By Diane Donofrio Angelucci, contributing writer, July 01, 2014
As increasing numbers of patients seek cosmetic therapy to turn back the clock, they often neglect an obvious site of aging — their hands. Like the face, the hands also develop fine wrinkles and lose volume as a person ages, exposing tendons and veins.
In addition, pigmentation changes and actinic keratoses emerge from longtime sun exposure. Although patients usually apply sunscreen to their faces and may apply it to their necks and ears, they almost always forget their hands, said Jeffrey Dover, MD, associate clinical professor of dermatology at Yale University School of Medicine and co-director of SkinCare Physicians in Chestnut Hill, Mass. “So they sometimes have unequal aging of the hands, where the hands are aging more rapidly than the face and neck,” he said. “There are famous sayings where, if you really want to know the age of a woman, look at her hands, don’t look at her face. The face may trick you, but the hands never do.”
Nevertheless, dermatologists are successfully using a threefold approach, addressing pigmentation issues, volume loss, and sometimes even prominent veins, to help erase the signs of aging on their patients’ hands.
The best approach to hand rejuvenation is to tailor treatments to each patient’s needs, said Neil Sadick, MD, who is in private practice and a clinical professor of dermatology at Weill Medical College in New York. He suggests understanding the patient’s concerns and then matching them to the right technology or combination of approaches.
William Philip Werschler, MD, associate clinical professor of medicine/dermatology at the University of Washington School of Medicine, always begins by assessing the skin for cancerous and precancerous lesions and other skin conditions. “Actinic keratoses are so common as we get older, especially in fair-skinned people and especially on the back of the hands,” he said.
To treat actinic keratoses, Dr. Werschler uses topical treatments, such as ingenol mebutate (Picato) or fluorouracil (Carac), or lasers for field therapy, rather than treating individual spots, and reminds patients to use sunscreen on the backs of their hands. He then prescribes fluocinolone acetonide 0.01 percent, hydroquinone 4 percent, and tretinoin 0.05 percent cream (TRI-LUMA, Galderma) for nightly use to fade the age spots. However, he said, this approach more effectively prevents pigmentation changes rather than treating them after they’ve occurred.[pagebreak]
Addressing pigmentation changes
Dermatologists can choose from a number of laser and light treatments, including intense pulsed light (IPL) and Q-switched and fractionated lasers, as well as chemical peels, to address pigmentation changes.
“In terms of brown spots and liver spots, the IPL treatments rule, and they are quite satisfying,” said Derek Jones, MD, associate clinical professor at the University of California, Los Angeles, and founder and director of Skin Care and Laser Physicians of Beverly Hills, California. Initially, brown spots darken, but then they flake off in one to two weeks. Robert Weiss, MD, director of the Maryland Laser Skin and Vein Institute and clinical associate professor at the University of Maryland, also prefers IPL. “It works not only on treating the spots, but because it’s a field therapy where you’re treating the back of the hand, the texture of the skin improves as well,” he said. Dr. Weiss prefers sapphire crystal versus quartz IPL therapy. “[With] quartz the heat can build up in the skin,” he said. Kimberly Butterwick, MD, a cosmetic dermatologist with Cosmetic Laser Dermatology in San Diego, uses IPL in patients with mottled pigment or skin that bruises easily. “It can help to thicken up the epidermis so it’s a little bit less prone to bruising,” she said. In the Journal of Cutaneous Medicine and Surgery, investigators reported good to excellent results in improving skin quality and lentigines in a group of 23 patients after four IPL treatments (2008;12:107-113).
To improve skin texture, Dr. Jones uses the fractionated erbium laser; however, he emphasized that CO2 lasers cannot be used for the hands because the hands do not have the follicular structure to heal properly.
Frederic Brandt, MD, head of the Dermatologic Research Institute in Miami, uses nonablative fractional lasers, such as the 1,927 thulium laser. “That’s great for erasing a lot of actinic damage on the hand, brown spots, and resurfacing the hand, giving it a smoother appearance,” Dr. Brandt said. For discreet lentigos, he combines this treatment with a Q-switched alexandrite or ruby laser.
Dr. Dover uses Q-switched lasers, such as the alexandrite, to remove brown spots, treating once per month for three months. “You can get between 80 and 95 percent improvement of the brown spots and they stay away,” he said. In a 2006 study in the Journal of the American Academy of Dermatology, the Q-switched alexandrite laser and IPL improved freckles and lentigines in Asian patients. Postinflammatory hyperpigmentation did not occur after IPL, but it did occur in eight patients with lentigines and one patient with freckles after treatment with the alexandrite laser (54:804-810).
To treat wrinkling, dermatologists can use a radiofrequency technology like Thermage or the Legacy, which plumps up the collagen, Dr. Sadick said.
To improve the texture of the skin, Dr. Brandt has injected azficel-T (Laviv, Fibrocell Science). With this procedure, three 3-mm punches of skin are removed from behind the ear and cultured; the cells are grown and fibroblasts are reinjected into the dorsum of the hand during three treatments over the course of three months. “That will not so much add volume but improve the texture, fine wrinkling around the hand, the crepiness,” he said. However, he said, because this is expensive, it is not widely used. A study in Dermatologic Surgery by Smith et al. demonstrated that it safely and effectively treated nasolabial fold wrinkles in the face (2012;38:1234-1243).
Although dermatologists sometimes use chemical peels, lasers are more common. “I think peels are done, but I think now people tend to go more toward lasers because you can be a little more selective and controlled,” Dr. Brandt said.
Resurfacing treatments carry the risk of hyperpigmentation, scarring, and infection, Dr. Werschler said. “But I find those risks to be very, very low and very acceptable in terms of a risk-benefit ratio,” he said. “I would say that they certainly fall within the same range as treatment on the face.”
To reduce the risk of hyperpigmentation, Dr. Butterwick suggested not using lasers on patients with very dark skin. “The lighter skin types, Fitzpatrick I through IV, are quite safe, although, in type III to IV you might choose a laser with a longer wavelength. With IPL, if a patient is tan you need to back off the energy and not try to hit a home run in the first treatment but maybe do two or three treatments a month apart,” she said.
To maintain the effects of resurfacing treatment, dermatologists recommend that patients consistently use sunscreen. Even with this precaution, however, patients probably will need to be treated approximately once per year, Dr. Weiss said. “Unless they wear something totally opaque, chances are that area of skin has accumulated enough lifetime ultraviolet exposure that there are going to be new lesions that occur,” he said.[pagebreak]
Addressing volume loss
To restore volume in the hands, autologous fat transfer has a long history of use. “But fat transfers do take a donor site, harvesting the fat, and then transferring it to the hands, so there is recovery, and it is quite expensive,” Dr. Jones said.
Dr. Butterwick explained that, before calcium hydroxylapatite (Radiesse, Merz Pharmaceuticals) was available, she injected approximately 10 ml of fat into the back of each hand. “It’ll stay swollen a while, but we get good longevity — up to certainly a year and often up to three years,” she said.
In a study published in Dermatologic Surgery, she reported that patients had better results with fat that had been centrifuged versus fat that was not (2002;28:987-991). “It’s a beautiful treatment for the back of the hands,” she said. “It hides the veins and it makes the overlying skin look better, and it seems to thicken it up because there are some stem cells in the fat.”
However, not everyone agrees on the value of the procedure. Dr. Werschler found that autologous fat lacked a normal appearance. “The backs of the hands kind of looked like they had fat in them, and there were problems with durability over time,” he said.
A range of dermal fillers also are being used off-label in the hands, and these may show benefits almost immediately. Calcium hydroxylapatite filler is a popular option, which was reported by Busso and Applebaum in Dermatologic Therapy in 2007 (20:385-387). It is undergoing a Food and Drug Administration (FDA) registration trial for that use. Dr. Werschler prefers this product, which, he explains, acts as a filler and collagen stimulator, thickening the skin.
Dr. Butterwick often uses calcium hydroxylapatite, diluting it with 0.5-1.0 ml lidocaine for a smoother result and to reduce discomfort. “We have patients then sit on a hand for a little bit to apply pressure to reduce the chance of bruising, and it always looks very smooth and nice,” she said.
Dr. Brandt uses Belotero Balance (Merz) or Juvderm (Allergan), both hyaluronic acid-based dermal fillers, injecting 2-3 ml subcutaneously with a 27-gauge cannula. In a Dermatologic Surgery study Dr. Brandt performed with his colleagues, small gel particle hyaluronic acid (Restylane, Medicis Aesthetics) improved the appearance of the veins, tendons, and bony prominence of the hands (2012;38:1128-1135).
Poly-L-lactic acid (Sculptra, Valeant), which stimulates collagen production, is another option. However, nodules can occur that may last for several years, Dr. Werschler said. A Dermatologic Surgery review by Fabi and Goldman described techniques that have been used to reduce the risk of nodule formation with poly-L-lactic acid (2012;38:1112-1127).
Dermal filler and fat injections can cause discomfort that may last several weeks, however, it appears to be temporary and can be treated with cool compresses, ice packs, or nonsteroidal anti-inflammatory medications, Dr. Werschler said.
When injected into the hands, poly-L-lactic acid results lasting at least 18 months in a patient have been reported in the Journal of Cosmetic and Laser Therapy (2010;12:284-287). Calcium hydroxylapatite lasts six to 12 months in the hands, Dr. Jones said. Diluted Juvderm Voluma XC may last longer, he said, although this is not definite. “We are not certain of that because it hasn’t been formally studied, and when it’s used in the hands, it really should be diluted down quite a bit—at least 30 percent, if not more,” he said.
When injecting fillers, safe technique is critical. “There are vessels that do communicate with the pulmonary system, so we must make sure that we are not accidently injecting product into a vessel because we could create a pulmonary embolus,” Dr. Jones said. “This is an advanced technique, not for the physician extender. This is a physician treatment only, in my view, and so you really must know your anatomy and be in the proper plane underneath the skin.”
Furthermore, the filler must be evenly distributed throughout the hand. “We massage it until it’s very smooth,” Dr. Brandt said.
In patients with very thin skin, Dr. Butterwick recommended using a 1.5-inch cannula rather than a needle to inject fillers or autologous fat to reduce the risk of bruising. “I also think it’s important when filling the hands to not just fill the back but go all the way to where the fingers meet the hand, between the knuckles, so you get a very natural look, and taper the filler at the base of the finger,” she said.[pagebreak]
Taking aim at prominent veins
Dermal fillers often camouflage protruding veins, but if veins are very large, some dermatologists may treat them.
“What we use is sclerotherapy or foam sclerotherapy for hand veins,” Dr. Sadick said. “We also developed an endovenous laser fiber a small little laser fiber that can be inserted into those very protuberant hand veins.”
“One of my personal favorite solutions to use is polidocanol (Asclera), which is one that was approved by the FDA in 2010,” Dr. Weiss said. “We get pretty nice results in one or two treatments. The veins typically will either completely disappear or often they reopen, but they are much, much smaller than when we started.”
However, Dr. Jones does not perform sclerotherapy. “My feeling is that, if you properly volumize the hands, the veins look a lot better, and you never know when you might need that vein for an IV when you get older, so I don’t like sclerosing the veins,” he said.
Although rare, a prolonged area of hardness of the vein can occur with sclerotherapy, and ulceration has been reported for leg treatments, Dr. Weiss said.
Maintaining therapy effects
To maintain results, dermatologists should remind patients to use sunscreen and products with tretinoin plus bleaching agents, Dr. Werschler said. “You can continue to do Fraxel or peels or IPL treatments, so you continue to maintain the effect of the surface of the skin to be smooth and even and less wrinkled and less blemished,” he said.
Like their patients, dermatologists may need to broaden their antiaging focus. “It would be so easy for us as a group to educate our patients,” Dr. Dover said. “When we talk about skin — it’s not just facial skin, it’s the face, neck, ears, chest, and hands. Never forget the hands.”
When prescribing antiaging creams and recommending sunscreen, dermatologists should remind patients not to forget their hands and areas other than the face. “That should be our mantra because it’s much easier to prevent the brown spots and fine wrinkles from forming than to treat them,” Dr. Dover said.
In the meantime, dermatologists have a lot to offer to patients whose hands have aged more quickly than their faces. “We have now developed some very, very effective — and I think very cost effective, very safe, and very quick treatment protocols — to rejuvenate the hands in such a fashion that now the hands match the face,” Dr. Werschler said.
Editor’s note: Dr. Werschler owns stock in Allergan and is an investigator, speaker, consultant, or advisory board member for Valeant Pharmaceuticals, Allergan, Merz Pharmaceuticals, and Galderma. Dr. Brandt serves on the advisory board for Allergan, Merz Pharmaceuticals, and Laviv. Dr. Jones is an investigator and consultant for Allergan and Merz Pharmaceuticals. Dr. Weiss serves on the advisory board and is a speaker for Cynosure, is a consultant for Merz Pharmaceuticals, and has been an investigator for Syneron and Candela. Dr. Butterwick is on the advisory board for Merz Pharmaceuticals, Valeant, and Allergan and is an investigator for Allergan. Dr. Sadick is an investigator, speaker, and consultant and has stock options for Venus Concept and is an investigator and speaker for Solta Medical. Dr. Dover has no financial interest related to his comments.