before age 20. Among white children, those with the palest complexions suffer the most damage. Comparisons of prevalence and incidence of outcomes in children and teenagers sharing common ancestry, but living at different latitudes, show that prevalence rates of photoaging and melanocytic naevi are higher in Australian compared with British children, and similarly for melanoma. Genetic risk for the majority of the melanomas in teens is a function of genes controlling naevus propensity and pigmentation in the skin. High numbers of naevi and freckles, red hair, blue eyes, inability to tan, as well as a family history are the primary determinants of melanoma among adolescents. Beyond the signs of skin damage seen in children are the latent effects observed later in adulthood. Childhood is believed to be a susceptible window for long-term harmful effects of UV, as evidenced by clear differences in skin cancer risk between child and adult migrants from high to low latitudes. Effective UV radiation protection from childhood is necessary to control both immediate and long-term harmful effects on children's skin.