HEALTH: WAR on WrinklesMy friend who lives in the Caribbean says it’s malpractice for a person my age not to be using a prescription wrinkle cream,” e-mailed a neighbor, friend and patient whom I will call Betty. “Please send me a prescription for Tazorac.”

It is amazing that Betty has time to be concerned. She and her husband are in just about every organization in the French Quarter. Rarely do they have a free night. Each weekend is a bevy of wine tastings, dinner parties, opera, theater and various neighborhood to-dos.

Wrinkles are not the first sign of aging but they are the most noticeable and worrisome to many. Other cutaneous changes of aging, such as dry skin and hair that’s thinning and graying, take a back seat to wrinkles and facial sagging.

The atomic bomb for the war on wrinkles is the face lift – a surgical stretching of the face. Other office-based procedures include peels, dermabrasions and injections of various fillers to expand shrunken spots and botulinum toxin (“Botox”) as a temporary erasure for wrinkles.

But there are less invasive and much cheaper potions around that really work in the long term. Many New Orleanians are turning to various prescription creams in a longer lasting war than the Arab/Israeli conflict – the War on Aging.

One of the newer weapons in this war are retinoids, which are chemical compounds related to vitamin A, an essential vitamin for healthy skin. Among other actions, these vitamin A derivatives regulate cell growth at the skin level. Sun depletes normal skin of these compounds. Prescription Retin-A first became popular more than 20 years ago as an acne treatment. For years dermatologists have used retinoids to treat acne and psoriasis. Now approved by the FDA to treat sun-damaged skin, retinoids were used off-label for years to blanch the dark spots related to sun exposures, to erase wrinkles and to keep skin more youthful in appearance.

Good clinical studies on retinoids to reverse aging skin changes date back to a pivotal 1988 study. University of Michigan dermatologists published results of a double blind trial comparing a placebo cream to the same cream with added Retin-A. All study participants had visibly sun-damaged skin. All applied a placebo cream to one forearm and the same cream spiked with Retin-A the other forearm. Half then smeared on the placebo cream to their faces while the other half used the cream with the active ingredient. Neither patient nor the evaluating physicians knew what was going where until the study ended. The code was broken after four months and the results were impressive. All forearms and all faces except one receiving the Retin-A showed statistically significant reductions in spots related to sun exposure and aging. Skin biopsies from the forearms confirmed favorable histologic changes in treated skin compared to skin treated with the placebo cream. A problem was the initial adverse effects. Retin-A often caused early excessive skin redness, peeling, scaling, dryness, burning, stinging and irritation.

In 1995 the FDA approved Renova, a retinoid similar to Retin-A, for the treatment of fine wrinkles, spotty discolorations and rough skin caused by sun damage and aging. The first prescriptions were as a 0.05 percent cream. Later the company marketed a 0.02 percent strength that was much less irritating with initial use.

There is a thin margin between the effective dose and adverse effects with the retinoids known well by this writer. When the FDA first released Renova, I got a sample tube from the pharmaceutical representative, smeared it on for a couple of days, awoke up a few mornings later with a red, peeling, painful face and I’ve feared retinoids ever since. This again proved an old adage in medicine: “A physician who treats himself has a fool for a patient.”

By 2002, a third generation retinoid was on the market. Avage and Tazorac contain the same active chemical ingredient and data on effectiveness is impressive. Properly supervised daily applications over several months reduce both fine and coarse wrinkles, mottled pigmentation, pore size, old age spots and skin roughness.

A problem with the non-prescription retinols is that the typical consumer doesn’t know where to begin, applies too much or too often, gets adverse effects and quits, says Dr. Deirdre Hooper. About 300 retinol containing cosmetics are sold under various confusing names in the U.S. “The problem with over-the-counter creams is that they come in various strengths and with other ingredients. It can be confusing, and there’s no way for the average consumer to know what to try,” says Hooper, one of two young dermatologists in Audubon Dermatology, a booming practice Uptown near Touro Infirmary. “I think the best over-the-counter retinols out there are Neutrogena’s and Green Cream. Neutrogena products are [available] at pharmacies and grocery stores. Earthsavers, specialty spas and many dermatologists sell Green Cream,” says Hooper.

The really effective stuff is where condoms were in the old days – back behind the counter with the prescription drugs. Most neophytes to the retinoid game need a coach and that’s where a good dermatologist is indispensable. “There is wide variability in efficacy and tolerability among the prescription products, and the best route is to discuss your individual needs with your physician. These creams and gels are more potent in producing exfoliation or skin cell turnover, decreasing pore size, and evening out the skin’s pigment distribution, but they can be more irritating if not used correctly,” says Hooper.

“There is no reason someone 15 years old should not be using a retinoid to help prevent sun damage and keep pore size down,” continues Hooper. They also help decrease acne changes. I think the time to start regular retinoid use is when a child sees his or her first blackhead.

A person who already has red or irritated skin needs to get that condition under control first, but I believe retinoids are a universally needed cream. It is important to use them correctly – tiny amounts as skin irritating adverse effects are common if too much is applied. (SEE BOX)

The vehicle is important, adds Hooper. These prescriptions come in both creams and gels. Most tolerate creams better. Gel preparations are more drying and better for oily skin types. But some men definitely prefer the gels.

Avage and Tazorac have a proven track record in improving skin marred by mottling, hyperpigmentation and sallow complexions. They decrease both fine and coarse wrinkling caused by sun damage. When used regularly over one year, there’s a decrease in skin cancer precursor cells along with improved collagen production.

The only drawback – results aren’t instant. Some people note improvement by two weeks and most by four weeks, but once-daily applications continue to ameliorate signs of aging and sun damage after one year. Like marriage, retinoid applications are for the long run.