As a result, we are often choosing the more aggressive treatments to get “better results,” only to find more side effects with the same marginal result two months later. Due to the increase in traumatic treatments, there is a battle brewing in the administrative offices of states throughout the country to minimize what aestheticians should be allowed to do. This includes a reasonable likelihood that chemical peels will be removed from the hands of aestheticians. It is critical that we all have a better understanding of the effects of our treatment choices and the skin to which they are being applied.
Before we break down current anti-aging strategies, we need to remind ourselves of the anatomy/physiology with which we are working. It is naive to think that we know what the skin wants/needs better than the skin itself. For example, healthy epidermal skin typically renews all layers within 30 to 40 days. When we are malnourished, (sadly, this includes most of America) or when the skin is not receiving enough nutrients and immune support due to reduced dermal blood flow (again, most of America), the turnover slows from 30 to 40 days (more or less) in its cycle. This results in dull, lifeless skin, exaggerated lines, and potentially worsened areas of pigmentation; but none of that occurred because the skin did not know what it was doing! The exact mechanisms of the skin are far more complex than our current understanding, and yet we often act as if we know its needs better than the skin. The skin slows down turnover when it knows it cannot maintain a healthy barrier at its (preferred) 30-day turnover rate. It takes longer to accumulate the necessary proteins, lipids, and cellular components when their supply has been reduced. Reduced circulation to the skin occurs primarily from cold and mental/physical stress. Reduced nutrition comes from eating artificial foods and gut malabsorption (a problem plaguing as much as 70 percent of the population). When we demand that this “starved skin” turn over faster by stripping valuable lipids and proteins from the epidermis (the “exfoliation method of skin renewal”), we put the skin in a compromised position that results in a more rapid aging process. If the skin felt that the most important aspect of its function was the rate of turnover, it would never slow down. Obviously, the skin puts a premium on having an intact barrier and we all should give the idea some consideration.
Over the years we have discovered that the appearance of dull, lifeless skin and the other conditions seen with reduced turnover are improved with exfoliation. Whether it is AHA’s, microdermabrasion, or excessive retinol, the immediate improvement in appearance was enough justification for us to inflict trauma on the skin. In fact, a common belief is that if we inflict enough trauma to the skin through aggressive chemical peeling, we may create a tightening effect. Unfortunately, that “effect” is either short-term (swelling that takes many weeks to resolve) or medium-term (scarring from medium-depth and deep treatments that takes a few years to resolve). There is rarely real improvement in the health of the dermis from these treatments. The skin remodels scarring; that is one of the primary functions to keep things working properly. Are you really hoping that one of your treatments leaves permanent scarring in your dermis? I know what you are thinking… “But the superficial treatments are renewing the epidermis and making more collagen!” After any exfoliating treatment, the skin is forced to utilize its (often scarce) resources to do its best to patch the holes created in its barrier. It will still take days to weeks to complete that task and it will result in increased epidermal turnover. But at what price? The collagen that is created is primarily to fix the damage just sustained, which means there is less available to fix the skin problem that your client started with. What I’m telling you is that the net effect of the treatment was a trade; the polished skin looks better for a few days to a few weeks, but the inflammation and utilized resources that resulted from that treatment ultimately may have aged the skin more.
I know what you are thinking again… “Inflammation? The lines look better, the pigmentation is lighter, what inflammation are you talking about?” First, let’s take a common sense look at the effects of a compromised barrier. We can all acknowledge that any exfoliating treatment increases sun sensitivity. This occurs because one of the functions of the skin is to reflect light. The skin reflects as much as 80 percent of the sun’s rays when it is intact. Any time there is a “hole” in the barrier from a retinol, an AHA, or a peel/treatment, there is an increase in free radicals and UV damage. Additionally, the antioxidants and already scarce nutrients that were earmarked for the day-to-day operations of the skin are now being redirected to “damage control” as a result of the exfoliation. The biggest challenge we have as skin care professionals is overcoming what we see on the surface because, more often than not, the micro-inflammation I am talking about is not always seen as redness. That is because it occurs at the cellular level and does not stimulate a big enough inflammation cascade to require increased blood flow to that area. My theory is that visibly increased blood flow only comes when a skin event utilizes or requires more resources than are readily available. The skin recognizes the deficiency and calls for more blood flow to supply the needed nutrients, hence redness/erythema appear. Have you ever noticed that fine lines are improved with high-dose retinols, AHA’s, and/or microdermabrasion for a day or so and then they seem to return unchanged shortly after? Have you ever used a 10 percent AHA, irritant (peppers, herbs, oxygen, etc.), or high dose retinol with “nice” results, only to see those results disappear within weeks after discontinuing the treatment? My explanation of these events is that micro-swelling from micro-inflammation tightens the skin temporarily, resulting in short term “improvement” but long-term damage. Everyone agrees and research shows that chronic inflammation thins the skin. Repeated micro-inflammatory insults to the skin definitely result in chronic inflammation. Remember that inflammation also utilizes your skin’s resources, which means there is less available to maintain epidermal/dermal health and integrity.
Here are a few questions that you should ask yourself: If the entire epidermis is going to completely renew itself in 30+ days, what is the value of reducing resources and increasing inflammation during that time if it only improved the turnover rate by a few days? Is using the tool of inflammation the best tool to restore the health and vitality of the skin?
The choice is simple; either we traumatize the skin to speed turnover, or we stimulate the skin to repair itself. By forcing exfoliation, we leave the skin in a continuous state of compromise. When we stimulate the skin, we need to communicate with the right receptors while increasing circulation so that there are enough nutrients for the request to be carried out. An often overlooked aspect of skin care products is their ability to communicate with the skin. For example, many people are passionate about glycolic acid. Have you ever heard of a receptor in the skin that recognizes glycolic acid? No, because it does not exist. This highly damaging acid has only one purpose, destruction. I know what you are saying… “but it loosens the upper epidermis and stimulates turnover.” A more appropriate way to look at it is that it eats away at our protective barrier which causes a repair response. It is not working with the skin, it is simply damaging the skin. Do you think the skin is happy that you placed the AHA night cream on your face? Do you think it was feeling lazy (not turning over) and it really needed the assistance (by being burned) to keep moving through the normal process of exfoliation? I’ve been looking at the results of chronic glycolic use over the past 10 years and more often than not, the skin is significantly thinner than when they started.
Not all AHA’s are the same. The chirally correct “L-lactic acid” (“lactic acid” is not found in the skin) is the only AHA that has receptors in the skin. It is recognized by the skin (because our bodies make it) and provides moisture and other functions. That does not mean that L-lactic acid in high volumes is good for the skin, though. It will still result in over-exfoliation and damage based on its pH and chemical nature if used improperly or excessively.
Retinols also have receptors in the skin. These ingredients are much more active in repair and remodeling, as their receptors are found on the fibroblast themselves which make our collagen, elastin, and glycosaminoglycans. The issue we have with retinols is not their mechanism of action, but rather their ability to absorb and reach their targets. One study found that only 2 percent of retinoic acid (presumably the best absorbing of the retinols, due to its pH and chemical structure) actually penetrated past the first few layers of the epidermis. This means that 98 percent of retinols applied sit on the surface of the skin damaging the barrier, over-exfoliating the skin, and increasing sun sensitivity and free radical formation. Additionally, not all retinols are the same. All-trans retinol is twice as strong at remodeling as regular retinol because regular retinol is made up of 50 percent “all-trans” and 50 percent “cis”. The “cis” form does not stimulate collagen. All-trans retinaldehyde and all-trans retinoic acid have similar strengths and are 500 to 1000 times stronger than all-trans retinol. Retinaldehyde is the least irritating form (in active doses).
So what does all of this mean? We are not achieving the results we would like; we are over-traumatizing the skin every day and we have grown accustomed to aggressive peeling techniques that have too many unwanted side effects for the results they generate. The state boards are taking notice.
In my opinion, it is time for change! I believe we need to stop relying on low pH and harsh chemicals to affect change in the skin. It is an almost barbaric approach when you think about it. I also believe that we need to stop using excessive retinols without a plan for increasing penetration better than 2 percent. Lastly, we need to reconsider anti-aging peels when their primary function is to burn the epidermis that was already on its way up/off anyway. This is a wake up call. Question everything… except that the skin knows best!