Daily Care for Acne, Hyperpigmentation, Aging, And

Skin Care Department

Daily Care for Acne, Hyperpigmentation, CE 2.0 Aging, and Sensitive Skin ANCC Contact Jennifer Linder , MD Hours

hoosing the correct daily care ACNE to gently exfoliate acne include C regimen for your patients’ mild alpha hydroxy acids (AHAs), specific skin condition does not At least 90% of the population salicylic, azelaic and kojic acids, have to become an overwhelming has suffered from the devastat- and creamy scrubs formulated task. Determining which ingredients ing effects of acne at some point with smooth, round beads such to include can form the foundation in their life ( Szabo & Kemeny , as polyethylene or jojoba beads 2011). This chronic skin disorder ( Baldo et al., 2010). for the successful treatment of each presents in four grades: Grades Increased sebum production of the most common skin condi- I and II—acne simplex; Grades must be controlled to effectively tions. In turn, you and your patients III and IV—acne vulgaris. Each address this condition. A misguid- will achieve quick and long-term grade is marked by the erup- ed practice often used by those success. Although each patient’s tion of a combination of pustules, suffering with acne is the over- skin is a unique combination of papules, comedones, or cysts. drying of the skin. Harsh, abra- their environment, lifestyle choices, Understanding the etiology of sive, or overly drying products hereditary background, and current acne is imperative to determining can cause an increase in sebum product usage, there are specific an appropriate daily care routine. production and further inflam- ingredients that will help minimize The four main causes of this con- mation, exacerbating the very the appearance of the more com- dition are increased keratiniza- condition being treated. Science monly treated skin conditions: tion within the follicle, increased indicates that acne patients are sebum production, Propionibac- deficient in essential fatty acids acne, hyperpigmentation, aging, terium acnes ( P. acnes ) bacteria in their surface lipids, which can and sensitive skin. proliferation, and inflammation also result in increased sebum (Mancini, Baldwin, Eichenfield, production (Treloar , 2003). Oils Friedlander, & Yan, 2011). To rich in essential fatty acids, such Jennifer Linder, MD, is in private practice, Dermatology and Mohs Surgery, Scotts- be effective, a daily care routine as borage seed oil, wheat germ dale, AZ; Chief Scientific Officer, PCA SKIN, for patients suffering with acne oil, and grape seed oil, can actu- Scottsdale, AZ; and Assistant Clinical Pro- should address these four main ally decrease sebum produc- fessor, WOS, Department of Dermatology, University of California, San Francisco. Dr. causes. tion, helping alleviate persistent Linder is a spokesperson for The Skin Can- Desquamation slows in acneic breakouts. Jojoba oil is also a cer Foundation; a member of the American skin due to increased sebum pro- satisfactory choice for those suf- Academy of Dermatology, the American Society for Dermatologic Surgery, and the duction and increased adherence fering with acne as its molecu- American College of Mohs Surgery; and of keratinocytes within the folli- lar structure closely resembles sits on the Editorial Board of the Cosmetics cle wall (Hsu, Litman, & Brodell, that of natural sebum, minimiz- Journal. 2011). Gentle exfoliation can help ing overproduction (Sandha & The authors report no conflicts of interest. minimize impactions by encour- Swami, 2009). Address correspondence to Jennifer Linder, MD, 6710 E. Camelback Road, Suite 220, aging the desquamation of com- A critical step in treating acne Scottsdale, AZ 85251. pacted surface cells. Ingredients is controlling the P. acnes bacte- DOI: 10.1097/PSN.0000000000000011 that have been found effective ria. Daily use of a cleanser or spot

PPSN-D-13-00030.inddSN-D-13-00030.indd 172172 111/22/131/22/13 7:257:25 PMPM treatment containing benzoyl per- Cutaneous inflammation is a pigmented lesions but also allow oxide delivers oxygen into the fol- direct cause of hyperpigmenta- for improvement in skin function licle where the anaerobic P. acnes tion. The source of the inflamma- and cellular turnover ( Dewandre bacteria reside, effectively reduc- tion can vary from overexposure & Rubin, 2006). This combina- ing their proliferation ( Kircik , to UV rays, hormonal fluctuations, tion of daily care products, along 2013). Salicylic acid is also effec- or cutaneous injury, such as a with professional treatments, will tive because of its lipophilic char- burn, cut, or infection (Briganti, provide an optimal outcome for acteristics and ability to penetrate Camera, & Picardo, 2003). The the patient. oil-filled follicles to clear impac- beginning of pigment formation Inhibiting melanogenesis at tions (Baumann, Oresajo, Yats- takes place after the initial trigger multiple points is imperative for kayer, Dahl, & Figueras, 2013). causes the release of melanocyte- patients suffering with unwanted Controlling inflammation is stimulating hormone ( Briganti et pigment. To discourage pigment key when customizing a daily al. , 2003). Once this process is set formation, strategic integration care regimen for acne patients. in motion, a few strategies must of the following melanogenesis- Anti-inflammatory ingredients be executed: gentle exfoliation, inhibiting ingredients into a daily that work to soothe the skin encouraging cellular turnover, care regimen will halt the chain and minimize irritation include inhibiting the melanogenesis pro- reaction that results in melanin bisabolol (the active component cess, and consistent use of broad- deposition ( PCA SKIN , 2013): found in chamomile), aloe vera, spectrum UV protection. panthenol, salicylic and azelaic Because hyperpigmentation • Hydroquinone is synthetically acids, boldine extract, resvera- is a direct result of inflamma- produced or naturally found in trol, and epigallocatechin gallate tion, it is advisable to take a wheat, berries, coffee, and tea. from green tea (Strowd , 2012). low-dose approach when exfo- It inhibits the binding of copper Ultraviolet (UV)-induced inflam- liating the skin. As keratinized to tyrosinase and induces mel- mation can antagonize the skin cells are exfoliated, pigment anocyte-specific cytotoxicity. of acne-prone patients, making deposition on the surface will • Retinoids are synthetically pro- sunscreen use essential. Broad- also dissipate. Using smooth, duced. They suppress the activ- spectrum sunscreen products round beads as the medium for ity of tyrosinase, decrease the containing higher percentages of exfoliation instead of crushed amount of melanosomes, and zinc oxide can make a profound kernels or nut hulls ensures inhibit melanosome transfer. difference in minimizing inflam- effective exfoliation without • Phenylethyl resorcinol is syn- mation. Additional ingredients causing unnecessary trauma. thetically produced. It inhibits to look for in a broad-spectrum Increasing and regulating cel- the conversion of tyrosinase to sunscreen product include milk lular turnover by implementing L-3,4-dihydroxyphenylalanine thistle-derived silybin and caf- strategic daily care products will (L-DOPA). feine for additional antioxidant amplify results and take treat- • Undecylenoyl phenylalanine protection. ment outcomes to the next level. is synthetically produced. It Stimulating cell renewal will aid prevents the synthesis of the in facilitating the removal of mel- melanocyte-stimulating hor- HYPERPIGMENTATION anin-filled keratinocytes ( Brigan- mone and, as a result, the for- ti et al., 2003). The family of vita- mation of tyrosinase, melanin, One of the more challenging con- min A derivatives, also referred to and melanosome transfer. ditions skin health care profes- as retinoids, has been used with • Arbutin is naturally found sionals aim to treat is hyperpig- much success because of its high in wheat, pears, bearberries, mentation. This frustrating con- level of efficacy in the regula- blueberries, and cranberries. dition can affect a wide range tion of cellular proliferation and It suppresses the activity of of patients and can be caused turnover, bringing healthy cells tyrosinase and inhibits mela- by myriad internal and external to the surface at an increased nosome maturation. factors. Outstanding results are rate ( Halder & Richards, 2004). • Kojic acid is naturally found often achieved when 2 treatment Pure retinol (0.5%) is often toler- in soy, mushrooms, and rice considerations are addressed: ated well when slowly integrated bran. It chelates copper bound daily application of melanogen- into the patient’s nightly rou- to tyrosinase and decreases the esis inhibiting ingredients and tine to regulate cellular turnover number of melanosomes and proper patient education. and bring dyschromias closer to dendrites. The melanogenesis process is the surface ( PCA SKIN , 2013). • Glycyrrhiza glabra root extract a complex and often misunder- Superficial blended chemical (licorice root) suppresses the stood chain of events that must peels performed every 3 weeks tyrosinase activity of melano- be controlled at varying points. will not only help remove the cytes without cytotoxicity.

PPSN-D-13-00030.inddSN-D-13-00030.indd 173173 111/22/131/22/13 7:257:25 PMPM • L-ascorbic acid is natural- To effectively control the vari- ing daily use of melanogenesis ly found in many botanical ous signs of aging, a comprehen- inhibitors such as low-percentage sources, such as citrus fruit sive daily care regimen should hydroquinone, kojic, lactic and and corn. It converts DOPAqui- gently exfoliate and increase cell azelaic acids, arbutin, retinol, none back to L-DOPA, prevent- turnover, increase matrix pro- or L-ascorbic acid will address ing melanin formation. teins, inhibit melanogenesis, visible pigmentation while also increase hydration, and protect staving off future discolorations Once a pigment-controlling from UV rays. (NYU Langone Medical Center, regimen has been implemented, As one ages, the stratum corne- 2011). Using various pigment- a broad-spectrum sunscreen with um becomes compacted because inhibiting ingredients with dif- a sun protection factor (SPF) of of a considerable slowing in cel- fering mechanisms of action is 30 or greater must be used daily lular turnover. Gentle exfoliation highly recommended, as this to further protect the skin from will not only help remove the method will effectively target the harmful UV rays, which lead to excessive buildup of keratinized various points of the melanogen- increased pigmentation. Because cells but also restore the youth- esis process. melanogenesis inhibitors tend to ful glow the patient once had in Dry skin is a common concern reduce the melanin content in epi- their younger years. Nightly use for the aging patient. Effective dermal cells, there is an increased of a 0.5% pure retinol will pro- hydrators should combine humec- risk of UV-induced upregulation vide a multitude of benefits for tant ingredients with occlusive of matrix metalloproteinases the patient, including a decrease agents. Humectants work by pull- and oxidative damage. Advanced in hyperkeratinization, address- ing moisture from the dermis up sunscreen products containing ing unwanted dychromias, and into the epidermis. An occlusive broad-spectrum protection along synthesizing collagen produc- agent acts as a barrier, locking in with antioxidants, such as caf- tion ( Halder & Richards , 2004). that moisture. Commonly used feine and silybin, provide well- Creamy exfoliating products humectant ingredients include rounded coverage from UV rays containing low percentage AHAs hyaluronic acid, honey, glycerin, and other inflammatory stimu- and smooth round beads, such and sodium PCA. Effective occlu- lants ( PCA SKIN , 2013). as polyethylene beads, provide sive agents include shea butter, a safe and effective means of niacinamide, silicones such as AGING SKIN exfoliation for the aging patient. dimethicone and cyclomethicone, Botanically sourced actives, such and titanium dioxide. Visible aging is a combination as vigna aconitifolia seed extract, Sun protection is particularly of intrinsic and extrinsic fac- also increase cellular turnover important to manage aging skin tors. Intrinsic aging refers to the without added irritation. because the majority of visible physiological breakdown that Intrinsic aging takes a toll aging is due to photo damage. naturally occurs because of the on the aging face, thinning the Regardless of skin condition, all passage of time and accounts for dermis while also decreasing the patients should be advised to use about 15% of the aging process. thickness of the epidermis (PCA a broad-spectrum sunscreen with Extrinsic aging accounts for 85% SKIN , 2013). Increasing matrix an SPF of 30 or higher for ade- of the visible signs of aging and proteins is a vital step in keep- quate UV protection every day, is directly related to UV expo- ing a youthful appearance. Topi- year-round. Well-formulated sun sure, lifestyle choices, chronic cally applied products containing protection products will contain inflammation, and environmen- AHAs, matrix-building peptides, antioxidants such as milk thistle- tal offenders. Common presenta- epidermal growth factor, and vita- derived silybin and caffeine. tions of aging skin include the mins trigger collagen synthesis, following ( PCA SKIN , 2013): leading to an increase in skin firm- ness ( Bernstein et al. , 1996). Con- SENSITIVE SKIN • sagging sider adding products containing • laxity rh-Oligopeptide-1, palmitoyl tri- Sensitive skin is defined as a • fine lines and wrinkles peptide-38, and hyaluronic acid to heightened intolerance to topi- • thinning or transparent-look- encourage healthy cell prolifera- cal products or external factors ing skin tion and improve the function of and often involves impaired • dryness or dehydration the extracellular matrix. barrier function. To effectively • hyperpigmentation Sun exposure accounts for treat sensitive skin conditions, • epidermal thickening the majority of extrinsic aging one must take into account that • enlargement of pores and the resultant damage all too the skin has been compromised • telangiectasias often appears as hyperpigmen- and is no longer able to function • coarsening of the skin tation (Fisher , 2002). Integrat- at the capacity of healthy skin.

PPSN-D-13-00030.inddSN-D-13-00030.indd 174174 111/22/131/22/13 7:257:25 PMPM A comprehensive sensitive skin • Evening primrose oil as a cern, and proper hydration along regimen should include products source of omega-3 gamma with a broad-spectrum SPF of 30 that gently exfoliate and increase linolenic acid (GLA), which or greater into each daily care cellular turnover, decrease red- provides both redness-reduc- regimen as a starting point for ness and inflammation, increase ing and anti-inflammatory success. hydration to control excessive benefits. dryness, and protect from UV • Bisabolol , which is the active exposure. component in chamomile that REFERENCES Gently exfoliating will help provides anti-inflammatory Baldo , A. , Bezzola , P. , Curatolo , S. , Flo- reduce excessive cell buildup benefits. rio , T. , Lo Guzzo , G. , Lo Presti , M. , without increasing irritation and • Willow bark extract , a natu- et al. (2010 ). Efficacy of an alpha- inflammation. When performed ral analgesic related to aspirin, hydroxy acid (AHA)-based cream, on a weekly basis with mild exfoli- also acts as a soothing and even in monotherapy, in patients ating media, such as polyethylene calming agent. with mild-moderate acne. Giornale beads or jojoba beads, patients • Menthyl lactate to soothe and Italiano Di Dermatologia E Venereo- will be less likely to run the risk cool irritated skin. logia , 145 ( 3 ), 319 – 322 . of overexfoliating or irritating Baumann , L. S. , Oresajo , C. , Yatskay- the skin. Other gentle exfoliating Because barrier function can er , M. , Dahl , A. , & Figueras , K. options include low-percentage be greatly reduced in those suf- (2013 ). Comparison of clindamy- cin 1% and benzoyl peroxide 5% AHAs or low-percentage retinols. fering with a sensitive skin condi- gel to a novel composition con- Retinol can be used safely and tion, maintaining adequate epi- taining salicylic acid, capryloyl can greatly improve the barrier dermal moisture is imperative. salicylic acid, hepes, glycolic acid, function of the skin by encourag- To effectively hydrate the skin, a citric acid, and dioic acid in the ing healthy cell turnover ( PCA moisturizing product must con- treatment of acne vulgaris . Jour- SKIN , 2013). tain humectant and occlusive nal of Drugs in Dermatology, 12 ( 3 ), Sensitive skin often presents ingredients, mentioned previ- 266 – 269 . with some degree of visible red- ously. Bernstein , E. F. , Underhill , C. B. , Lak- ness and inflammation, which As with aforementioned con- kakorpi , J. , Ditre , C. M. , Uitto , J. , causes the patient some discom- ditions, every patient should use Yu , R. J. , et al. ( 1997 ). Citric acid fort. Integrating topical anti- a broad-spectrum SPF of 30 or increases viable epidermal thickness and glycosaminoglycan con- inflammatory ingredients to help greater every day. When it comes tent of sun-damaged skin. Dermato- combat redness will oftentimes to sensitive skin conditions, the logic Surgery , 23 , 689 – 694 . also improve microcapillary func- barrier function is often impaired, Briganti , S. , Camera , E. , & Picardo , M . tion by suppressing the proin- allowing for a higher risk of UV- ( 2003 ). Chemical and instrumental flammatory mediators, vascular induced inflammation, which can approaches to treat hyperpigmenta- endothelial growth factor (VEGF) worsen many of the sensitive skin tion . Pigment Cell Research , 16 ( 2 ), 101 – 110 . and prostaglandin E2 (PGE2 ), and conditions skin health profession- inhibit the production of inflam- als aim to treat. This increased Dewandre , L. , & Rubin , M. G. (Eds.). matory cytokines (PCA SKIN, inflammatory response can fur- ( 2006 ). The chemistry of peels and 2013). ther weaken damaged capillaries a hypothesis of action mechanisms. Redness-reducing ingredients and lead to increased vasodila- In: Chemical peels (pp. 1 – 12) . Phila- delphia, PA : Elsevier. include the following: tion. Proper UV protection can Fisher , G. J. ( 2002 ). Mechanisms of help mitigate these negative out- • Brown and red algae extract photoaging and chronological skin comes. to reduce VEGF and PGE . aging. Archives of Dermatology , 2 Although the presentation • Caper bud fruit extract to 138 ( 11 ), 1462 – 1470 . of each skin condition will vary inhibit the production of pro- Halder , R. M. , & Richards , G. M. (2004 ). greatly from patient to patient, Topical agents used in the manage- inflammatory cytokines. setting up a foundation for suc- ment of hyperpigmentation. Skin- Ingredients with higher levels cess with daily care will ultimate- CareGuide . Retrieved July 31, 2013, of omega-3 and omega-6 essen- ly lead to healthy, beautiful skin. from Skintherapyletter.com tial fatty acids act as potent anti- Recognizing the unique char- Hsu , P. , Litman , G. I. , & Brodell , R. inflammatory agents ( PCA SKIN , acteristics of each skin condi- T . (2011 ). Overview of the treatment of acne vulgaris with topical 2013). Specific support ingredi- tion is imperative to developing retinoids. Post-Graduate Medicine, ents assist in calming and sooth- a customized regimen for each 123 ( 3 ), 153–161. ing the skin. patient’s individual combination Kircik , L. H. ( 2013 ). The role of benzoyl Anti-inflammatory and calm- of skin concerns. Aim to inte- peroxide in the new treatment para- ing ingredients include the fol- grate gentle exfoliation, treat- digm for acne. Journal of Drugs in lowing: ment of the specific skin con- Dermatology , 6 ( Suppl. 12), S73 – S76 .

PPSN-D-13-00030.inddSN-D-13-00030.indd 175175 111/22/131/22/13 7:257:25 PMPM Mancini , A. J. , Baldwin , H. E. , Eichen- PCA SKIN . (2013 ). Hyperpigmentation . Szabo , K. , & Kemeny , L. ( 2011 ). Study- field , L. F. , Friedlander , S. F. , & Skin biology & chemical peel textbook ing the genetic predisposing factors Yan , A. C. ( 2011 ). Acne life cycle: (Vol. 48) . Scottsdale, AZ: PCA SKIN. in the pathogenesis of acne vulgaris. the spectrum of pediatric disease. Sandha , G. K. , & Swami , V. K. ( 2009 ). Studying the Genetic Predisposing Seminars in Cutaneous Medicine and Jojoba oil as an organic, shelf stable Factors in the Pathogenesis of Acne Surgery , 30 ( 3 ), S2 – S5 . standard oil-phase base for cosmet- Vulgaris , 72 ( 9 ), 766 – 773 . NYU Langone Medical Center . (2011). ic industry. Rasayan Journal , 2 ( 2 ), Treloar , V. (2003 ). Diet and acne redux. Aging skin. NYU Langone Medical 300 – 306 . Archives of Dermatology, 139 ( 7 ), 941 . Center . Retrieved August 9, 2013, Strowd , L. C. (2012 ). Current treatment from http://www.med.nyu.edu/ options for acne. The Dermatologist , content?ChunkIID=38389. ( Suppl.), 5 – 12 .

For more than 27 additional continuing education articles related to plastic surgery nursing, go to NursingCenter.com/CE.

PPSN-D-13-00030.inddSN-D-13-00030.indd 176176 111/22/131/22/13 7:257:25 PMPM