W ith the exception of the face, the hands are the most expressive portion of the body. We use our hands to greet one another, to enhance verbal communication through gestures, and to offer comfort. As such, aesthetically pleasing hands are a desirable asset. Along with the face, our hands are the only body part constantly visible to others in our society — they are markers of health and beauty. And, as the hands age they can signal declining vitality. The hands are subject to the same aging processes as other parts of the body. As the hands are constantly exposed to the elements, both photoaging and intrinsic aging play a role.1 Changes related to photoaging include epidermal atrophy, solar elastosis, pigmentary irregularities, and the development of actinic keratoses. Intrinsic aging results in loss of collagen and subcutaneous fat as well as decreased barrier function of the stratum corneum. The net effects of these processes result in hands that may appear thin and bony with clearly visible veins and tendons. The overlying skin can show wrinkling, uneven pigmentation, a dry and dull surface appearance and purpura. Fortunately, there are several tools available to rejuvenate aging hands. You have several options when faced with a patient desiring younger appearing hands, including topical treatments, treatment with light, and surgical interventions. This article will present a brief overview of these treatment options (See Table 1). Patient Evaluation As with all cosmetic interventions, rejuvenation of the hands begins with a thorough patient evaluation. Carefully examine the hands to ascertain the extent of aging and to rule out the presence of dermatologic disorders, such as hand eczema and skin cancer. Address and manage these medical conditions before considering cosmetic concerns. Along with the physical examination, start a dialogue with the patient in an effort to define what aging changes of the hands are most bothersome to the patient. After the patient’s desires are clearly delineated, discuss treatment. This should include information on likely treatment outcomes, number of treatments needed for optimal results, cost, and all possible adverse effects. When possible, the discussion should include representative before and after photographs of previously treated patients. Rejuvenation options for aging hands can be divided into general skin care considerations, topical treatments, treatment with light and surgical interventions. General SkinCare Considerations The principles for maintaining healthy and youthful appearing skin on the hands are the same as for other cosmetic units. A certain amount of intrinsic aging changes are inevitable. However, a thoughtful and consistent skincare regimen can slow the overall aging process and make the final results of any cosmetic intervention more long lasting. Such a regimen should include daily sun protection, regular use of moisturizers, and a healthy lifestyle that includes adequate nutrition with appropriate vitamin supplementation and the avoidance of smoking. These minimum measures should be recommended to all patients seeking cosmetic consultation for aging hands. Topical Treatments Topical treatments for aging hands include retinoids, alpha-hydroxy acids, bleaching agents, microdermabrasion, chemical peels and cryotherapy. They are generally aimed at the correction of surface irregularities with the exception of medium depth chemical peels, which also induce collagen remodeling. Retinoids. Topical retinoids can be used for the rejuvenation of aging hands just as they are used for the aging face. Regular use can result in more even skin pigmentation and increased epidermal thickness.2 These results are usually appreciable but not dramatic, and they are slow in onset, generally requiring many weeks of treatment before optimal results are obtained. Additionally, retinoid use must be continued indefinitely to maintain the positive effects. Adverse effects are limited to retinoid-induced dermatitis that can be corrected with decreased frequency of application. Alpha-Hydroxy Acids. Just as retinoids can, alpha-hydroxy acid-containing products can produce reliable results when used consistently over the long term.3 They help with pigment irregularities and epidermal thinning. Maintenance therapy is required for prolonged effects. Alpha-hydroxy acids, such as glycolic acid, have the benefit of being incorporated into many over-the-counter cosmetic products making them easily accessible for patients. Few adverse effects result from their use. Bleaching Agents. A common concern of the patient with aging hands is the appearance of lentigines. While these pigmented lesions will fade slightly with the use of retinoids or alpha-hydroxy acids, they often do not respond to the point of patient satisfaction. In these cases, a topical bleaching agent may be of benefit. Hydroquinones; compounded and proprietary combinations of hydroquinone, retinoid and low-potency steroid (Tri-Luma); and mequinol and tretinoin solution (Solagé) are all proven bleaching agents. They are applied once or twice a day to the hyperpigmented spots. Care must be taken not to treat the surrounding normal skin as halo hypopigmentation can occur. These medicines may take several weeks to months to achieve the desired effect. Microdermabrasion. Microdermabra-sion is yet another option to improve surface irregularities of the hands.4 Treatment is generally performed in a physician’s office with a microdermabrasion unit that propels minute aluminum oxide crystals into the skin and immediately removes them via an integrated suction unit. This promotes gentle exfoliation of the stratum corneum that over the course of several treatments can result in improved skin texture and more even pigmentation. Most physicians recommend a series of six or more treatments at 2-week intervals for maximum effect. While treatment is usually well tolerated, reported adverse events include scarring and pigmentary abnormalities that can be a consequence of over aggressive treatments. Maintenance treatments at longer intervals are necessary for durable results. Chemical Peels. Chemical peels have long been valuable tools in the treatment of aging skin, and their application to the hands is well known. Commonly used peeling agents include glycolic acid, Jessner’s solution, and trichloroacetic acid. The final results and the adverse event profile depend on the depth of the peel, which, in turn, is dependent on the peeling agent used, its concentration, pre-peel skin preparation, and length of time that the agent is in contact with the skin.5 Superficial peels result in controlled destruction of the stratum corneum and part of the epidermis, and produce improved skin texture and pigmentation over the course of a series of treatments. Medium-depth peels cause injury to the level of the papillary dermis and require a longer recovery time than superficial peels. Medium-depth peels produce earlier and more lasting effects on surface irregularities and can also stimulate remodeling of dermal collagen. Adverse events are more likely with increasing depth of the peel and include post-treatment hypopigmentation or hyperpigmentation, abrupt demarcation between the treated and untreated skin, and scarring. Deep resurfacing of the dorsal hands to the level of the reticular dermis is rarely performed due to a high rate of complications. Cryotherapy. Cryotherapy is an easily administered treatment with a long track record of effectiveness in the treatment of lentigines and other benign growths often found on the skin of aging hands. Liquid nitrogen is readily available in most physician offices, and a single freeze-thaw cycle of 5 to 15 seconds is usually adequate for the complete destruction of most benign growths. Drawbacks to this method of treatment include the pain associated with cryogen application and the possibility of permanent pigmentary change and scarring. Treatment with Light One of the paradoxes of dermatology is that light can be both the cause and the treatment for skin disease. Sunlight accelerates the aging process and, as previously mentioned, regular use of sunscreen is important in any hand rejuvenation regimen. At the same time, intense pulsed light and laser treatments are both valuable in improving the appearance of the hands. Intense Pulsed Light Treatment. During intense pulsed light (IPL) treatment, the skin is protected with a cooling gel, and light is applied to the skin through a handpiece. The handpiece contains a filter that determines the range of wavelengths of light to be transmitted to the underlying skin. The handpiece is designed to deliver light to a relatively large surface area with each pulse of treatment, making IPL well suited to quickly treat a skin region such as the dorsal hands. The goal of treatment is more even skin pigmentation.6 The patient should expect optimal results with a series of three to six treatment sessions. The ability of this non-ablative device to induce dermal remodeling is debated. Maintenance therapy at variable intervals is required. Side effects are uncommon but include bruising, pigmentary alteration and, in rare cases, scarring. Increased side effects are associated with more aggressive treatment settings. Laser Treatment. Treatment of the dorsal hands with laser light is generally restricted to the spot treatment of lentigines. As with deep chemical peels, laser resurfacing of the hands has too great a side effect profile to be useful. Laser treatment of lentigines is based on the theory of selective photothermolysis. The target chromophore, in this case epidermal melanin, preferentially absorbs the energy of photons relative to the surrounding tissues, resulting in its selective destruction. As melanin is a dark pigment with a broad range of absorbance, it is effectively targeted by a number of different laser devices. These include the Q-switched ruby (694 nm), the Q-switched alexandrite (755 nm), and the frequency doubled Q-switched Nd:YAG (532 nm) among others.7 By utilizing a small spot size, each lentigo can be precisely targeted avoiding halo hypopigmentation. Multiple treatments may be required, but good resolution can often be obtained in one session (See Figure 1). Adverse events include pigmentary alteration and scarring. These can be minimized by treating patients in the winter when background pigmentation due to tanning is decreased and by using conservative energy settings. Photodynamic Therapy. Recent attention has been given to enhancing the effectiveness of light-based treatments for rejuvenation by the topical application of a porphyrin precursor prior to treatment. Further research will be needed before a final decision on the merits of this tactic can be made. Surgical Treatment To this point several options for addressing the surface imperfections associated with aging hands have been outlined. To address the deeper irregularities associated with dermal atrophy and the loss of subcutaneous fat, a surgical approach is required. Various synthetic and natural filler substances are available for the treatment of dermal and subcutaneous defects. While these have been quite effective for the treatment of facial rhytids, their successful cross application to the treatment of aging hands faces several problems. In addition to the usual requirements of biocompatibility, longevity and a natural feel and appearance, use in the rejuvenation of atrophied hands requires a large volume and the thinness of the dermis in this area demands placement of the filler in the subcutaneous fat rather than intradermally. This disqualifies most fillers currently in use. Some newer substances, such as injectable poly-L-lactic acid (Sculptra), may eventually prove effective, but for now the best approach may be the use of autologous fat transfer. Autologous fat transfer provides a filler that is readily available in large volumes, can be placed in the subcutaneous planes, is biocompatible, and can provide natural appearing correction of atrophied hands for periods of 6 to 18 months.8 Plump and youthful appearing hands can often be produced in one treatment session, although some patients may require multiple sessions to maximize results (See Figure 2). Adverse events include bruising and swelling of the hands, which may temporarily affect the majority of patients to varying degrees.9 A Combination Approach The hands are an important but often neglected cosmetic unit. With their careful assessment, sound knowledge, and proper technique, physicians can help patients recapture some of the lost vibrance and vitality of the hands. A multimodality approach combining topical therapy, treatment with light, and surgical intervention can be implemented for successful hand rejuvenation.
Exploring Aesthetic Interventions, Part X: Rejuvenation Options for Aging Hands
W ith the exception of the face, the hands are the most expressive portion of the body. We use our hands to greet one another, to enhance verbal communication through gestures, and to offer comfort. As such, aesthetically pleasing hands are a desirable asset. Along with the face, our hands are the only body part constantly visible to others in our society — they are markers of health and beauty. And, as the hands age they can signal declining vitality. The hands are subject to the same aging processes as other parts of the body. As the hands are constantly exposed to the elements, both photoaging and intrinsic aging play a role.1 Changes related to photoaging include epidermal atrophy, solar elastosis, pigmentary irregularities, and the development of actinic keratoses. Intrinsic aging results in loss of collagen and subcutaneous fat as well as decreased barrier function of the stratum corneum. The net effects of these processes result in hands that may appear thin and bony with clearly visible veins and tendons. The overlying skin can show wrinkling, uneven pigmentation, a dry and dull surface appearance and purpura. Fortunately, there are several tools available to rejuvenate aging hands. You have several options when faced with a patient desiring younger appearing hands, including topical treatments, treatment with light, and surgical interventions. This article will present a brief overview of these treatment options (See Table 1). Patient Evaluation As with all cosmetic interventions, rejuvenation of the hands begins with a thorough patient evaluation. Carefully examine the hands to ascertain the extent of aging and to rule out the presence of dermatologic disorders, such as hand eczema and skin cancer. Address and manage these medical conditions before considering cosmetic concerns. Along with the physical examination, start a dialogue with the patient in an effort to define what aging changes of the hands are most bothersome to the patient. After the patient’s desires are clearly delineated, discuss treatment. This should include information on likely treatment outcomes, number of treatments needed for optimal results, cost, and all possible adverse effects. When possible, the discussion should include representative before and after photographs of previously treated patients. Rejuvenation options for aging hands can be divided into general skin care considerations, topical treatments, treatment with light and surgical interventions. General SkinCare Considerations The principles for maintaining healthy and youthful appearing skin on the hands are the same as for other cosmetic units. A certain amount of intrinsic aging changes are inevitable. However, a thoughtful and consistent skincare regimen can slow the overall aging process and make the final results of any cosmetic intervention more long lasting. Such a regimen should include daily sun protection, regular use of moisturizers, and a healthy lifestyle that includes adequate nutrition with appropriate vitamin supplementation and the avoidance of smoking. These minimum measures should be recommended to all patients seeking cosmetic consultation for aging hands. Topical Treatments Topical treatments for aging hands include retinoids, alpha-hydroxy acids, bleaching agents, microdermabrasion, chemical peels and cryotherapy. They are generally aimed at the correction of surface irregularities with the exception of medium depth chemical peels, which also induce collagen remodeling. Retinoids. Topical retinoids can be used for the rejuvenation of aging hands just as they are used for the aging face. Regular use can result in more even skin pigmentation and increased epidermal thickness.2 These results are usually appreciable but not dramatic, and they are slow in onset, generally requiring many weeks of treatment before optimal results are obtained. Additionally, retinoid use must be continued indefinitely to maintain the positive effects. Adverse effects are limited to retinoid-induced dermatitis that can be corrected with decreased frequency of application. Alpha-Hydroxy Acids. Just as retinoids can, alpha-hydroxy acid-containing products can produce reliable results when used consistently over the long term.3 They help with pigment irregularities and epidermal thinning. Maintenance therapy is required for prolonged effects. Alpha-hydroxy acids, such as glycolic acid, have the benefit of being incorporated into many over-the-counter cosmetic products making them easily accessible for patients. Few adverse effects result from their use. Bleaching Agents. A common concern of the patient with aging hands is the appearance of lentigines. While these pigmented lesions will fade slightly with the use of retinoids or alpha-hydroxy acids, they often do not respond to the point of patient satisfaction. In these cases, a topical bleaching agent may be of benefit. Hydroquinones; compounded and proprietary combinations of hydroquinone, retinoid and low-potency steroid (Tri-Luma); and mequinol and tretinoin solution (Solagé) are all proven bleaching agents. They are applied once or twice a day to the hyperpigmented spots. Care must be taken not to treat the surrounding normal skin as halo hypopigmentation can occur. These medicines may take several weeks to months to achieve the desired effect. Microdermabrasion. Microdermabra-sion is yet another option to improve surface irregularities of the hands.4 Treatment is generally performed in a physician’s office with a microdermabrasion unit that propels minute aluminum oxide crystals into the skin and immediately removes them via an integrated suction unit. This promotes gentle exfoliation of the stratum corneum that over the course of several treatments can result in improved skin texture and more even pigmentation. Most physicians recommend a series of six or more treatments at 2-week intervals for maximum effect. While treatment is usually well tolerated, reported adverse events include scarring and pigmentary abnormalities that can be a consequence of over aggressive treatments. Maintenance treatments at longer intervals are necessary for durable results. Chemical Peels. Chemical peels have long been valuable tools in the treatment of aging skin, and their application to the hands is well known. Commonly used peeling agents include glycolic acid, Jessner’s solution, and trichloroacetic acid. The final results and the adverse event profile depend on the depth of the peel, which, in turn, is dependent on the peeling agent used, its concentration, pre-peel skin preparation, and length of time that the agent is in contact with the skin.5 Superficial peels result in controlled destruction of the stratum corneum and part of the epidermis, and produce improved skin texture and pigmentation over the course of a series of treatments. Medium-depth peels cause injury to the level of the papillary dermis and require a longer recovery time than superficial peels. Medium-depth peels produce earlier and more lasting effects on surface irregularities and can also stimulate remodeling of dermal collagen. Adverse events are more likely with increasing depth of the peel and include post-treatment hypopigmentation or hyperpigmentation, abrupt demarcation between the treated and untreated skin, and scarring. Deep resurfacing of the dorsal hands to the level of the reticular dermis is rarely performed due to a high rate of complications. Cryotherapy. Cryotherapy is an easily administered treatment with a long track record of effectiveness in the treatment of lentigines and other benign growths often found on the skin of aging hands. Liquid nitrogen is readily available in most physician offices, and a single freeze-thaw cycle of 5 to 15 seconds is usually adequate for the complete destruction of most benign growths. Drawbacks to this method of treatment include the pain associated with cryogen application and the possibility of permanent pigmentary change and scarring. Treatment with Light One of the paradoxes of dermatology is that light can be both the cause and the treatment for skin disease. Sunlight accelerates the aging process and, as previously mentioned, regular use of sunscreen is important in any hand rejuvenation regimen. At the same time, intense pulsed light and laser treatments are both valuable in improving the appearance of the hands. Intense Pulsed Light Treatment. During intense pulsed light (IPL) treatment, the skin is protected with a cooling gel, and light is applied to the skin through a handpiece. The handpiece contains a filter that determines the range of wavelengths of light to be transmitted to the underlying skin. The handpiece is designed to deliver light to a relatively large surface area with each pulse of treatment, making IPL well suited to quickly treat a skin region such as the dorsal hands. The goal of treatment is more even skin pigmentation.6 The patient should expect optimal results with a series of three to six treatment sessions. The ability of this non-ablative device to induce dermal remodeling is debated. Maintenance therapy at variable intervals is required. Side effects are uncommon but include bruising, pigmentary alteration and, in rare cases, scarring. Increased side effects are associated with more aggressive treatment settings. Laser Treatment. Treatment of the dorsal hands with laser light is generally restricted to the spot treatment of lentigines. As with deep chemical peels, laser resurfacing of the hands has too great a side effect profile to be useful. Laser treatment of lentigines is based on the theory of selective photothermolysis. The target chromophore, in this case epidermal melanin, preferentially absorbs the energy of photons relative to the surrounding tissues, resulting in its selective destruction. As melanin is a dark pigment with a broad range of absorbance, it is effectively targeted by a number of different laser devices. These include the Q-switched ruby (694 nm), the Q-switched alexandrite (755 nm), and the frequency doubled Q-switched Nd:YAG (532 nm) among others.7 By utilizing a small spot size, each lentigo can be precisely targeted avoiding halo hypopigmentation. Multiple treatments may be required, but good resolution can often be obtained in one session (See Figure 1). Adverse events include pigmentary alteration and scarring. These can be minimized by treating patients in the winter when background pigmentation due to tanning is decreased and by using conservative energy settings. Photodynamic Therapy. Recent attention has been given to enhancing the effectiveness of light-based treatments for rejuvenation by the topical application of a porphyrin precursor prior to treatment. Further research will be needed before a final decision on the merits of this tactic can be made. Surgical Treatment To this point several options for addressing the surface imperfections associated with aging hands have been outlined. To address the deeper irregularities associated with dermal atrophy and the loss of subcutaneous fat, a surgical approach is required. Various synthetic and natural filler substances are available for the treatment of dermal and subcutaneous defects. While these have been quite effective for the treatment of facial rhytids, their successful cross application to the treatment of aging hands faces several problems. In addition to the usual requirements of biocompatibility, longevity and a natural feel and appearance, use in the rejuvenation of atrophied hands requires a large volume and the thinness of the dermis in this area demands placement of the filler in the subcutaneous fat rather than intradermally. This disqualifies most fillers currently in use. Some newer substances, such as injectable poly-L-lactic acid (Sculptra), may eventually prove effective, but for now the best approach may be the use of autologous fat transfer. Autologous fat transfer provides a filler that is readily available in large volumes, can be placed in the subcutaneous planes, is biocompatible, and can provide natural appearing correction of atrophied hands for periods of 6 to 18 months.8 Plump and youthful appearing hands can often be produced in one treatment session, although some patients may require multiple sessions to maximize results (See Figure 2). Adverse events include bruising and swelling of the hands, which may temporarily affect the majority of patients to varying degrees.9 A Combination Approach The hands are an important but often neglected cosmetic unit. With their careful assessment, sound knowledge, and proper technique, physicians can help patients recapture some of the lost vibrance and vitality of the hands. A multimodality approach combining topical therapy, treatment with light, and surgical intervention can be implemented for successful hand rejuvenation.
W ith the exception of the face, the hands are the most expressive portion of the body. We use our hands to greet one another, to enhance verbal communication through gestures, and to offer comfort. As such, aesthetically pleasing hands are a desirable asset. Along with the face, our hands are the only body part constantly visible to others in our society — they are markers of health and beauty. And, as the hands age they can signal declining vitality. The hands are subject to the same aging processes as other parts of the body. As the hands are constantly exposed to the elements, both photoaging and intrinsic aging play a role.1 Changes related to photoaging include epidermal atrophy, solar elastosis, pigmentary irregularities, and the development of actinic keratoses. Intrinsic aging results in loss of collagen and subcutaneous fat as well as decreased barrier function of the stratum corneum. The net effects of these processes result in hands that may appear thin and bony with clearly visible veins and tendons. The overlying skin can show wrinkling, uneven pigmentation, a dry and dull surface appearance and purpura. Fortunately, there are several tools available to rejuvenate aging hands. You have several options when faced with a patient desiring younger appearing hands, including topical treatments, treatment with light, and surgical interventions. This article will present a brief overview of these treatment options (See Table 1). Patient Evaluation As with all cosmetic interventions, rejuvenation of the hands begins with a thorough patient evaluation. Carefully examine the hands to ascertain the extent of aging and to rule out the presence of dermatologic disorders, such as hand eczema and skin cancer. Address and manage these medical conditions before considering cosmetic concerns. Along with the physical examination, start a dialogue with the patient in an effort to define what aging changes of the hands are most bothersome to the patient. After the patient’s desires are clearly delineated, discuss treatment. This should include information on likely treatment outcomes, number of treatments needed for optimal results, cost, and all possible adverse effects. When possible, the discussion should include representative before and after photographs of previously treated patients. Rejuvenation options for aging hands can be divided into general skin care considerations, topical treatments, treatment with light and surgical interventions. General SkinCare Considerations The principles for maintaining healthy and youthful appearing skin on the hands are the same as for other cosmetic units. A certain amount of intrinsic aging changes are inevitable. However, a thoughtful and consistent skincare regimen can slow the overall aging process and make the final results of any cosmetic intervention more long lasting. Such a regimen should include daily sun protection, regular use of moisturizers, and a healthy lifestyle that includes adequate nutrition with appropriate vitamin supplementation and the avoidance of smoking. These minimum measures should be recommended to all patients seeking cosmetic consultation for aging hands. Topical Treatments Topical treatments for aging hands include retinoids, alpha-hydroxy acids, bleaching agents, microdermabrasion, chemical peels and cryotherapy. They are generally aimed at the correction of surface irregularities with the exception of medium depth chemical peels, which also induce collagen remodeling. Retinoids. Topical retinoids can be used for the rejuvenation of aging hands just as they are used for the aging face. Regular use can result in more even skin pigmentation and increased epidermal thickness.2 These results are usually appreciable but not dramatic, and they are slow in onset, generally requiring many weeks of treatment before optimal results are obtained. Additionally, retinoid use must be continued indefinitely to maintain the positive effects. Adverse effects are limited to retinoid-induced dermatitis that can be corrected with decreased frequency of application. Alpha-Hydroxy Acids. Just as retinoids can, alpha-hydroxy acid-containing products can produce reliable results when used consistently over the long term.3 They help with pigment irregularities and epidermal thinning. Maintenance therapy is required for prolonged effects. Alpha-hydroxy acids, such as glycolic acid, have the benefit of being incorporated into many over-the-counter cosmetic products making them easily accessible for patients. Few adverse effects result from their use. Bleaching Agents. A common concern of the patient with aging hands is the appearance of lentigines. While these pigmented lesions will fade slightly with the use of retinoids or alpha-hydroxy acids, they often do not respond to the point of patient satisfaction. In these cases, a topical bleaching agent may be of benefit. Hydroquinones; compounded and proprietary combinations of hydroquinone, retinoid and low-potency steroid (Tri-Luma); and mequinol and tretinoin solution (Solagé) are all proven bleaching agents. They are applied once or twice a day to the hyperpigmented spots. Care must be taken not to treat the surrounding normal skin as halo hypopigmentation can occur. These medicines may take several weeks to months to achieve the desired effect. Microdermabrasion. Microdermabra-sion is yet another option to improve surface irregularities of the hands.4 Treatment is generally performed in a physician’s office with a microdermabrasion unit that propels minute aluminum oxide crystals into the skin and immediately removes them via an integrated suction unit. This promotes gentle exfoliation of the stratum corneum that over the course of several treatments can result in improved skin texture and more even pigmentation. Most physicians recommend a series of six or more treatments at 2-week intervals for maximum effect. While treatment is usually well tolerated, reported adverse events include scarring and pigmentary abnormalities that can be a consequence of over aggressive treatments. Maintenance treatments at longer intervals are necessary for durable results. Chemical Peels. Chemical peels have long been valuable tools in the treatment of aging skin, and their application to the hands is well known. Commonly used peeling agents include glycolic acid, Jessner’s solution, and trichloroacetic acid. The final results and the adverse event profile depend on the depth of the peel, which, in turn, is dependent on the peeling agent used, its concentration, pre-peel skin preparation, and length of time that the agent is in contact with the skin.5 Superficial peels result in controlled destruction of the stratum corneum and part of the epidermis, and produce improved skin texture and pigmentation over the course of a series of treatments. Medium-depth peels cause injury to the level of the papillary dermis and require a longer recovery time than superficial peels. Medium-depth peels produce earlier and more lasting effects on surface irregularities and can also stimulate remodeling of dermal collagen. Adverse events are more likely with increasing depth of the peel and include post-treatment hypopigmentation or hyperpigmentation, abrupt demarcation between the treated and untreated skin, and scarring. Deep resurfacing of the dorsal hands to the level of the reticular dermis is rarely performed due to a high rate of complications. Cryotherapy. Cryotherapy is an easily administered treatment with a long track record of effectiveness in the treatment of lentigines and other benign growths often found on the skin of aging hands. Liquid nitrogen is readily available in most physician offices, and a single freeze-thaw cycle of 5 to 15 seconds is usually adequate for the complete destruction of most benign growths. Drawbacks to this method of treatment include the pain associated with cryogen application and the possibility of permanent pigmentary change and scarring. Treatment with Light One of the paradoxes of dermatology is that light can be both the cause and the treatment for skin disease. Sunlight accelerates the aging process and, as previously mentioned, regular use of sunscreen is important in any hand rejuvenation regimen. At the same time, intense pulsed light and laser treatments are both valuable in improving the appearance of the hands. Intense Pulsed Light Treatment. During intense pulsed light (IPL) treatment, the skin is protected with a cooling gel, and light is applied to the skin through a handpiece. The handpiece contains a filter that determines the range of wavelengths of light to be transmitted to the underlying skin. The handpiece is designed to deliver light to a relatively large surface area with each pulse of treatment, making IPL well suited to quickly treat a skin region such as the dorsal hands. The goal of treatment is more even skin pigmentation.6 The patient should expect optimal results with a series of three to six treatment sessions. The ability of this non-ablative device to induce dermal remodeling is debated. Maintenance therapy at variable intervals is required. Side effects are uncommon but include bruising, pigmentary alteration and, in rare cases, scarring. Increased side effects are associated with more aggressive treatment settings. Laser Treatment. Treatment of the dorsal hands with laser light is generally restricted to the spot treatment of lentigines. As with deep chemical peels, laser resurfacing of the hands has too great a side effect profile to be useful. Laser treatment of lentigines is based on the theory of selective photothermolysis. The target chromophore, in this case epidermal melanin, preferentially absorbs the energy of photons relative to the surrounding tissues, resulting in its selective destruction. As melanin is a dark pigment with a broad range of absorbance, it is effectively targeted by a number of different laser devices. These include the Q-switched ruby (694 nm), the Q-switched alexandrite (755 nm), and the frequency doubled Q-switched Nd:YAG (532 nm) among others.7 By utilizing a small spot size, each lentigo can be precisely targeted avoiding halo hypopigmentation. Multiple treatments may be required, but good resolution can often be obtained in one session (See Figure 1). Adverse events include pigmentary alteration and scarring. These can be minimized by treating patients in the winter when background pigmentation due to tanning is decreased and by using conservative energy settings. Photodynamic Therapy. Recent attention has been given to enhancing the effectiveness of light-based treatments for rejuvenation by the topical application of a porphyrin precursor prior to treatment. Further research will be needed before a final decision on the merits of this tactic can be made. Surgical Treatment To this point several options for addressing the surface imperfections associated with aging hands have been outlined. To address the deeper irregularities associated with dermal atrophy and the loss of subcutaneous fat, a surgical approach is required. Various synthetic and natural filler substances are available for the treatment of dermal and subcutaneous defects. While these have been quite effective for the treatment of facial rhytids, their successful cross application to the treatment of aging hands faces several problems. In addition to the usual requirements of biocompatibility, longevity and a natural feel and appearance, use in the rejuvenation of atrophied hands requires a large volume and the thinness of the dermis in this area demands placement of the filler in the subcutaneous fat rather than intradermally. This disqualifies most fillers currently in use. Some newer substances, such as injectable poly-L-lactic acid (Sculptra), may eventually prove effective, but for now the best approach may be the use of autologous fat transfer. Autologous fat transfer provides a filler that is readily available in large volumes, can be placed in the subcutaneous planes, is biocompatible, and can provide natural appearing correction of atrophied hands for periods of 6 to 18 months.8 Plump and youthful appearing hands can often be produced in one treatment session, although some patients may require multiple sessions to maximize results (See Figure 2). Adverse events include bruising and swelling of the hands, which may temporarily affect the majority of patients to varying degrees.9 A Combination Approach The hands are an important but often neglected cosmetic unit. With their careful assessment, sound knowledge, and proper technique, physicians can help patients recapture some of the lost vibrance and vitality of the hands. A multimodality approach combining topical therapy, treatment with light, and surgical intervention can be implemented for successful hand rejuvenation.
