Aging skin basics by Dr. Mary Amy Fatima Cagayan-Chua, FPDS. This article originally published in Health and Lifestyle magazine August 2019 issue. This is also published in their website.

Learn more about aging skin basics: factors affecting aging, changes in the laters of the skin, and basic skin care for the elderly.

Aging of the skin is a complex process characterized by the interplay of both intrinsic and extrinsic factors. Intrinsic, or natural skin aging, is largely determined by genetics – and is inevitable with the passage of time. Hormonal changes, such as those seen in postmenopausal women, also contribute to intrinsic aging.

Extrinsic, or external skin aging, is primarily caused by ultraviolet (UV) radiation (photoaging). As much as 80 percent of facial skin aging is due to photoaging. Photoaging is markedly observed in sun-exposed areas, such as the face, neck and hands. Photoaged skin is wrinkled, rough skin, with poor skin elasticity, with pigmentary changes and growth of benign and possibly malignant neoplasms. Other extrinsic factors include atmospheric pollution, lifestyle (smoking, sleep deprivation) and diet.

Aging of the skin occurs throughout the different layers of the skin.

Epidermis

In aged skin, flattening of the dermo-epidermal junction (DEJ) is observed. This leaves the epidermis with insufficient blood supply and nutrients, resulting in impaired thermo regulation and skin pallor. There is also a slower epidermal turnover, which contributes to the dull and rough appearance of the skin. The epidermal changes influence the delay in wound healing.

Dermis

As we age, the dermis undergoes about 20 percent decrease in thickness and has relatively fewer cells and blood vessels. Both intrinsic and extrinsic aging are characterized by increased expression of matrix metalloproteinases (MMP), enzymes which degrade collagen. Collagen production decreases at a rate of about 1 percent per year. Collagen bundles in the aged are thicker but more disorganized and fragmented, resulting in less structural support. Decreased collagen types IV and VII at the base of the wrinkles imply their role in wrinkle formation. Degenerative changes seen in elastin result in sagging skin with poor elasticity and resilience. There is also a decrease in glycosaminoglycans (GAG), particularly hyaluronic acid. The decrease in functional melanocytes causes decreased protection from harmful UV rays.

Subcutis

On a deeper level, there is atrophy of subcutaneous fat particularly in the face and back of the hands. This contributes significantly to sagging or the aged look.

All these changes in the skin predispose the elderly to skin disorders and not just aesthetic concerns. With the increasing life expectancy, there is now more focus on the aging skin disorders and skin care. The most common skin disorder in the geriatric population is senile xerosis. This is closely associated with pruritus, or itching.

Geriatric patients are also frequently diagnosed with skin tears and moisture associated skin damage (MASD). Skin tears are commonly found on the arms and are associated with trauma, such as bumping into furniture. MASD is linked to incontinence-associated dermatitis (perineal dermatitis), intertrigo, ostomy leakage, periwound skin, etc.

Skin care regimen

The most basic and important goal of skin care for the aging is to maintain the integrity of the skin barrier. These are the recommendations in literature.

1. Use gentle cleansers. It is best to use syndets (liquid) with neutral pH and preferably with an emollient.

2. Avoid further friction with use of scrubs, bath cloths, and loofahs. Instead, gently pat the skin dry using a towel.

3. Avoid hot and prolonged baths (i.e., more than 10-15 minutes).

4. Generally, bath oils are not recommended in the elderly due to an increased risk of accidents (may result in slippery floors, causing falls).

5. To relieve xerosis (drying of the skin), pruritus and prevent skin tears, use emollients containing humectants (moisture-retaining substances) and skin lipid replacement agents. Some ingredients to look for are ceramides (20-40 percent concentration), dimethicone, lactic acid (5 percent), urea (10 percent), glycerin and alpha-hydroxy acids (AHA). These improve hydration of the stratum corneum and enhance skin barrier function.

6. Some also advise avoiding perfumes and fragrances that can cause skin irritation.

7. For incontinence-associated dermatitis, a protective barrier cream is recommended. These are usually emulsion with a metal oxide (zinc or titanium), or siliconbased with dimethicone.

8. In the geriatric population, it is still important to protect the skin from UV radiation. Apply a generous amount of a broad-spectrum sunscreen in sun-exposed areas. Wear wide-brimmed hats and clothes with UV protection when outdoors. Often neglected areas include the ears, eyelids, and lips.

Lifestyle and the aging skin

The aging population is advised to increase intake of antioxidant-rich food and avoid a hyperglycemic diet. Attaining the recommended nutritional micronutrients is more challenging in the elderly due to their usually restricted diets and the loss of some of their ability to absorb nutrients.

Avoid smoking and exposure to secondhand smoke. Minimize exposure to pollution, if possible.

A good night’s sleep is important in maintaining healthy skin. A study has shown that elderly women who slept for less than 5 hours a day had compromised transepidermal water loss and skin barrier recovery after UV-induced erythema. Likewise, poor sleep quality results in disruption of the circadian rhythm, leading to cellular dysfunction and changes in various tissues, including the skin.

With the increase in life expectancy, we expect its related comorbidities including its effects on the skin. Having a thorough understanding of the causes of skin aging can help us manage the skin problems of our patients.

• Bibliography:
• Addor FAS. (2018). Beyond photoaging: additional factors involved in the process of skin aging. Clinical, Cosmetic and Investigational Dermatology, 20(11), 437–443. doi: 10.2147/CCID.S177448.
• Baumann, L. (2009). Cosmetic Dermatology: Principles and Practice Second Edition. McGraw-Hill.
• Humbert P, Dréno B, Krutmann J, Luger TA, Triller R, Meaume S, Seité S. (2016). Recommendations for managing cutaneous disorders associated with advancing age. Clinical Interventions in Aging. 12(11), 141-8. 10.2147/CIA.S96232.
• Kottner J, Lichterfeld A, Blume-Peytavi U. (2013). British Journal of Dermatology.169(3), 528-42. doi: 10.1111/bjd.12469.
• Ruxton, C. (2016). Tea: Hydration and other health benefits. Primary Health Care, 26(8), 34-42. doi:10.7748/phc.2016.e1162 Tobin DJ. (2017). Introduction to Skin Aging. Journal of Tissue Viability. 26(1), 37-46. doi: 10.1016/j.jtv.2016.03.002.

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