ReachMD:
Hello this is Doctor Prathima Setty and I am your host for this segment on ReachMD. Today we have with us Doctor Dina Anderson. Doctor Anderson is a board certified dermatologist in New York City, she was also the director of cosmetic cosmetology at SUNY Downstate in Brooklyn. She is the recipient of multiple national and international awards for clinical research and has lectured nationally and internationally on aging skin, acne and facial rejuvenation techniques.
Doctor Anderson thank you so much for being with us today.
Dina Anderson:
Thank you so much for having me.
ReachMD:
Doctor Anderson’s going to discuss the cosmetic concerns of our patients in menopause today. Doctor Anderson, what are some of the most common complaints you see in the office from postmenopausal patients?
Dina Anderson:
They vary. I would say very common women come to my office and complain of dryness, blotchy skin, textural changes and then they delve into the deeper issues. ‘Well, I have a lot more lines, my face is starting to sag, I have jowls forming, my eyes aren’t as open, the skin’s kind of falling over my eyelids.’ These are very, very specific complaints that I hear from the majority of women in this age group.
ReachMD:
Can you talk a little bit about estrogen and its effects on the skin?
Dina Anderson:
Sure. Estrogen has a myriad of very different broad range of effects. It not only effects the surface of the skin but we have to think about delving deeper into the epidermis and the subcutaneous layer, and the periosteal layer, because they’re all intertwined. The changes in all of these layers is what women see on the surface of their skin. The drop in estrogen during menopause causes a shift in transepidermal water loss, which basically means you don’t have a good barrier and this leads to dryness and textural changes of maybe feeling rough, their skin doesn’t feel quite as supple. Additionally you do get…I think in the perimenopausal period you get surges in hormone, and that surge causes some pigmentation and dyschromia.
Women also complain about their skin just looking uneven and blotchy, and pigmented, especially in lighter skin women who live in more sunny climates. When women start to complain about lines that’s directly a cause of estrogen having effect on decreased collagen production and fibroblast stimulation. When that happens that causes a whole cascade of effects where collagen then can’t hold on to elastin so the skin doesn’t feel as supple and it also won’t bind hyaluronic acid, which is our glycosaminoglycan in the dermis, which causes moisture retention.
All of those issues lead to fine line and then a deeper wrinkle as all of these components in the skin disintegrate over time due to the drop in estrogen. A decrease estrogen also causes a dynamic change in bone resorption. The increase in bone resorption leads to a biometric volume bone loss, so the mandible contracts, which is why women start to see a jowl or a sagging skin.
The skin around the eye, the eye skeletal component also contracts and shrinks, so there’s no support structure for the skin anymore, so the skin starts to droop over their eyes. All of these changes of estrogen affecting multiple layers is what people come into your office looking for simple solutions.
ReachMD:
How do you counsel these patients and what are the first line recommendations for these patients regarding treatment?
Dina Anderson:
I think there’s two components. I think there are universal recommendations that I tell all of my patients and this can even start in the premenopausal area. I think the earlier you start with good habits, whether it’s dietary, behavioral, sun protection, all of those things are very important especially in the perimenopausal groups.
I always tell them, for universal recommendations, that they should stay out of the sun during the bright hours, wear a physical based sun block, something with at least six percent zinc because that will broadly block UVA, which causes, not the burn, but all of the blotchiness. I also tell them to wear hats and UPF clothing if they’re going to be out in a sunny climate or if they live somewhere by the beach and I always talk about just reducing oxidative stress on the skin, trying to eat well and avoid anything process or trans fats and increase their omega-3 intake. On this line I also talk about, obviously, if you’re going to smoke a pack of cigarettes and go out in the sun then you’re just wasting your time in a dermatologist’s office.
Those kind of tips are also inherent but we like to go over them. Then I talk about different things we can do to change the appearance of the skin, and those are more targeted therapies.
ReachMD:
Along those lines, what are some prescription therapies, medications that you would give these types of patients?
Dina Anderson:
Sure. I think the universal prescription that most dermatologists talk about are topical retinoids, and they work in so many different ways to keep the skin healthy, the increase collagen, which will directly help the drop in estrogen effects on collagen. They also decrease collagenase and they cause angiogenesis, and they cause up regulations of all of these good modifiers in the skin that we tend to lose during menopause.
Some women can’t tolerate the irritating effects of retinoids, so then I’ll supplement with maybe a retinol, which is not quite as effective as retinoic acid but it’s the pure form of vitamin A and it’s not as irritating, and I’ll combine that with a topical antioxidant, which gives you a different level of protection than sunblock. Like resveratrol, ECGC, green tea, caffeine, stable vitamin C in capsules because it’s very unstable to light. All of those topical therapies will really help.
Additionally, if a woman is very dry, I tell them if they can pour a moisturizer out of a bottle it has too much water content. You like something that you can scoop out, it has more a humectant property so when we lose the hyaluronic acid from the estrogen loss we can kind of seal the skin with a humectant topical therapy.
ReachMD:
If you are just tuning in you are listening to ReachMD and I am your host Doctor Prathima Setty. I am speaking with Doctor Dina Anderson and we are talking about postmenopausal skin concerns.
How long do you prescribe these medical therapies before you go to procedures or treatments, or peels and things like that or do you do both in combination?
Dina Anderson:
I let the patient guide me in regards to that. I don’t like to…if someone has a huge crevasse on one side of their face but they’re focusing on something little on the other side of the face that’s what bothers them, so if a patient comes to me and says ‘what should I do,’ I do everything at once. They get the topical, then we talk about…if their skin textures a problem we talk about peels or light fractionated resurfacing procedures to help tone and texture, and then we talk about injections, like toxins to smooth out hyperdynamic lines, filling and volumizing agents for the lower face.
ReachMD:
Along that answer can you talk a little bit more in depth about some of those treatments and what’s your first line of treatments and where you go from there?
Dina Anderson:
I think, again, it depends on the ethnicity of the…patient’s age differently, but I think in the perimenopausal group their biggest problem relates to the fat, collagen and bone loss, and most of these woman, unless they’re overweight, tend to have a lot of contour deficiencies and hollowing. I think if they have kept up with things in their 30s and 40s, most of my patients have in New York City, and they’ve been doing the retinoids, staying out of the sun, doing line fillers, doing toxin injections. That at this part they’re ready for structural changes such as Poly-L-lactic acid injections or Voluma injections, which are deeper injections that causes collagen stimulation and support structures to be rejuvenated under the skin.
ReachMD:
Doctor Anderson how would you treat fine lines in a postmenopausal patient?
Dina Anderson:
It’s a great question because fine lines can be around the mouth, and those are very fine lines, they can be in the cheek, they could be around the eyes, they can be between the eyebrows and this is an area I really like to treat. I think that we’ve come a long way with our procedures and what we can do in treating fine lines. We used to only have injectable products for fine lines that lasted about two months and patients got very frustrated with having to come back. Now we have a whole myriad of different hyaluronic acid products that, again, is the glycosaminoglycan in the dermis that is gone, or a lot of it is gone, when you reach the perimenopausal period.
We can use these different gels and we can thin them out with extra anesthetic, like lidocaine so they’re thinner, so when you put them in a fine line with a very fine 31 gauge needle, you put them directly in that fine line and they just blow the line out, and you get good results lasting about six to nine months. What’s more interesting, and this has been proven over the last 15 years of repetitively treating patients and seeing them over time, is that just from the trauma of the needle injection you get fibroplasia in the area and the lines sometimes don’t come back, but they come back a lot softer, so you get this cumulative change that goes on.
ReachMD:
That’s very interesting doctor Anderson and such a great review. Do you have any final thoughts on treatment of skin disorders such as these in postmenopausal patients for our listeners?
Dina Anderson:
As we were talking about before, I think, in the postmenopausal female a lot of the skin and bony changes lead to a lot of hollowing and sagging, and for women that aren’t ready to have surgery some of these newer deeper injectable hyaluronic acids that provide structural support or these collagen stimulators that increase collagen deposition over time are wonderful. The collagen stimulators it’s a series of three treatments.
A woman comes in, she’s like I don’t want everyone to know, well, it’s a very gradual subtle but significant change. They come in three times over six months and the Poly-L-lactic acid particles are mixed with water, they’re implanted in the area that you want to stimulate collagen and get a fibroplastic response, and it happens slowly and subtly. Kind of like planting seeds, so slowly over time, and I tell woman ‘don’t expect anything until about a month after the second treatment’ and six to nine months later they just look like a different person. I tell them ‘you’re not going to be 60 and look 20, that’s not reality, but you can bring a picture of yourself 10 years ago and we might be able to get you to that point.’ The results are permanent, in the clinical trials they last three years but you’re three years older at that point so you probably need a little boost.
I think those types of treatments have been the most dramatic in the last five to 10 years in treating this age group.
ReachMD:
That’s such a wonderful review. Thank you so much Doctor Anderson for being with us today.
Dina Anderson:
Thank you very much for having me.
ReachMD:
I’m your host Doctor Prathima Setty and you’ve been listening to ReachMD radio. If you missed any part of this discussion please visit ReachMD.com to download this podcast. Thank you for listening.
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