Management of Wrinkle :

Prevention and Treatment

Nelva K. Jusuf

Department of Dermatovenereology
Medical Faculty University of Sumatera Utara
Medan-Indonesia
2017
 Introduction

AGING PROCESS

Happens to:
• All living things
• Every organs in the body

(Facial skin)
dry skin tumors
Directly show
symtomps of skin aging
rough mottled
pigmentation
laxity skin fold
wrinkle 1
 Wrinkles can signify
wisdom / some level of
maturity

But the real concern : wrinkles Skin aging is a complex

defined as furrows or ridges on multifactorial process that
the skin surface appear to be involves genetic &
multifactorial in etiology and environmental factors
consequence of skin aging

Combination of intrinsic and

extrinsic skin aging

Wrinkles are the most

representative manifestation &
have an important social impact
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 SKIN
SKINAGING PROCESS
AGING PROCESS

Intrinsic Extrinsic
(chronologic aging) (premature aging)

External factors
Natural factors
sun exposure (major cause)
genetics smoking
hormones pollutants
ethnic humidity
temperature
poor nutrition
The whole skin
Exposed skin

Cannot be prevented
Can be prevented
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 CLINICAL CHANGES

INTRINSIC AGING EXTRINSIC AGING

 Thinning of the skin
 Dryness
 Fine wrinkles, expression lines
deeper
 Laxity of the skin
 Benign skin tumor
 Thickened and rough skin
 Dryness
 Wrinkles deeper and more obvious
 Pigmentation spot
 Telangiectasia
 Benign, precancerous and malignant
skin tumor

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 Glogau Photoaging Classification
TYPE I TYPE II TYPE III TYPE IV
NO WRINKLES WRINKLES IN WRINKLES AT REST ONLY WRINKLES
MOTION
Usually in age Usually in age Usually in age Usually in age
group 20s-30s group late 30s-40s group 50 or older group 60 or older

Early photoaging Early-to-moderate Advance Severe photoaging

photoaging photoaging
Mild pigmentary Early senile Obvious Yellow-gray skin
changes lentigines dyschromias,
teleangiectasis
No keratoses Palpable but not Visible keratoses Prior skin
visible keratoses malignancies
Minimal wrinkles Parallel smile lines Persistent No normal skin
beginning to wrinkling
appear lateral to
mouth

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 80% of facial aging ~ sun exposure

Cancer
Photosynthesis
Sunburn

Photosensitivity Vision dan Photoresponse

Photoimunology Vit D. Synthesis

Alterations Warmth

Cataracs Killing of patogens

Photoaging Phototherapy

Phototoxicity Photo chemotherapy

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 Sunlight

Free radicals
Dermis (more pronounced)

Damage of protein and amino acid

(the prominent component of collagen and elastin) Skin appendages

Degradation of collagen & accumulation of elastin

•  Sebum excretion
 Strength and elasticity •  Activity of
Epidermis Blood vessel sweat gland
• Thinning of skin
Wrinkle lipid surface 
Weakness,  barrier defense
dilated
Disturbing
•Thickening of str.corneum pigmen distribution
•  TEWL
•  Immune system
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Molecular mechanism of photoaging

Collagen synthesis Collagen degradation

Invisible solar scar

Visible solar scar

(wrinkle of photoaging)
(Rittie & Fisher 2002, Rabe et al 2006, Yaar & Glichrest, BA 2007) 8
 Most wrinkle associated with aging
appear on the parts of the body where
sun exposure is greatest

Face

Neck

The back of the

hands

The tops of the

forearms 9
Tobacco smoke has a drying effect on the the surface of the
skin and reduces the amount of blood flowing to the skin,
thus depleting the skin of oxygen and essential nutrients

May develop hollow cheeks through repeated drawing of

cigarettes, which is particularly noticeable in smokers
underweight, resulting in a skeletal appearance

10
Tobacco smoke extracts induce MMP-1 expression in human
fibroblasts and keratinocytes

Effects of cigarette smoke are irreversible,

further deterioration can be avoided with the
cessation of smoking

Skin of smokers prematurely aged

between 10 and 20 years
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Festooning cheek

Perioral wrinkle

Smoker Non Smoker

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Caucasians and Asians have different
skin aging features
Pilot skin aging study between
Chinese and European
individuals showed wrinkle
onset is delayed about 10 years
in Chinese women vs French
women for each facial skin area Study in Japan (Tsuhara , 2008)
(Noureav –Richard S, 2005)

Chinese women (+) more severe 87 women in Tokyo (Japan), 100

wrinkle in the area around the eyes women in Shanghai (China), 90
vs Japanese women women in Bangkok (Thailand)

Thai women (+) significantly more

severe wrinkles in the lower valves
of their faces vs Chinese women Result : indicates the
diversity of Asian skin
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 Wrinkles come in two
categories :

Fine surface lines Deep furrows due to

muscular contraction

2 basic approaches
to amelioration these
signs : prevention and
treatment

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 Prevention
1 • Photoprotection
2 • Don’t smoke
3 • Healthy life and good nutrition

Delay wrinkles

15
 Photoprotection

A key primary preventive strategy in photoaging

Good protective measures include wearing

hat, anti UV sunglasses, sun protective
clothing, appropriate sunscreen application,
sun avoidance during peak UV times
(10 am – 4 pm)

Sunscreen :
• Broad spectrum (UVA and UVB)
• SPF 30+
• Total amount of sunscreen applied to the skin
• The uniformity of application
• Applied 15-30 min before sun exposure and
reapplied every 2 to 3 h especially after bath ,
sweating or swimming
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17
18
 Topical Treatments Reviewed
Drug
Rhytids and Lentigines
Tretinoin (cream/gel)
Tretinoin micro sphere (gel)
Tazarotene (cream/gel)
Retinol moisturizer
Cytokine, growth factor,
matrix protein gel
Manganese peptide
complex
Strengh of
Dosage/Frequency Level of Evidence
Recommendation
0.02% and 0.05%/daily 1 A
0.1%/daily 1 B
0.1%/daily 1 A
0.1%/daily 1 A
Unspecified/twice daily 1 B
Unspecified/twice daily 2 B
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 Broccoli study as a potential topical
antiwrinkle in the future

Study of Broccoli
Effect of Broccoli flower extract (BFE) on
inhibition of photoaging

in vitro study on UVB-irradiated human skin

fibroblast cultured

viewed from matrix metalloproteinase-1 and

procollagen type-1 expression

at mRNA and protein level

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Role of ROS in photoaging

Chen L, Hu JY, Wang SQ. J. Am Acad Dermatol. Nov 2012;67(5):1013-23

21
 Broccoli
(Brassica oleracea L.var.italica Plenck)

Multiple
antioxidant

Sulphoraphane, Vit A, C, E, riboflavine, nicotinamide, betacarotene,

indole, quercetine, gluthatione, iberine, cyanohydroxibuthene,
selenium, kaempferol

Sulphoraphane → anticancer
(Fahey 1999, Singh 2005,Cornblatt 2007, Munday 2008)

Talalay 2007 : inhibit UV induced erythema

Topical (antiinflammatory in vitro / in vivo)
Kerns et al 1997 : Epydermolysis bullous simplex
(antimutagenic in vitro) 22
Photoaging Inhibition Test

BFE MMP-1 mRNA Inhibitor MMP-1

MMP-1 protein

23
 4.

3.

type 1 procollagen mRNA Synthesis type 1 procollagen

type 1 procollagen protein

Compare to group (–) BFE in UVB irradiated human fibroblast culture

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 Cytotoxicity test

Mean of viability cell 113,46%

→ No cytotoxicity → Safe to human skin

→ Promote proliferation of fibroblast suspected because
of BFE (+) antioxidant

25
 Conclusion of the study
BFE
(alkaloids, glycosides, steroids, triterpenoids, saponins, flavonoids)

- +
MMP -1 expression Type 1 procollagen expression
no cytotocic

mRNA + protein mRNA + protein

BFE effective and safe for antiphotoaging in vitro study

It is suggested Further investigation

involving animal and human subjects
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27
 Animal study
The Effectiveness of Broccoli Flower Extract
(Brassica oleracea L. var. Italica Plenck)
as Antiaging in Guinea pigs

70

wrinkled
very
60

50
Wrinkle
wrinkled

40

30

20
no wrinkle

10

0
before UV
sebelum after UV
UV setelah UV week I I
minggu week IIII
minggu week III
minggu III week IVIV
minggu
recovery
krim blanko
Blank cream
krim of broccoli
ekstrak bungaflower
brokoli 1% cream
krim of broccoli
ekstrak bungaflower
brokoliextract
3%
cream extract 1% 3%

Result: Broccoli flower extract cream concentration 1% was able to show effectiveness as antiaging.
Effectiveness is best seen in BFE 3% which is capable of restoring moisture, evenness of skin and
amount of spot in the first week. It also able to restore wrinkle in the third week

Nababan , Jusuf, Saragih (2014)

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 Procedure options

Heat and
Chemical Laser
Dermabrasion radio Botox Fillers
peeling resurfacing
frequency

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Chemical Peels

Medium/Deep peel  wrinkle

Simposium Umum Kesehatan

Tampil Menarik dengan Kulit dan Rambut Sehat
Medan 5 Agustus 2017
30
 PHOTOREJUVENATION
Ablative Laser Skin
Resurfacing (ALSR)

CO2 (Gold Standard)

Non Ablative Laser

Other light-based
tools
eg: IPL, etc.
Goal : Neocollagenesis
A. BEFORE B. AFTER
Simposium Umum Kesehatan
Tampil Menarik dengan Kulit dan Rambut Sehat
Medan 5 Agustus 2017
31
Radiofrequency (RF)

• Skin Tightening
• Skin Lifting
• Skin Rejuvenation
• Wrinkle Reduction.

Simposium Umum Kesehatan

Tampil Menarik dengan Kulit dan Rambut Sehat
Medan 5 Agustus 2017 32
 Botox Procedure
Indication : dynamic wrinkle (crow’s feet, glabellar, horizontal line)

Simple 10-minute procedure consisting of a few tiny injections

Recovery time is minimal

No anaesthesia is required

After injection, it take 3 days for

botox to begin taking effect and
around 7 days to see the full results

The effects of Botox treatment last

up to months
Simposium Umum Kesehatan
Tampil Menarik dengan Kulit dan Rambut Sehat
Medan 5 Agustus 2017
BEFORE AFTER 33
 Skin Filler

Indication

• Improve facial contour

• Raise depressed scars
• Puff up wrinkles

Simposium Umum Kesehatan

Tampil Menarik dengan Kulit dan Rambut Sehat
Medan 5 Agustus 2017 34
 Conclusion
Wrinkles are the most prominent
manifestation and a
consequence of intrinsic and
extrinsic skin aging

There are many ways and

modalities in combating wrinkles
but prevention is still a mainstay

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