Fine Lines Between Hype and Hope

Heaven in a jar, my friend Carla calls it. Walking toward the skin-care counter, I wonder what’s in the baby-blue cream she swears makes her feel as if she’s had a “mini-face lift.”

The lavender-scented cream, the sales rep says, is made from a “patented copper peptide complex” used on burn victims’ ravaged skin and diabetics’ slow-healing wounds. If it can stimulate the production of collagen for them, he says, consider the power it could unleash on aging skin--a casualty of collagen breakdown.

I feel myself drawn in. After all, there’s just enough science here to make me think the cream might work.

Across the country and around the world, women--and men too--are looking to eliminate wrinkles, those records of stress, smiles, smoking and, most of all, sun exposure.

A flourishing industry stands ready to accommodate us, proffering over-the-counter and prescription creams and lotions, injectable wrinkle fillers, chemical peels and laser resurfacing that generally smooth, Spackle or burn away skin defects.

Much of the demand is being met by cosmetics manufacturers, which have branched out into a lucrative area they call cosmeceuticals, where cosmetics meet pharmaceuticals.

These aren’t your mother’s lipstick and mascara makers. No, these are multinational corporations engaged in “a very serious worldwide war” over skin rejuvenation, says Dr. James J. Leyden, a University of Pennsylvania dermatologist. Companies such as Revlon, L’Oreal and Shiseido have beefed up their research and development, employing battalions of researchers to study plant extracts, minerals, proteins and other promising molecules.

Just listen to some of the science-inflected descriptions: Renergie Lift Contour Skin Firming and Contouring Complex (“a high-tech serum fortified with a special Dermo-Cohesion Complex”), Re-Surface Eye Retinol Concentrate Wrinkle Corrector (with “advanced Retinol technology”) and Extra Triple Lifting Day Cream (promising “a 60% improvement in fine lines and wrinkles” in a week).

The problem is, many product promises are supported by results forged in a test-tube or in laboratory mice, which don’t automatically translate to people, even though they’re widely tested for safety, as required by federal regulators. Many skin treatments are so new that long-term effects aren’t known. That leaves consumers to take their chances on results.

Apparently they do.

Anti-aging skin care, which grew in sales nearly 25% from 1999 to 2000, is the fastest-growing segment of the cosmetics business, said Bill Martineau, a senior research consultant for the Freedonia Group, a Cleveland market research firm. This year, he estimates, Americans will spend $950 million for anti-wrinkle creams alone.

They’ll also shell out $935 million for chemical peels, $235 million for collagen and Botox injections and about $250 million for laser resurfacing. Not to mention nearly $1 billion more for face lifts and eyelid surgery.

But with new treatments coming on board at a rapid pace, often without a long track record, “it’s caveat emptor,” says Dr. Richard Glogau, a UC San Francisco dermatologist.

Wrinkle potions, for example, fall into a regulatory gray area. If the components are found in nature, or work only superficially, they escape the regulatory reach of the Food and Drug Administration. Although manufacturers may not make drug claims, they can, and do, carefully craft phrases such as “reduces the appearance” or “helps eliminate signs” of fine lines and wrinkles.

Dr. William P. Coleman III, a cosmetic surgeon who also teaches dermatology at Tulane University, cautions: “Anything sold to you by a cosmetic company or drugstore that you pick up, you’re relying on the honesty of that manufacturer to tell you what’s really in it and what it does.”

The Louisiana dermatologist says many over-the-counter products are “really questionable in efficacy and may cost more than things that are truly proven to work.”

Even some of the treatments available in dermatologists’ offices aren’t universally endorsed within medical circles.

Some doctors prefer laser skin treatments to rejuvenate aging skin; others advocate chemicals they’ve grown comfortable using over several years.

For those attracted to the promises of a better complexion, keep in mind that basic anti-aging remedies can do only so much. For the deepest wrinkles and facial sagging, it’s off to the plastic surgeon. But if you’re looking for something less risky, you can begin with topical preparations:

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Acids (alpha hydroxy and beta hydroxy): Available in prescription and nonprescription strengths, these acids remove dead skin cells, revealing newer, tauter skin, and essentially making fine lines and superficial wrinkles look better. Among the alpha hydroxy acids are lactic acid, the active ingredient in Cleopatra’s beautifying sour milk baths, and glycolic acid, which comes from fruits. Salicylic acid, a beta hydroxy around for a century, smooths skin and eliminates scaling and roughness. But the strength of the acid makes a difference. Stronger solutions can have a significant impact but must be administered by a physician. For example, at concentrations of 30% and higher, glycolic acid is known to increase collagen production and skin elasticity and to thicken the top section of skin--the epidermis. The over-the-counter solutions slough off the the topmost layer, the stratum corneum, making skin look brighter, but many dermatologists say they do little else.

Antioxidants: In the body, this group of chemicals, such as Vitamins C, E, coenzyme Q-10 and superoxide dismutase, scoop up cellular waste products called free radicals. Accordingly, research indicates they may have disease-fighting properties. But the jury remains out on topical application. Some dermatologists believe the Vitamin C patch can raise collagen levels and create some surface plumping that eases facial lines. But Coleman, for one, doesn’t see “any good proof a topical antioxidant makes any real difference long term in the skin.” Regardless, the primary caution here is skin sensitivity. Some users develop a rash. And a word of caution: Although manufacturers may tout that their product contains antioxidants, often they’re in the product primarily to stabilize other ingredients.

Copper peptide: Copper has long been an essential mineral, but it wasn’t until a biotechnology company began combining it with amino acids that anyone could get it into skin cells. Copper peptide creams were first developed for burn victims and diabetics with wounds that wouldn’t heal. They’ve now become a new horizon in the cosmeceutical business, with some large cosmetics companies expected to add copper peptide to their skin care lines. Right now, dermatologists’ offices sell copper peptide products, you can buy them over the Internet through companies including Neova and Skin Biology, and a Denver-based cosmeceutical firm called Osmotics sells a $98-a-jar cream called Blue Copper at upscale store counters. So far, small scientific studies show that skin treated with copper peptides had less pigmentation, reduced wrinkling and held more moisture; one very small biopsy study found a copper peptide cream produced more collagen formation than creams containing Retin-A, Vitamin C or melatonin. Glogau uses copper peptide creams to help heal the skin of patients who have undergone laser resurfacing but contends that the scientific evidence for its usefulness with aging skin isn’t strong enough yet.

Furfuryladenine: Skin care, biotechnology and drug companies are focusing attention on this anti-withering agent, found in the leaves of green plants, and have turned it into a promising new area of the cosmeceutical business. Early industry-sponsored studies at UC Irvine and elsewhere indicate that with weeks to months of use, it reduces signs of sun damage, such as blotchiness, fine wrinkles and roughness. So far it’s available in only a few products. ICN Pharmaceuticals sells it as Kinerase, and Osmotics sells it as Kinetin. It will soon be incorporated in other cosmetics lines. A big selling point: Because it doesn’t irritate the skin, many dermatologists see it as an alternative for those who can’t tolerate more irritating retinoids.

Retinoids: These Vitamin A derivatives are available in prescription and nonprescription strengths. The prescription versions, Retin-A (whose chemical name is tretinoin) and Renova (Retin-A tempered by a moisturizer), are known to build collagen, regenerate the elastin that lets skin stretch and reverse abnormal pigmentation. Much of what’s known about Retin-A is based on a 30-year track record of use as an acne treatment. The anti-aging case is less clear for retinol, a weaker, over-the-counter retinoid. Other retinoids, including adapalene, an acne drug marketed as Differin, and tazarotene, marketed as Tazorac, are also being studied.

By removing dead surface cells that become harder to shed as we age, and by thinning and flattening the stratum corneum, retinoids give skin that much-valued “rosy glow.” They do that by creating a smooth surface that reflects light more brightly, just like smoothly brushed hair has more luster than tousled hair. However, retinoids often produce irritation, dryness and peeling. They make skin sensitive to the sun’s burning rays, so sunscreens are a must. Dr. Gerald Weinstein, the dermatology chairman at UC Irvine, says retinoid benefits last as long as you use the products. Stop, and your wrinkles and pigmented patches return.

Some doctors believe that retinoids not only reverse sun damage, but prevent development of skin cancer, although that hasn’t been proved. Some dermatologists recommend Retin-A as a first-line treatment for photodamaged skin. Coleman tells women over 30 living in Sunbelt states: “If you’re going to do anything, you ought to be putting Retin-A on your skin.”

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As promising as topical products may sound, sometimes they simply don’t work--or they stop working. Doctors can then step in with products and procedures that are more invasive, but often effective, in more damaged skin.

Chemical peels: Peels tighten up the skin by promoting growth of collagen and elastin; they also remove fine lines and wrinkles and burn off precancers called actinic keratoses. The stronger the acid used, the more dramatic the improvement. Mild peels costing a few hundred dollars cause the outer layer of skin to slough off in two to three days. Medium-strength peels, averaging $1,000 per treatment, create enough crusting, scaling and oozing to remove deeper scars and wrinkles, but they’ll keep you out of circulation for a week to 10 days. Deep phenol peels, costing thousands of dollars, can eliminate major sun damage and wrinkles, but the patient is out of commission for a couple of weeks, and the resulting redness takes months to fade. These peels carry the highest risks, including hyperpigmentation, scarring, persistent redness, itching and a demarcation where the peel stopped.

Injected fillers: These substances, most often collagen, are injected directly into the wrinkle and plump up the skin. But the effect is temporary, and some people can have allergic reactions.

The most commonly injected collagen comes from cows (doctors say from specially isolated herds that are not exposed to mad cow disease) or from human cadavers (some doctors worry about a theoretical risk of disease). But risks and side effects could be averted with bioengineered human collagen, which is unlikely to be rejected by the body and is expected to reach the market soon.

Other fillers are expected to hit the market eventually, and some already can be obtained in Europe and South America.

“The market is about to explode with new filler substances that are being introduced at a rate of one every six to eight months,” says Glogau, the UC San Francisco dermatologist. “I personally don’t think they’ve got a lot of controlled clinical studies behind them.”

Among fillers not yet approved in this country is Artecoll, which combines bovine collagen that temporarily plumps the area with polymethylmethacrylate that stimulates natural collagen to fill in the area permanently. Several fillers under FDA consideration contain hyaluronic acid, a substance found in all mammals that forms the soup in which skin cells float.

Injected toxin (Botox): Injections of botulinum toxin, the most potent known poison, paralyze the facial muscles that cause frowning, forehead lines and some crow’s feet. Because Botox wears off in a few months, injections must be repeated to maintain the effect. Doctors have learned from giving repeated injections that many wrinkles relax when the chemical keeps the muscle from being used. Says Glogau: “A lot of lines we thought at least partially were skin damage turn out to be predominantly lines of facial expression.”

A warning: Sometimes the injections can cause temporary drooping of the eyelid.

Laser skin resurfacing: This is the brave new world of skin rejuvenation. A pulsed carbon dioxide laser or an erbium:YAG laser burns off top skin layers in lined areas and injures the dermis so collagen will re-form. Healing takes a week or more; redness persists for weeks to months. The newer “laser facial” or “photo-facial” procedures bypass the skin surface and go straight to the dermis, where they’re said to encourage collagen production, but this can take months. Glogau says he hasn’t seen “extensive, long-term studies on the outcomes of laser work because they haven’t been around that long.” He’s convinced that the beauty industry and much of the media bombard the public with the message that “newer is better.” But he cautions that they also are so new that they don’t have long-term follow-up, and there may be unexplored risks from these various forms of light.

Microdermabrasion: This popular procedure is essentially a mild sanding of the skin’s surface, a kind of mechanical acid peel with a bit of vacuum effect. Some dermatologists say their patients swear by it for good skin; others find it a waste. “I consider it a boondoggle,” said Coleman. “We don’t have any evidence it does as much as a glycolic acid peel, yet people are paying four times as much.”

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Regardless of what those with aging skin are willing to try in the pursuit of younger-looking skin, dermatologists agree on one point: The vast majority of aging comes from sun damage. So they advise staying in the shade during peak sun hours and slathering on the sunscreen.

Says Dr. Norman Levine, a University of Arizona dermatologist: “All the stuff that’s sold in the drugstores pales in comparison to the use of sunscreens for prevention of wrinkles.”

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SAVING FACE

A variety of anti-aging preparations and procedures has come on the market in recent years.

Frown lines and furrows respond well to Botox injections, which paralyze the underlying muscles for about three to six months. These injections can be used on crow’s feet and occasionally on downward-drooping corners of the mouth. They also can be used to soften horizontal bands in the neck called platysma.

Fine lines and wrinkles, especially along the cheeks and just beyond the delicate under-eye area, respond to topical creams and lotions containing mild acids, retinoids, plant extracts and copper peptide. (Eye irritation can result if the creams are applied too close to the eye.)

Laugh lines and the nasolabial folds that extend from the nose area to the mouth are often eased with injectable fillers, such as bovine collagen.

For the deepest wrinkles and heavily etched lines, patients turn to a dermatologist or plastic surgeon for facial peels and laser facial resurfacing, which tighten facial skin, promote formation of new collagen and burn off signs of sun damage.