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Jenifer Hammond MD Anita Wolfe FNP Park Meadows Center for Cosmetic Procedures. Cosmetic Dermatology in Primary Care. What is Skin?. A protective, yet permeable barrier for the human body Body’s largest organ Most essential source of sensory stimulation. Three layers of skin. Epidermis

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cosmetic dermatology in primary care
Jenifer Hammond MD

Anita Wolfe FNP

Park Meadows Center for Cosmetic Procedures

Cosmetic Dermatology inPrimary Care
what is skin
What is Skin?
  • A protective, yet permeable barrier for the human body
  • Body’s largest organ
  • Most essential source of sensory stimulation
three layers of skin
Three layers of skin
  • Epidermis
  • Dermis
  • Subcutaneous fat (hypodermis)
epidermis outer layer
Epidermis (outer layer)
  • 1. Stratum corneum - “dead outermost layer” consists of 15 - 40 layers
  • 2. Granular layer
  • 3. Spinous layer- is the matrix
    • Melanocytes produce the pigment, melanin
    • Langerhans’ immune cells
    • Merkel’s sensory stimulation cells
  • 4. Basal layer- basal cells divide to make new skin about every 30 days
dermis middle layer
Dermis (middle layer)
  • 1. Papillary layer
    • haphazardly arranged thin collagen
  • 2. Reticular layer
    • thick collagen arranged parallel for structure
    • elastin fibers
    • sebaceous glands, hair follicle, blood vessels
free radical theory of aging dehnam harman 1956
Free Radical Theory of Aging Dehnam Harman, 1956
  • First proposed theory of aging
  • Free radicals occur naturally with human metabolism and aging
  • Free radicals cause damage to DNA/RNA leading to decreased cell function and disease.
intrinsic aging
Intrinsic Aging
  • Genetics set the internal clock of human metabolism
  • Decreased estrogens during menopause contribute to collagen loss in women
extrinsic aging
Extrinsic Aging
  • Photodamage - 80%
  • Smoking
  • Stress
  • Poor nutrition
  • Pollution
  • Excess alcohol
facts of aging skin
Facts of Aging Skin
  • Signs begin about age 30
  • Texture changes
    • Decreased cellular turnover in epidermis causing fine lines and wrinkles
    • Collagen decreases by 1% yearly after age 30 causing thinner skin
    • Decreased elastic fibers, fat, and blood vessels causing decreased elasticity
    • Decreased hair follicles, sweat ducts, and sebaceous glands
    • Decreased water binding capability causing dryer skin
clinical signs of aging skin
Mild dryness

Fine lines and wrinkles



Spider veins

Skin tags

Red spots

Clinical Signs of Aging Skin
clinical signs of photoaging skin
Clinical Signs of Photoaging Skin
  • Texture changes
    • dryness, enlarged pores, wrinkles
    • pigment changes- sun spots, freckles, melasma
  • Vascular changes
    • spider veins, red spots, rosacea
  • Degenerative changes
    • Benign- seborrheic keratosis, skin tags, moles
    • Precancerous- actinic keratosis
    • Cancerous- melanoma, basal cell, squamous cell
facts about photoaging
FACTS about PhotoAging
  • 20 minutes of sun exposure is enough to cause damage to the skin.
  • Sunburn and sun-tanning causes wrinkles and thinning skin.
  • Number one risk factor for all skin cancers is SUN EXPOSURE! (one blistering sunburn doubles the risk of skin cancer)
what is the treatment for photoaging skin
What is the treatment for Photoaging Skin?
  • Diet high in fruits and vegetables
  • Adequate oral hydration ( 64 oz + daily)
  • Good daily skin care regimen
  • No Smoking
  • Rejuvenation procedures
  • Protection/Prevention
you are what you eat
You Are What You Eat!
  • 64 oz water per day to hydrate
  • 6 servings of fruits
  • 6 servings of vegetables
  • Omega 3 fatty acid or fresh fish 3x week
  • Less than 2 servings of caffeine/day
what is good skin care
What is Good Skin Care?
  • Cleanse-PH balanced wash 2x/day
  • Exfoliate-chemical and physical
  • Hydrate-topically and orally
  • Protect
    • UVA/UVB Sunscreen
    • Topical antioxidants
  • Rejuvenate
    • Retinoid 3 – 5x weekly
    • Optional Rejuvenation Procedures readily available
  • 1. Chemical exfoliation
      • Glycolic or Salicylic Acid daily skin care
      • Chemical peels
      • Retinoids
  • 2. Physical exfoliation
      • Fine granular scrubs
      • Microdermabrasion
  • 2nd most common non-surgical cosmetic procedure in the United States
  • Mechanical removal of the outer 1-2 dead layers of skin with a “sand blasting” technique
  • No down time
  • Works well with chemical peels

1. Drink 64 oz water daily

2. Topical moisturizers

  • Barriers- block water loss
    • Petroleum, lanolin, paraffin, beeswax
  • Emollients- smooth edges
    • Petroleum
  • Humectants- draw water into skin
    • Glycerin, urea, hyaluronic acid, glycolic and lactic acid
skin cancer facts 2007
Skin Cancer Facts 2007
  • 3% increase in all skin cancers
    • 1 million new cases of non-melanoma
    • 60,000 new cases of melanoma
    • 8,000 deaths last year from melanoma
topical c
Topical C
  • L-ascorbic Acid
  • Lasts 72 hours
  • Increases collagen synthesis
  • Decreases cell damage from sun 58%
  • 10% minimum concentration to be effective
prevage md
Prevage MD
  • Topical antioxidant Idebenone
  • 0.5% available over the counter
  • 1% is prescription strength
  • Protects from sun, air pollution, smoke, and ozone 95%
  • Use twice daily; titrate up
uvb protection
UVB Protection
  • SPF (Sun Protection factor) is a measurement of UVB protection only.
    • Refers to the ability of a sunscreen to delay sun-induced redness in epidermis
    • SPF 30 blocks 97% for 2 hours;
      • SPF 15 blocks 93%,
      • 50 blocks 97%,
      • 70 blocks 97%
uva protection
UVA Protection
  • Measured by PFA (protection factor)
  • Present sunrise to sunset
  • Present cloudy days, even in winter
  • Passes through windows
  • Penetrates deep into dermis
  • Cause up to 80% of skin damage
sun protection tips
Sun Protection Tips
  • Apply 30 minutes prior and every 2 hours
  • Apply generously
  • Choose Total UVB/UVA protection
    • Titanium dioxide, zinc oxide – Sunblock
      • Blue Lizard sensitive skin SPF 30+
    • Helioplex – avobenzone w/oxybenzone
      • Neutragena Ultra Sheer Dry Touch SPF 55
    • Mexoryl SX – avobenzone w/Octocrylene
      • Lancome UV Expert 20
      • La Roche-Posay Anthelios SX
      • Ombrelle Sunscreen Lotion
uva protection what s new
UVA protection “What’s New”
  • Zinc Oxide or Titanium Dioxide
    • Physical barrier to block all sun rays
  • Parsol 1789 (Avobenzone)
    • Developed in 1992 to protect against UVA
    • Recently found unstable and loses effectiveness in 2 hours of exposure to sun.
  • Helioplex
    • Avobenzone stabilized with Oxybenzone to protect against UVA for 6 hours
    • Neutragena Ultra Sheer Dry touch
  • Mexoryl
    • Avobenzone stabilized with Mexoryl SX or Tinosorb to protect against UVA for 4 hours
    • Lancome UV Expert 20 and LaRoche-Posey Anthelios SX
summer solstice
Summer Solstice
  • June 21st is the day of highest sun intensity.
  • On a clear day, intensity April 21st equals that of August 21st.
  • Stimulates collagen production
  • Decreases cell damage from sun exposure
  • Increases skin cell turnover
  • Helps prevent skin cancer
    • Tretinoin (Retin-A, Renova)
    • Terazatane (Tazorac)
    • Differin (Adapalene)
rejuvenation procedures
Chemical Peels


Facial Fillers

Laser treatments

Rejuvenation Procedures
what are chemical peels
What are Chemical Peels?
  • Application of a chemical solution to produce a controlled peel.
  • Purpose: To allow peeling of the sun-damaged layers resulting in rejuvenation of the skin. Newer healthier cells and more even skin tones.
benefits of chemical peels
Benefits of Chemical Peels
  • Benefits:
    • Stimulates collagen and reduces the appearance of wrinkles.
    • Diminishes pigmentation associated with sun damage, acne, and melasma.
    • Treats pre cancerous changes of the skin.
    • Improves texture and pore size.
glycolic acid aha
Glycolic Acid (AHA)
  • Promotes exfoliation
  • Increase the density of collagen
  • Functions as moisturizer
  • Good for regular skin types
  • Causes superficial flaking and redness for 1 – 4 days
salicylic acid 17
Salicylic Acid 17%
  • Lipophilic : Penetrates the oil filled follicles in acne
  • Good for oily skin types
  • Anti-inflammatory properties are good for rosacea and acne
jessnar s peel
Jessnar’s Peel
  • Medium depth peel
  • Lactic acid, Salicylic acid and Resorcinol
  • Causes minimal inflammation
  • Good for acne, rosacea and most sensitive skin
  • Good on all skin types
tca peel
TCA Peel
  • Medium depth “Wounding Peel”
  • Controlled peel of entire epidermal layer or down to papillary dermis
  • 5 – 10 days “down time”
  • Builds collagen, decreases pore size, evens out skin tone, decreases pigment
  • Not for use on darker skin types
  • Injection of botulinum toxin A
  • FDA approved for cosmetic use in Glabella
  • Works by causing temporary block in nerve signals preventing contraction of muscles
  • Glabella, crow’s feet, forehead and around mouth lasting approximately 3 months
  • Used for cosmetic purposes since 1981
facial fillers
Facial Fillers
  • Collagen
    • Human – no skin testing required
      • Cosmoderm, Cosmoplast
    • Bovine – rarely used due to skin testing
      • Is gold standard
  • Hyaluronic Acid
    • Restylane, Hylaform, Juvaderm
  • Radiesse – injectable facial contouring agent
  • Sculptra – injectable volumizing agent
  • Human vs Bovine
  • Cosmoplast is thicker than Cosmoderm
  • Last 3 – 4 months
  • Great for lip border, peri-oral lines, fine lines and wrinkles
  • No down time
hyaluronic acids
Hyaluronic Acids
  • Hydrophilic in nature
  • Lasts 6 – 9 months
  • Great for nasolabial folds and deeper lines and wrinkles
  • No testing needed
  • Hylaform, Restylane & Juvederm
  • Injectable implant
    • Nasolabial folds, marionette lines, cheek implants
  • Calcium Hydroxylapatie
  • Injected deeper into skin
  • Lasts 12 – 18 months
  • Shown to promote collagen after 3 months
  • Synthetic Poly-L-lactic acid
  • Injected into subcutaneous tissue
  • Increases skin thickness
ipl photo facial
IPL Photo-Facial
  • Multiple wavelengths of light penetrate to different depths in the skin treating various conditions
  • Minimal down-time
  • Lightens age spots, decreases redness and red veins, and evens the skin tones
  • Stimulates collagen
  • Excellent for rosacea
ipl with levulan therapy
IPL with Levulan Therapy
  • Combination IPL with the chemical Levulan to provide a more aggressive rejuvenation of epidermis
  • Treats photoaging, precancerous skin lesions, hyperpigmentation, acne, and rosacea
  • Causes temporary photosensitivity
  • Light peeling for 5 – 7 days
laser hair removal
Laser Hair Removal
  • Takes 6-8 treatments
  • Permanent hair reduction
  • Fast
  • Convenient
what s new
“What’s New”
  • Tissue tightening
  • Ablative fractional resurfacing
  • Non-ablative fractional resurfacing
  • Ablative erbium resurfacing
  • Profractional resurfacing
ablative non ablative skin resurfacing
Ablative & Non-Ablative Skin Resurfacing

CONFIDENTIALPalomar Medical Technologies, Inc.

mechanism of light induced skin rejuvenation
Mechanism of Light-induced Skin Rejuvenation

Light absorption by tissue water

Limited thermal damage

Inflammatory response

Release of inflammatory mediators into dermal interstitium

Stimulation of fibroblast activity

Increase of collagen production and proliferation of keratynocytes

CONFIDENTIALPalomar Medical Technologies, Inc.

non ablative skin resurfacing lux 1540 and fraxyl
Non-ablative skin resurfacingLux 1540 and Fraxyl
  • Produces microthermal treatment zones
  • Improves texture and pore size
  • Removes skin discolorations
  • Improves acne scarring
  • Treats hands, neck & de’collete’
  • Reduces crows feet around eyes
  • Does not remove epidermis
lux1540 fractional laser for texture wrinkles and acne scars
Lux1540 Fractional™ Laser for Texture, Wrinkles and Acne Scars

CONFIDENTIALPalomar Medical Technologies, Inc.

lux 1540 fractional
Lux 1540 Fractional

Pre Tx 1 Immediately After Tx 1

1 Week after Tx 1 8 Weeks after Tx 1

Photos courtesy of Dr. Dwight Scarborough


Lux1540 Fractional™

6 weeks post tx #2 @50 MJ


Aesthetica Cosmetic & Laser Center

David B. Vasily, M.D.

CONFIDENTIALPalomar Medical Technologies, Inc.


Lux 1540 Fractional™

PreTx 1 PostTx 2

Tiffani Hamilton, MD

lux 1540 fractional1
Lux 1540 Fractional™

3 WeeksPost2 tx

PreTx 1

CONFIDENTIALPalomar Medical Technologies, Inc

lux 1540 fractional2
Lux 1540 Fractional™

Stan Kovak MD-2 Weeks Post 4 TXs

Post 4 Treatments w/o Botox

lux 1540 fractional 2 weeks post 1 st treatment
Lux 1540 Fractional™2 weeks Post 1st Treatment



CONFIDENTIALPalomar Medical Technologies, Inc.

non ablative tissue tightening
Non-ablative tissue tightening

Causes dermal and subcutaneous heating, without damaging the surface of the skin.

  • Thermage-radiofrequency heating
  • Polaris – combined technology
  • Titan- infrared broadband
  • Starlux IR - infrared
other new treatments in 2007
Other New Treatments in 2007
  • Cellulite laser therapy
  • Portrait laser technology
  • Longer lasting fillers
  • Ablative lasers
  • We live a time of changing technology. There is something new every couple of months.
provider role in skin care
Provider Role in Skin Care
  • Educate yourself
  • Evaluate patient risk
  • Do skin checks yearly
  • Discuss good skin care
  • Recommend sunscreen
  • Encourage smoking cessation
  • Provide education about services available