Sun-damaged skin has wrinkles, texture alterations, dispigmentation with melasmas and lentigines yellowing or sallow appearance, thinning, fine telangiactasia and mottling.
Sun damaged skin can have pre-malignant changes such as solar keratoses (actinic keratoses), basal papilomas and seborrhoaic keratoses. Sun damaged skin is predisposed to the development of malignant skin tumours, the most common of which can be found around the periocular area and face being the basal cell carcinoma.
People with skin number 1 and 2 skin type (red or blonde haired individuals) are more prone to both sun damage and skin tumours. Skin tumours caused by sun also include squamous cell carcinoma and malignant melanoma, fortunately more rare, but more serious.
In particular, sun damaged skin looks older because of the dehydration, pigment changes, thinning and wrinkles.
Deep lines occur in the periorbital area and face partly becuase of sun damage but more due to muscle action from the muscles of facial expression which cause deep lines in an already thin and aged skin.
First, the patient will be asked what aspect of their sun damaged skin concerns them.
Examination of patients with sun damaged skin will involve taking a thorough history concerning sun exposure when younger, whether they have lived abroad or worked outside, habitual sunscreen use and skin care. Any family history of maligant skin tumours such as basal cell carcinoma should be given. Any known dermatochalogical conditions should be discussed.
It is important for the oculoplastic surgeon to know whether the patient has recieved or is recieveing treatments such as tretinoin cream, chemical peel (e.g. TCA), laser skin resurfacing, filler (e.g. Restylane®). Similarly, it is important to know whether they have had any previous periorbital or facial surgery.
The periorbital area and face is assessed for fine wrinkles and deep lines, skin elasticity, skin quality including the presence of dispigmentation with melasma and lentigenes. Other ageing features such as brow or eyelid ptosis, mid-face decent, malar bags and dermatochalasis are assessed.
The patient will be asked on smoking habits, drug allergies and current medications.
Photographs of the sun damaged areas will normally be taken. You should bring along photographs of your face when younger as this helps plan treatment.
Sun damaged skin can be greatly improved with treatment. The treatment is multimodal:
- Diet high in Omega-3,6 and 9 foods, to improve overall quality of skin
- Daily skin care with paraben free and perfume free moisturise and cleanse
- Sun damage protection with sun cream which has a very high, broad and stable UVA/B protection, such as La Roche-Posay Anthelios XL 50+ Extreme Tinted Fluid or Antithelios AC SPF30 Extreme Fluid which both contain Mexory® SX and XL. Many other sun creams are available with similar protection.
- Tretinoin treatment. Tretinoin, commonly known as Retin-A, is a topical cream or gel to treat photo-ageing skin with fine wrinkles and dispigmentation. The most commonly used strengths around the periorbital area and face are tretionoin 0.05% and 0.025%. Tretinoin will produce a rosey glow to the skin with a fine translucence and healthier appearance. It does reduce fine wrinkles, surface roughness and may help prevent adverse effects of ultra-violet light by increasing the amount of collagen in the skin. Tretinoin is available by prescription, e.g. as Differin ®. Tretinoin is applied lightly to the perioribtal areas and face, neck and backs of hands at least three times a week at night. Once the patient has accustomed to it, it can be applied daily. It is imperative that patients using tretinoin treatments wear a strong factor (50+) sunblock during the day. It can take between two and six months of application before noticeable improvement of skin quality. Its use can be continued over years.
- Higher strength tretinoin cream 0.1% (e.g. Pigmanorm ®), combined with hydroquinone and a small amount of steroid can be prescribed for larger melasmas (flat, brown patches), but their use has to be monitored closely by the oculoplastic surgeon.
- Chemical peels (e.g. TCA). TCA 20-30% is used to provide a superficial depth epithelial peel and can reverse solar lentigenies, imrpove solar keritoses, improve skin texture and slightly improve fine wrinkles. Its effect is to tighten the skin by correcting some of the epidermal atrophy and helping to lay down new collagen. The peel represents superficial layers of the epidermis exfoliating and then there is re-epithelisation with fresher looking skin. Peeling involves producing the effect equivilant to a moderate sunburn with redness, some discomfort and irritation occuring before the peel. Please see the chemical peel section for more information.
Skin tumours such as basal cell carcinoma are diagnosed by making a small biopsy of a suspicious lesion and sending the tissue for cellular analysis. Once a basal cell carcinoma has been diagnosed, the whole tumour can be removed using Mohs’ micrographic surgery. The eyelid and periorbital reconstruction is performed by the oculoplastic surgeon.