Topical Vitamin C for the skin

There are a lot of vitamin C products on the market and many of them will claim to give amazing results! A true formula that will improve the skin will include all of the following. 

Vitamin C

There have been lots of talk about all the benefits of topical vitamin C. Vitamin C is found in dark green leafy vegetables, citrus fruits and is made synthetically for topical application. It is commonly known for it antioxidant properties. Vitamin C has a low molecular weight and is a weak acid. Ascorbic acid is known for being notoriously unstable. It can easily oxidise and turn yellow when the solution has been exposed to air. Therefore, causes short shelf life. Many product brands have chosen to mix pure stable crystal forms of ascorbic acid with a chosen solution prior to application. This helps the brand keep its stability for their vitamin c products. Before purchasing any vitamin C look for the concentration. The maximum required concentration for percutaneous absorption is 20% therefore higher concentrations is just a waste. Look for lipophilic formulations, this means formulations that have included Vitamin E to keep the stability of the vitamin C and allow for ease of penetration. Also look for it its is Ascorbic Acid. Ascorbic Acid provides the best bioavailability in the skin. A formulation that has been made in a dark glass bottle with a air tight lid can also keep its stability. There are so many brands in the market but only a few have scientific research for   vitamin C formulations. Therefore, knowledge and research should be done before purchasing any product. 

What does Vitamin C do?

Antioxident Properties 

Vitamin C is a free radical scavenger of reactive oxygen species, making it now of the most powerful antioxidants in human tissues. The reason why vitamin C is such a powerful antioxidant is because it donates electrons to the free radicals helping to neutralise them and making them stable in an aqueous compartments of the cell. It is not effective against lipophilic free radicals that is why it works synergistically with Vitamin E in tissues. Vitamin C is an antioxidant to oxidative damage caused from both UVR and environmental pollution. 

Antiageing properties 

Vitamin C is also needed for the formation of collagen. Deficiency of it can cause problems like scurvy. It is essential for the stability of the collagen, as well as the cross linking of collagen fibres. Vitamin C helps to stimulate collagen types IV and VII and stimulates fibroblast proliferation and hence collagen production. 

Inhibition of Melanogenesis

Ascorbic acid has been shown to reduce the level of quinones in the skin, such as dopaquinone, which are enzymatically generated and therefore tyrosine cannot convert to melanin 

Photoprotective Effects  

The photo protective effects are enhanced when working synergistically with Vitamin E. There must be high concentrations to have an effect however, can reduce the signs of ageing. 

Anti-inflammatory Effects

Reduces the inflammatory response when swelling is caused. 

Herbal Peels and Do they work?

How do Herbal Peels work?

Herbal peels contain active ingredients from many sources including vitamins and minerals and different plants and enzymes that give it the metabolic and exfoliative effects. 

Herbal peels have been around for decades and is quite a popular treatment in the aesthetic industry. Due to my practical experience working with herbal peels I have found the treatments do provide great results. Providing the therapist has performed thorough consultation and the client can follow the strict after care advice that is. 

So how does this treatment really work? 

Herbal peels are based on the principle of being a strong mechanical exfoliative procedure. It is applied and massaged into the skin with light to firm pressure. The treatments may be superficial light to medium depth depending on the amount of time that the peeling agent has been massaged into the skin and which technique was used. 

There is quite a bit of discomfort involved and can be extreme for some people. 

Post treatment the client will feel tingling or prickly up to 48 hours and will feel like a mild sunburn sensation. Due to this reason, people can feel agitated and lose sleep. Depending on the depth of the treatment the client may experience light to heavy exfoliation. Shedding can will occur from day 3 to day 8 of the treatment. 

It is recommended for the client to prepare themselves on anti-vital medication prior to the treatment if they are prone to herpes simplex eruptions.

Who can have a herbal peel?

- Striae

- Poor circulating skin

- Dull Skin 

- Fine superficial lines

- Mild acne scarring and pitting

- Photodamage

- Acne 

- Oily skin

- Sebaceous congestion

- Rough skin

- Keratosis pilaris

- Melasma

- Hyperpigmentation

- The ageing skin

Who can't have a herbal peel? (Contraindications)

- Allergy to any of the agents in the peeling preparation

- Pregnancy and lactating

- People who have low pain thresholds

- People who have special occasions within the next 5 days 

- People who are going on tropical holidays in the next 2 weeks

- People who can't afford the down time

The Treatment of Melasma with Laser Toning Q Switched ND:Yag 1064nm

What is Melasma?

The clinical definition of melasma is known as bilateral brown patches or macules, generally observed in the centrofacial, malar or mandibular regions. It is an acquired chronic pigmentary disorder of the skin. The prevalence of melasma predominantly occurs in women from a childbearing age, and is seen less frequent in men. It is also more common in darker skin types with fitzpatrick phototypes from III-IV, and is more susceptible to people living closer to the equator, hence having more impact on racial skin types including Asians, Hispanics, Latinos, and African-Americans. The etiopathogenesis of melasma is also linked to racial and genetic factors. Exposure to ultra violet (UV) radiation is seen as the most significant contributing factor to the development of melasma due to its severity in showing solar elastosis. Melanogenesis is increased when UV irradiation is induced causing inflammation. Activation of fibroblasts occurs as well as an upregulation of melanocyte stimulating cytokines and stem cell factor in dermal melasma.

Other triggering factors that can lead to the onset of melasma includes: sex hormones (estrogen and progesterone), paracrine factors, pregnancy and the use of contraceptive pills. In addition to this studies have also found hormonal therapies, autoimmune thyroid disease, stress, endocrine dysfunction, overian dysfuncation/cancer, nutritional disorders, hepatic disease, stress, cosmetic products, phototoxic medications, photoallergic and antiepileptic medications to also be causative agents of this disorder. Melasma that develops post pregnancy is often referred to as cholasma or the pregnancy mask. In some instances cholasma can resolve within months post delivery. Although these factors are caused from endogenous or exogenous influences there is a common similarity between all of these factors. They will all appear as hyperactive melanocytes.

Determining the depth of Melasma

Proper skin analysis and consultations must be performed prior to any treatment to prevent complications from occurring following treatment. By using a Wood’s lamp skin diagnostic tool, it can help to identify the disposition of the melasma to determine if the lesion is epidermal, dermal or combined. There will also be high levels of melanin in the dermis associated with epidermal melasma. Whereas, in dermal melasma the appearance of epidermal pigmentation is less prominent, and superficial and deep perivascular melanophages are found in the dermis. The importance in understanding the exact location of the melasma is for proper treatment diagnosis and to minimize the risk of complications.

Treatment of Melasma with a low fluence laser toning method using QSwitched Nd:YAG 1064nm Laser

A proven and effective modality is by using a low fluence Q-Switched 1064nm Neodymium:yttrium aluminium garnet (QSNY) laser. Using a well-researched technique called ‘laser toning’, it has been known and proven for its capabilities to create minimal thermal damage to the tissue to treat melasma. The use of a longer wavelength (1064nm) reduces absorption of melanin coefficient, but also is able to penetrate deeper into the dermis. The technique uses multiple passes with low energy to promote favourable changes in the skin. Laser toning with a QSNY laser uses nanosecond pulse duration ranges. It creates a shattering effect on the tissue by sufficient kinetic energy delivered from the acoustic waves. Therefore it produces both photothermal and photoacoustic effects on tissue. The laser toning approach uses a similar concept known as subcellular selective photothermolysis. However, this concept is more based on non-specific dermal heating. The application of ultra short pulses allows for minimal heating to the cells thus the pigmented cells remained alive. During this process the destruction of keratinocytes, melanocytes and dermal melanophores takes place. A reduction of the activity of melanocytes and dermal melanophages are seen. Concurrently, it is able to encourage neocollagensis by contraction of collagen fibres. 

Post Laser Toning

Following a laser toning procedure the wound healing phases will start to take place. The heat induced to the shock proteins results in reduced proinflammatory interleukin (IL)8 to the wound healing mediator. This transforms into growth factor (TGF)-B resulting in collagenesis. Type I collagen will be replaced with new collagen type III and therefore, wound romedelling phase will take place. Laser toning is therefore not only beneficial for treating melasma, but also in its dual effects for toning and rejuvenating the skin. Laser toning can also improve in evening out skintone as well as rhytids. Therefore, laser toning is a minimal invasive approach whereby, reducing inflammation and the risks of PIH from occurring post treatment, as well as providing little to no downtime for the patient. Cooling post treatment is important to reduce the risk of PIH and topical application of a physical sunscreen minimum SPF of 30 is mandatory for all patients. 

Combination Treatment

Adjunctive conventional treatments often effective for epidermal melasma and can also include: topical therapies including bleaching agents like hydrquinone, Kligman-Willis Formula (5% hydroquinone, 0.1% tretinoin and 0.1% dexamethasone), topical steroids, retinoids, Azelaic acid, Kojic acid, Ascorbic acid and a variety of chemical peels (e.g. Gycolic, Lactic, Tricholoracetic acid and salicylic peels). However, dermal and mixed types of melasma are found resistant to these treatments. Hence the results can be temporary and have significant risk of pigmentary changes.

My conclusion 

Unfortunately, there is no single modality found in current literature for the treatment of melasma. It seems that a single modality can only yield temporary results. Patients must be diligent with photoprotection and remain out of direct sun exposure, as UV radiation has been found to be one of the leading causes of its onset. Topical treatments have been found satisfactory with treating epidermal melasma. Whereas laser toning with a QSNY laser has been found an effective and popular modality for treating dermal and mixed melasma. However, the limitations and complications from all interventions mentioned has only proven how difficult it is in finding the most appropriate solution for melasma. There needs to be more studies and researched performed in treating melasma. 

Vitamin B (Niacinamide) For The Skin

Vitamin B for the skin

 Niacinamide is a much loved vitamin. It is a water-soluble vitamin, grouped under the B₃ group vitamins and is amide to nicotinic acid. Niacinamide is known for its safe and effective use in common cosmeceutical formulations. It is frequently used in dermal therapy treatments for various applications for its relevance in its mechanisms of action and in the treatment of skin conditions.

Mechanisms of action of niacinamide 

Niacinamide has been found to have many functions on a cellular level. Topical application of niacinamide reduces trans-epidermal water loss (TEWL) in the epidermis and increase moisture levels by binding on the epidermal cells in the cornified layer. It encourages biosynthesis of ceramides, lipids, free fatty acids and cholesterol found in the stratum corneum by the activation of the mRNA expression. All of which is why niacinamide has an important function of homeostasis and maintaining the epidermal barrier function. There is an improvement in the stratum corneum thickness by 10% with the use of a topical moisturizer containing niacinamide.

Topical niacinamide is proven to have anti-inflammatory effects for the treatment of various skin disorders. This is mainly because its inhibitor role. The major inhibition of the nuclear enzyme poly-ADP-ribose polymerase-1 (PARP-1) takes place when activated by UV radiation. PARP-1 on the other hand has many important functions, which involve: controlling the nuclear factor-kB (NFkB)-mediated transcription, its involvement with DNA repair, genomic stability and its regulation of some transcription factors with the expression of inflammatory cytokines, adhesive molecules and inflammatory mediators. Niacinamide is the key inhibitor for the expression of intercellular adhesion molecule-_I  (ICAM-_I) and for major histocompatiability complex II (MHC-II). A steroid sparing effect can be seen from the inhibition of macrophage migration inhibition factor (MIF) due to the up regulation not encountering anti-inflammatory effects on their use compared with other cytokines.

Topical niacinamide can reduce sebum production with its sebo-suppressive properties and have direct inhibitory effect on propionbacterium acne when there is an inhibition of the Sir₂ enzymes. Improvements in acne with the topical application of 4% of niacinamide has been studied. However, in cases of excess sebocyte secretions niacinamide is reported to be dose dependant.

Niacinamide is also able to inhibit the transfer of melanosomes from melanocyts to keratinocytes giving a lightening effect on the skin. The combination of topical niacinamide with other lightening ingredients containing tyrosinase inhibitors synergistically gives better results. This is due to minimal inflammation induced by the anti-inflammatory effects of niacinamide.

The Topical Use of Niacinamie for Skin Conditions 

The topical treatment of niacinamide has been widely used for the treatments of various inflammatory skin conditions such as acne vulgaris, atopic dermatitis (AD), rosacea and autoimmune bullous dermatoses. It has also shown to have great improvements in the skin barrier function by decreased sebum excretions, reduced hyperpigmention and redness in visible photoageing. Nicainamide has been seen to having positive effects on the reduced appearance of fine lines and wrinkles, skin sallowness and skin elasticity.

My Views on Topical Niacinamide

Niacinamide is known for so many of its benefits for the skin. It is an ingredient that can  remain efficacious, as it is able to remain stable in light, heat and oxygen. A pH ranging from 4 to 7 is optimal for a product containing niacinamide. This is one of my favourite ingredients as there is very little evidence in scientific data to suggest niacinamide is toxic, but rather a lot more research and findings have been related to its low-toxic profile. It serves as a very important cell metabolizer, inhibitor and helps with DNA repair. There are many treatments available for various skin conditions that all have a commonly use topical niacinamide for its anti-inflammatory effects, lightening effects, and effects on the epidermal barrier function of the skin. 

Topical Vitamin A for the skin

Retinoids 

Retinoid have many compounds that include: Retinol, Retinoids, Retinaldehyde, Retinoic Acid, Retinyl palmitate, Adapalene, Tazarotene, Retinyl retinoate, Isotretinoin/Tretinoin (Accutane or Roaccutane)

Vitamin A is naturally derived from beta carotene. It can be derived from both synthetic and natural forms. It has low stability when exposed to light, heat and oxygen and therefore should be applied at night time. It has the ability to penetrate through both the sebaceous glands and intracellularly. Retinoic acid is the most bioactive form. It can diffuse into the stratum corneum rapidly and then slow in pace when entering the epidermis and dermis.

How it works in the skin

Retinoids form covalent bonds with dermal protein structures altering signalling pathways. It  binds and attach to Retinoid Acid Receptors or  Retinoid X Receptors. When bound to these receptors it will regulate gene transcription which is important in tissue growth and differentiation. It regulates the epidermal proliferation and differentiation. This accelerates the shedding of corneocytes and can reduce the appearance of comedones.  The ongoing proliferation and differentiation leads to thickening of the epidermis. Retinoids up regulate collagen synthesis by stimulating the synthesis of TGF, collagen type III and fibronectin synthesis by fibroblasts. The arrangement of collagen fibres will form in a more organised and dense arrangement. Collagen type VII is also produced. Regulation of angiogenesis and the immune responses also occurs. Retinoids can have anti-inflammatory effects by inhibiting  the mass infiltration of inflammatory mediators and it can down regulate the inflammatory response of P.acnes. Retinoids have the ability to reduce pigmentary changes in the skin. Another effect retinoids have is they are antibacterial agains P.acnes. 

Who should use Retinoids?

Retinoids are suitable for photo aged skin, acne, fine rhytids, thickened and rough skin texture, vascular insufficiency, thin skin, melasma, post inflammatory Hyperpigmentation, psoriasis and dermatitis and rosacea. 

Contraindications to Retinoids

- Pregnancy and breast feeding

- Retinol based products must be ceased 3 days prior and after chemical peel procedures

- Severe liver disorders

- Photosensitising medication

Microdermabrasion: a treatment so many different skin types can benefit from

Many clients walk into my clinic and tell me they've had a microdermabrasion treatment before. One of my first questions I ask in response is "Do you know if you had a crystal or a diamond tip microdermabrasion?" I think about 1 out of 10 clients will actually know which one they had and the benefits of the treatment. This reflects on how much people are being educated before they have a treatment performed. The most important part of the consultation is to inform your client of the benefits, the risks, the possible side effects and all that comes with any treatment. I'm writing this post because microdermabrasion has been a very popular treatment in the last decade and it has so many benefits. But not many people are being educated on the importance of it. So I hope this post can help those who would like some answers!

  

What is microdermabrasion?

In a nutshell, it is a mechanical exfoliation procedure. Through its abrasive nature it can reach different depths of the skin. Overall this will resurface the skin and stimulate the wound healing process which can improve skin barrier function, smoother skin texture, reduce surface pigmentation and have many other benefits for the skin. 

There are 2 different types of microdermabrasion: Crystal or Diamond

Crystal microdermabrasion: The crystals are made up of substances that include aluminium oxide, sodium chloride, sodium bicarbonate and magnesium oxide. 

The most common particulate used is aluminium oxide. This is due to that it is naturally found. It has many properties including it is water insoluble and it naturally abrasive. 

These crystals are propelled onto the skin by the positive pressure from the suction of the machine and the negative pressure removes the crystals and cellular debris into a waste jar.

Diamond microdermabrasion: This is using a diamond encrusted tip for the abrasive action. A combination of the diamond tip and the suction are used to achieve clinical results. There are coarser tips for different areas of the body and generally the machines have the ability for the operator to control the level of abrasion during the treatment. The benefits of using diamond tip compared to crystals is the ability to perform a more invasive treatment when wanting to reach pinpoint bleeding. Sometimes, crystal particulate can be an annoyance to clean and remove and clients can leave feeling gritty. However, the disadvantages of the diamond tips is they need to be sterilised after each use to prevent infection risk. Unfortunately, not every clinic has access to an autoclave and performs diamond microdermabrasion. These clinics and operators are putting themselves and clients at risk.

What are the benefits of a microdermabrasion?

This treatment can be performed on all skin fitzpatrick types, there is low risk of complications such as scarring and pigmentation, minimal side effects, can be used in combination with many other treatments and has short recovery time.

Who can have it?

This is one of the best things I love about performing microdermabrasion treatments as nearly every skin type can have this treatment done!

Here is a list of all the suitable candidates for this treatment:

- Uneven/rough texture

- Minor photodamage: thickening of stratum corneum, keratosis, superficial pigmentation

- Hyperpigmentation (very superficial), lentigines, melanoma

- Dull, sallow skin

- Enlarged pores

- Mild scarring & Striae

-Acne grade I to II (non-cystic acne)

- Fine rhytids 

- Chronological ageing

- Dry, thickened and scaling skin

- Oily, thickened skin

- Milia

- Keratosis pilaris

- Seborrhoeic keratosis scaling

- Enhancement of penetration of active ingredients and medications

- Blending of treatment boundaries

- Rosacea and telangiectasia: The treatment will improve the barrier function of the skin so can help indirectly with skin sensitivity

Who can't have it?

People who have unrealistic expectations may often feel disappointment after a microdermabrasion if they have rhytids at rest, deep scarring, ice pick scarring, deep hyper pigmentation disorders and deep melasma. Microdermabrasion may not be a suitable treatment for them, however they can have microdermabrasion for the benefits suggested above. 

Possible complications and side effects 

Although microdermabrasion is a fairly safe and minimally invasive treatment low side effects and complications can still occur. These complications can include:

- Post-inflammatory hyperpigmentation

- Eye sensitivity due to crystals lodging on the cornea

- Bruising, purpura and petechiae

- Urticaria (vary rare cases)

- Infection due to cross-contamination of non-sterilised hand pieces

- Scarring

- Pronounced bleeding, pain, heat/burning, oedema and erythema

- Stripping

- Photosensitivity and Hypersensitivity 

- Micro-blisters: Applying microdermabrasion in a stationary mode separating the epidermis from the dermis

What to expect post microdermabrasion

Immediately post treatment the skin will have no barrier as the stratum corneum has been removed. The skin will feel taught and may flake, it can also feel irritated. There can be mild to moderate erythema which dissipates within 24 hours of treatment. Some mild oedema and heat can also be noticed. At day 3 there may also be some shedding from the re-epithelialisiation after 24 hours. Therefore, it is important to NOT pick, pull or scratch the treated skin and to avoid the sun completely. Application of sunscreen daily is mandatory and avoiding make up, exercise and waxing of the treated area is also recommended for 48-72 hours. Ceasing retinol, AHA and BHA products for up to 4 days is recommended and re introducing these products will be less sensitive for the skin.  

For optimal results

The best way to achieve great results is to pre treat the skin with ingredients that can encourage desquamation for example retinols, AHA's and BHA's. It is crucial to follow through with post treatment care as the barrier is lost for 24 hours and needs to be replenished with lipids and moisture e.g. Hyalauronic acid, aloe vera and anti-inflammatory or antioxidant ingredients. For clinical efficacy at least 6 treatments should be performed within a spacing of 4-6 weeks. It is important for the operator to go through all the health and safety issues, precautions, contraindications and complications as well as the potential benefits before a treatment and also have a clear understanding of the treatment parameters, variables and technique to achieve desirable clinical endpoints.     

Micro-focused Ultrasound Skin Lifting

 How does ultrasound technology is offering non invasive surgical facelift results?

How it works:

Micro-focused ultrasound uses ultrasound energy to create an interaction with tissue. This causes tissue to reflect, scatter and be absorbed. The reflective and scatter effects enables an ultrasound imaging to be created which then the energy is focused and absorbed in the tissue. A transducer is used to visualise the treatment area so when treating it will target focused areas and deliver the energy below the skin. This will also help to avoid treating unwanted areas for example bone and blood vessels.  

The tissue is heated to about 60-70 degrees, coagulating tissue and denaturing collagen. The coagulation of tissue occurs in evenly spaced thermal coagulation points surrounding by healthy tissue which promotes immediate tissue tightening, neocollagenesis and the wound healing process. 

Figure 1.1 

Wound Healing Phases

Inflammatory phase - The heating of tissue at 60-70 degrees will denature and coagulate tissue causing thermal coagulation points which is an injury or controlled wound. This will then stimulate an expected natural wound healing process to take place. During this phase  the uninjured healthy surrounding the thermal coagulation points will help to speed up the inflammatory period. 

Proliferative phase- During this phase the deposition of new collagen is formed by a process called neocollagenesis 

Remodelling phase- As new healthy and organised collagen fibres are deposited this results in lifting and rejuvenation of the skin.

Structure in Facial Tissues with Ultrasound visualisation

It is very important to understand the structure of the facial tissue to find a treatment that can deliver results at the depth required. For effective results energy must be deposited a specific depths below the surface of the skin. Because of ultrasound's mechanical properties, it is able to be micro-focused below the skin's surface at any depth without causing injury to competing chromophores or the surface of the skin. 

Figure 1.2

Depth of energy delivery 

Figure 1.3