New tricks revive old hands

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New tricks revive old hands

Dec 1, 2007
Cheryl Guttman
Dermatology Times

New York Û Patients seeking skincare advice and cosmetic treatments to improve the appearance of an aging face are likely to be very grateful if offered treatments to rejuvenate aging hands, says Kimberly J. Butterwick, M.D.

Dr. Butterwick

"With increasing age, hands develop vein prominence, loss of volume, skin textural changes, and other signs of photodamage, and yet patients usually will not complain about their hands," says Dr. Butterwick, a private practitioner in La Jolla, Calif. "A number of modalities are available for addressing those features and can give old hands a younger look."

Resurfacing

Chemical peeling is one option that can be used for rejuvenating the skin on the back of the hands.

However, because this site is more prone to slower healing and complications, it is important to be more conservative than when performing chemical peeling on the face.

"I would particularly advise against combining treatments. One published report described scarring after trichloroacetic acid (TCA) peeling combined with fat grafting in the hands," Dr. Butterwick tells Dermatology Times.

Patients should also be told that a series of peels will be necessary, and that they will see improvement relatively slowly. The peels used are generally superficial, such as TCA 10 percent to 25 percent or up to a single coat of TCA 35 percent, Jessner's solution, salicylic acid, alpha hydroxy acids, tretinoin solution or modified Unna's resorcinol paste.

Microdermabrasion can also be performed, and Dr. Butterwick notes she offers it as a "gift" to patients undergoing facial microdermabrasion. The effect is modest, but the treatment does not take long and results in temporary increased smoothness.

"Perhaps one of the greatest benefits is that it reminds patients to pay attention to skincare for their hands. Whatever they are using to prevent or reverse photoaging of the face, I encourage them to use on their hands," Dr. Butterwick says.

Ablative lasers can be used for resurfacing the hands, but relative to treatment of the face, they need to be used with greater caution, and they involve a longer healing period of two to three weeks.

The available literature, which is minimal, suggests resurfacing with an erbium: YAG laser or a single-pass ultrapulse CO2 laser with the debris left in place.

However, the newer, less invasive lasers are probably best for resurfacing the backs of the hands compared with either of those ablative technologies, Dr. Butterwick says.

"Observations from experienced laser surgeons show moderately good results can be achieved with fractional photothermolysis (Fraxel, Reliant) or plasma resurfacing with excited nitrogen gas. Healing occurs rapidly, although multiple treatments are required. Still more research is needed to better define the benefits, duration of effect and the optimal treatment parameters," she says.

Lentigines

Use of any Q-switch pigmented laser is Dr. Butterwick's preferred modality for clearing solar lentigines, as the treatment can provide excellent results after only one or two sessions. Light cryosurgery, however, should not be forgotten as a viable option.

"Some of the lentigines are actually slightly palpable, thin seborrheic keratoses that will not respond to pigmented lasers," Dr. Butterwick says.

Topical bleaching agents are not very effective as monotherapy for lentigines on the hands. Combination products or a combined treatment approach using light cryotherapy and a topical agent appear to be better.

Nevertheless, once the topical agent is discontinued, the lentigines tend to darken again.

When there are multiple lentigines, Dr. Butterwick says she prefers using an intense pulsed light (IPL) source with or without a photosensitizer. The lentigines respond readily, and good global improvement can generally be obtained after two or three treatments. Because the treatment may also stimulate collagen synthesis, it appears to be helpful for resolving senile purpura as well.

However, IPL treatment of the hands also needs to be approached with greater caution. Relative to the settings used on the face, the energy should be reduced by about 3 to 4 J and the treatment will result in more superficial crusting that can persist for about two weeks.

Actinic keratoses

Photodynamic therapy is the treatment of choice for patients with extensive actinic keratoses on the hands, but with this modality it is necessary to be more aggressive than when it is used on the face.

Dr. Butterwick's technique involves two weeks of pretreatment with topical 5-fluorouracil and application of 5-aminolevulinic acid for one hour under occlusion. Then, any of a variety of light sources can be used.

Unsightly veins

For prominent veins, Dr. Butterwick says sclerotherapy is an effective and simple treatment that is relatively ignored.

"This is a generally safe and successful technique that may be offered by physicians who do not perform sclerotherapy for the lower extremities," Dr. Butterwick says.

Published studies report achieving 90 percent to 100 percent improvement after one to two treatments with sotradecol 1.5 percent to 3 percent. Dr. Butterwick's technique employs 1 ml of 2 percent sotradecol that is foamed with 4 cc of room air. Then, with the nurse holding the patient's forearm as a tourniquet, about 2 ml to 3 ml is injected into a single vein, followed by immediate compression.

"Significant edema can develop and persist for up to four days. Patients should remove their rings before treatment, avoid strenuous activity with their hands after surgery, and I treat only one hand at a time," Dr. Butterwick says.

Volume enhancement

Volume depletion can be addressed using autologous fat or synthetic fillers. Since Dr. Butterwick performs a lot of liposuction, she often uses lipoaugmentation. While the literature reports wide variance in the duration of the effect, Dr. Butterwick says her technique provides good volume restoration for at least six months, with some persistence of effect still maintained at one year.

The delivery of small aliquots of fat is key, since it enables the adipose tissue to establish a better blood supply. A total of about 10 ml of fat is delivered into each hand, and patients are given prophylactic antibiotics to prevent infection. In comparative studies, Dr. Butterwick established that persistence is better using centrifuged versus noncentrifuged fat, and that frozen fat is preferred over fresh.

"We found the longevity was similar with fresh and frozen material, but the frozen fat was associated with less swelling and no dusky discoloration of the skin," Dr. Butterwick says.

Among the synthetic fillers, poly-L-lactic acid (Sculptra, Sanofi-aventis) appears to be the most cost-effective option, as it produces longer-lasting results than hyaluronic acid or collagen products. However, further study is needed to optimize the technique.

"Poly L-lactic acid provides augmentation by stimulating collagenesis, but if the effect is too great, nodules and granulomas can occur. To reduce this risk, it appears that a larger volume of sterile water should be used for reconstitution, compared with the 5 cc recommended when using poly-L-lactic acid for facial augmentation," Dr. Butterwick says.

In her office, Dr. Butterwick dilutes the lyophilized product with 12 ml of sterile water and delivers 6 ml into each hand, with the injections administered using a 26-gauge, 1.5-inch needle from two directions at a total of seven sites. Patients are advised that two to three treatments will be needed at intervals of two to three months, which is longer than for the face, and they are cautioned that bruising is likely and should be treated with ice.

"The results are impressive, and while available follow-up is only to one year, we expect the benefit should persist for two or three years," Dr. Butterwick says.

Injection of a bolus of Radiesse (BioForm Medical) is a newer alternative that appears to produce good results, but of yet undetermined duration. The thick product is mixed with 0.15 ml of 2 percent lidocaine, which also reduces the pain of injection. After tenting the skin, the needle is placed just above the fascia. After the bolus is delivered and the needle withdrawn, the product is distributed through vigorous massage and by asking the patient to make a fist.

Disclosure: Dr. Butterwick is a consultant or speaker for several companies marketing products used in hand rejuvenation.

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